Subaortic Stenosis Fibromuscular Obstruction

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Aortic Leaflet Extension

aortic valve

Figure 14-5. Repair of this anomaly is performed with cardiopulmonary bypass and aortic clamping, cardioplegia, and profound local cardiac cooling, working through a proximal ascending aortotomy. Typically, the aortic valve is normal as seen here. There are three leaflets without commissural stenosis.

aortic valve

Figure 14-5. Repair of this anomaly is performed with cardiopulmonary bypass and aortic clamping, cardioplegia, and profound local cardiac cooling, working through a proximal ascending aortotomy. Typically, the aortic valve is normal as seen here. There are three leaflets without commissural stenosis.

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Subaortic Stenosis

fibromuscular [edge

Figure 14-6. With retraction of the valve, a fibromuscular ledge is seen in the left lateral part of the outflow tract immediately below the valve annulus.

fibromuscular [edge

Figure 14-6. With retraction of the valve, a fibromuscular ledge is seen in the left lateral part of the outflow tract immediately below the valve annulus.

Rectangular Annulus
Figure 14-7. A stitch is placed in the middle of the ledge to facilitate grasping it while the resection is carried out.

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Sub Aortic Valve Stenosis

rectangular wedge

Figure 14-8. A rectangular wedge of fibromuscular tissue is resected. It is safe to resect tissue as far anterior as the region beneath the middle of the right coronary cusp. The bundle of His' pierces the ventricular septum beneath the noncoronary cusp, after which the bundle moves forward in the ventricular septum to the commissure between the noncoronary and right coronary cusps. Tissue is resected to the left and posteriorly as far as the base of the anterior mitral leaflet, which is located in the posterior wall of the left ventricular outflow tract.

rectangular wedge

Figure 14-8. A rectangular wedge of fibromuscular tissue is resected. It is safe to resect tissue as far anterior as the region beneath the middle of the right coronary cusp. The bundle of His' pierces the ventricular septum beneath the noncoronary cusp, after which the bundle moves forward in the ventricular septum to the commissure between the noncoronary and right coronary cusps. Tissue is resected to the left and posteriorly as far as the base of the anterior mitral leaflet, which is located in the posterior wall of the left ventricular outflow tract.

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Subaortic Stenosis

Figure 14-9. The resected specimen is seen here.

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Figure 14-9. The resected specimen is seen here.

Fibroma Pulmonary

fibrous collar

Figure 14-10. In another child, a typical fibrous collar is seen in the outflow tract immediately below the aortic valve annulus.

fibrous collar

Figure 14-10. In another child, a typical fibrous collar is seen in the outflow tract immediately below the aortic valve annulus.

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Sub Aortic Valve Stenosis

Figure 14-11. The fibrous collar has been resected along with a wedge of muscle.

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Figure 14-11. The fibrous collar has been resected along with a wedge of muscle.

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Subvalvular Aortic Stenosis

aortic valve

Figure 14-12. In another patient, a normal aortic valve is seen.

aortic valve caud

Figure 14-12. In another patient, a normal aortic valve is seen.

Retracted Cusp
Figure 14-13. The valve cusps are retracted and a fibromuscular obstruction is seen immediately below the annulus.

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parallel incisions

Figure 14-14. A stitch is placed in the mid part of the ledge for retraction, and parallel incisions are made in the obstructing tissue. The rightward one is below the mid part of the right coronary cusp.

Images Pulmonary Artery Stenosis

muscle ledge to be resected

Figure 14-15. The obstructing muscle ledge is pulled into the field.

muscle ledge to be resected parallel incisions caud

Figure 14-14. A stitch is placed in the mid part of the ledge for retraction, and parallel incisions are made in the obstructing tissue. The rightward one is below the mid part of the right coronary cusp.

Figure 14-15. The obstructing muscle ledge is pulled into the field.

Sub Aortic Valve Stenosis
Figure 14-16. The resected specimen is shown. The obstruction extended deep into the sinus portion of the left ventricle, and the long resected specimen depicts the length of the obstructive process.

area of resection area of resection

Figure 14-17. The area of resection is wide to ensure relief of the obstruction.

Figure 14-17. The area of resection is wide to ensure relief of the obstruction.

14-2-1. Anomalous Mitral Valve Papillary Muscle caud

Aortic Valve Leaves

fibrous extension into base of mitral leaflet aortic valve leaf

Figure 14-18. After placing another child on cardiopulmonary bypass, an opening is made in the proximal ascending aorta. A trileafed aortic valve is retracted, as is a narrow membrane located anteriorly. An obstructing muscle mass is exposed in the posterior left ventricular outflow tract. This is an anomalous extension of the mitral valve posterior medial papillary muscle with a fibrous tissue extension into the base of the anterior mitral leaflet.

anomalous papillary muscle extension

Into subaortic area fibrous extension into base of mitral leaflet

Figure 14-18. After placing another child on cardiopulmonary bypass, an opening is made in the proximal ascending aorta. A trileafed aortic valve is retracted, as is a narrow membrane located anteriorly. An obstructing muscle mass is exposed in the posterior left ventricular outflow tract. This is an anomalous extension of the mitral valve posterior medial papillary muscle with a fibrous tissue extension into the base of the anterior mitral leaflet.

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Sub Aortic Valve Membrane

right coronary cusp anomalous papillary muscle extension fibrous attachment left coronary cusp

Figure 14-19. The fibrous membrane located beneath the right coronary cusp is excised and the anomalous muscle bundle is more easily seen.

right coronary cusp anomalous papillary muscle extension fibrous attachment left coronary cusp

Figure 14-19. The fibrous membrane located beneath the right coronary cusp is excised and the anomalous muscle bundle is more easily seen.

Figure 14-20. The cephalad 25% of the posterior medial papillary muscle is excised. The lower portion of this papillary muscle is left intact and is attached to normal chords. The raw surface of the muscle excision is seen.

Heart Valve Membrane Attached Cords

papillary muscle excision mitral valve chords

Figure 14-20. The cephalad 25% of the posterior medial papillary muscle is excised. The lower portion of this papillary muscle is left intact and is attached to normal chords. The raw surface of the muscle excision is seen.

papillary muscle excision mitral valve chords

Figure 14-21. The raw surface of the excised muscle is again seen and normal mitral valve chords are identified. The lower 75% of the papillary muscle remains intact with these chords to provide mitral valve support. After closing the aorta and removing the child from bypass, there was no residual pressure gradient.

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Responses

  • christian
    What is a Fibromuscular ridge.0.6 cm from aortic valve annulus?
    2 years ago
  • tanta t
    What is the fibromuscular stenosis of the subaortic?
    2 years ago

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