Primum Atrial Septal Defect

Inlet Vsd Near Bundle His

ceph a tad rim of atrial septal defect mitral chord supports cephaiad part of anterior mitral leaflet tricuspid septal leaflet is absent cleft in mitral leaflet extends to annulus fibrous thickening along margin of mitral valve cleft

Figure 4-1. The patient is on cardiopulmonary bypass, and a right atriotomy has been made. The low primum atrial septal defect (ASD) allows excellent exposure of the anterior mitral leaflet, which is lifted into the field. There is a cleft that separates the leaflet into cephaiad and caudad components, and it extends to the common annulus between mitral and tricuspid valves. Chordae support the rim of this leaflet at the cleft, and no evidence of mitral regurgitation is apparent. There is thickening and fibrosis of the leaflet above and below the cleft; this provides tissue of good substance into which stitches can be placed for the repair. There is a deficiency or absence of the adjacent tricuspid valve septal leaflet.

ceph a tad rim of atrial septal defect mitral chord supports cephaiad part of anterior mitral leaflet tricuspid septal leaflet is absent cleft in mitral leaflet extends to annulus

Figure 4-1. The patient is on cardiopulmonary bypass, and a right atriotomy has been made. The low primum atrial septal defect (ASD) allows excellent exposure of the anterior mitral leaflet, which is lifted into the field. There is a cleft that separates the leaflet into cephaiad and caudad components, and it extends to the common annulus between mitral and tricuspid valves. Chordae support the rim of this leaflet at the cleft, and no evidence of mitral regurgitation is apparent. There is thickening and fibrosis of the leaflet above and below the cleft; this provides tissue of good substance into which stitches can be placed for the repair. There is a deficiency or absence of the adjacent tricuspid valve septal leaflet.

fibrous thickening along margin of mitral valve cleft

Interatrial Septum Primum

rim of primum atrial septal defect rim of primum atrial septal defect

Figure 4-2. The area beneath the atrio-ventricular valves is inspected for small ventricular septal defects. The tip of a right-angle clamp passes beneath the tricuspid valve leaflet and through a small ventricular septal defect.

tip of right angle clamp passes through small ventricular septal defect

stitches in mitral valve cleft
Primary Patch Closure Mitral Cleft

rim of ASD

mitral leaflet attachment beneath coronary sinus stitches beneath coronary sinus near His' bundle

Figure 4-4. Additional interrupted mattress sutures with felt pledgets are placed in the upper margin of the ventricular septum or passed through the base of the tricuspid leaflet to be used in closing the lower rim of the ASD Interrupted sutures are placed in tissue beneath the coronary sinus in the region of the His' bundle placing them superficially and on the left atrial surface of the septum. The posterior annulus attachment of the anterior mitral leaflet is immediately adjacent to the coronary sinus in some cases, and stitches can be safely placed at the base of this leaflet to avoid the His' bundle.

caud

Primum Atrial Septal Defect

thickened mitral leaflet at margin of cleft

Figure 4-3. The mitral valve cleft is repaired with multiple simple interrupted sutures. The thick fibrous margin of the cleft can be seen. Care is taken not to close the cleft excessively to avoid iatrogenic mitral stenosis, although ideally the cleft is closed to the free margin of the leaflet. The first ASD repair stitch is placed as a mattress suture with a Teflon® felt pledget opposite the cleft. This stitch is placed in the upper ventricular septum along the right ventricular surface and is used as a traction suture during repair of the cleft.

first ASD repair stitch placed on RV surface of inlet septum rim of ASD

interrupted mattress sutures for ASD repair passed through septal muscle or in base of tricuspid leaflet

Figure 4-3. The mitral valve cleft is repaired with multiple simple interrupted sutures. The thick fibrous margin of the cleft can be seen. Care is taken not to close the cleft excessively to avoid iatrogenic mitral stenosis, although ideally the cleft is closed to the free margin of the leaflet. The first ASD repair stitch is placed as a mattress suture with a Teflon® felt pledget opposite the cleft. This stitch is placed in the upper ventricular septum along the right ventricular surface and is used as a traction suture during repair of the cleft.

mitral leaflet attachment beneath coronary sinus

Figure 4-4. Additional interrupted mattress sutures with felt pledgets are placed in the upper margin of the ventricular septum or passed through the base of the tricuspid leaflet to be used in closing the lower rim of the ASD Interrupted sutures are placed in tissue beneath the coronary sinus in the region of the His' bundle placing them superficially and on the left atrial surface of the septum. The posterior annulus attachment of the anterior mitral leaflet is immediately adjacent to the coronary sinus in some cases, and stitches can be safely placed at the base of this leaflet to avoid the His' bundle.

caud thickened mitral leaflet at margin of cleft stitches beneath coronary sinus near His' bundle

ASD inferior repair stilches are tied

ASD inferior repair stilches are tied

Primum Atrial Septal Defect

Figure 4-5. A knitted Dacron® patch is cut to the size and shape of the ASD and the mattress sutures are passed through the patch. Stitches along the inferior rim of the ASD are tied. The aortic clamp is removed, and rewarming started. When normal sinus rhythm is observed, the stitches beneath the coronary sinus are tied. If these stitches are too near the His' bundle, heart block will be observed immediately when the offending stitch is tied. If this occurs, the stitch is removed and replaced. The upper margin of the ASD is closed with a continuous suture while rewarming continues.

stitches beneath coronary sinus near His1

bundle caud

Figure 4-5. A knitted Dacron® patch is cut to the size and shape of the ASD and the mattress sutures are passed through the patch. Stitches along the inferior rim of the ASD are tied. The aortic clamp is removed, and rewarming started. When normal sinus rhythm is observed, the stitches beneath the coronary sinus are tied. If these stitches are too near the His' bundle, heart block will be observed immediately when the offending stitch is tied. If this occurs, the stitch is removed and replaced. The upper margin of the ASD is closed with a continuous suture while rewarming continues.

4-1-1. Primum Atrial Septal Defect with Mitral Leaflet Tissue Deficiency

Primum Atrial Septal Defect

rim of ASO

leaflet deficiency at base of cleft stitches in cleft near free margir of leaflet

Figure 4-6. In another child, cardiopulmonary bypass has been established and the right atrium opened. There is an area of tissue deficiency at the base of the mitral valve cleft near the annulus. Primary closure of this part of the cleft was thought inadvisable for fear this would cause distortion of the mitral leaflet and mitral regurgitation.

rim of ASO

leaflet deficiency at base of cleft

Figure 4-6. In another child, cardiopulmonary bypass has been established and the right atrium opened. There is an area of tissue deficiency at the base of the mitral valve cleft near the annulus. Primary closure of this part of the cleft was thought inadvisable for fear this would cause distortion of the mitral leaflet and mitral regurgitation.

stitches in cleft near free margir of leaflet ceph

Primum Atrial Septal Defect

Figure 4-7. The mitral valve cleft near the free margin of the leaflet is closed primarily. A triangular-shaped pericardial autograft is stitched over the area of leaflet deficiency near the annulus. The primum ASD is then closed in the usual way.

pericardial patch in area of leaflet deficiency ceph

Figure 4-7. The mitral valve cleft near the free margin of the leaflet is closed primarily. A triangular-shaped pericardial autograft is stitched over the area of leaflet deficiency near the annulus. The primum ASD is then closed in the usual way.

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