Subpulmonary Ventricular Septal Defect

Subpulmonary ventricular septal defects are located high in the ventricular septum and immediately below the pulmonary valve. Myocardial relaxation with cardioplegic arrest allows the upper septum to be retracted inferiorly, so that many subpulmonary defects can be closed completely through the transatrial approach. In many cases, an aortic valve cusp is intimate with the rim of this ventricular defect and care must be used to avoid damage to the valve. If exposure through the atrium is not satisfactory, this approach should be aborted and a high small transverse right ventriculotomy or proximal main pulmonary arteriotomy used for the repair. Working through the proximal ascending aorta with retraction of the aortic valve is an alternative repair exposure.

Figure 5-10. The supracristal subpulmonary VSD is seen immediately below the pulmonary valve by looking through a right atriotomy while retracting the anterior tricuspid valve leaflet.

Tricuspid Valve Right Atriotomy

subpulmonary ventricular septal defect membranous ventricular septum

Figure 5-10. The supracristal subpulmonary VSD is seen immediately below the pulmonary valve by looking through a right atriotomy while retracting the anterior tricuspid valve leaflet.

subpulmonary ventricular septal defect membranous ventricular septum

Figure 5-9. In another patient who was re-explored 7 years after VSD repair, the totally endothelialized patch is invisible beneath endocardial tissue, as seen through a right atriotomy.

Vsd Repair

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Subpulmonary Vsd

ventricular septal defect

Figure 5-11. With retraction, the upper ventricular septum is shifted caudad for satisfactory exposure of the VSD, which was closed through this approach.

ventricular septal defect ceph

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Figure 5-11. With retraction, the upper ventricular septum is shifted caudad for satisfactory exposure of the VSD, which was closed through this approach.

Leaflets Pulmonary Valve

main pulmonary artery pulmonary valve leaflet ventricular septal defecl

Figure 5-12. In another patient, exposure of the VSD is through a proximal transverse main pulmonary arterotomy with retraction of pulmonary valve leaflets.

main pulmonary artery pulmonary valve leaflet ventricular septal defecl

Figure 5-12. In another patient, exposure of the VSD is through a proximal transverse main pulmonary arterotomy with retraction of pulmonary valve leaflets.

Position Ventricular Septal Defect

pulmonary valve leaflet aortic valve leaflet

Figure 5-13. With the aortic valve in the closed position during delivery of cardioplegia, an aortic cusp fills most of the VSD. Without repair, the resulting stretching and distention of the cusp may lead to aortic insufficiency. Felted mattress stitches are placed around the rim of the VSD for the repair. Because there is a common annulus between the aortic and pulmonary valves, stitches at the cephalad rim of the VSD are placed at the base of a pulmonary valve leaflet through the common semilunar valve annulus without felt pledgets.

pulmonary valve leaflet

Figure 5-13. With the aortic valve in the closed position during delivery of cardioplegia, an aortic cusp fills most of the VSD. Without repair, the resulting stretching and distention of the cusp may lead to aortic insufficiency. Felted mattress stitches are placed around the rim of the VSD for the repair. Because there is a common annulus between the aortic and pulmonary valves, stitches at the cephalad rim of the VSD are placed at the base of a pulmonary valve leaflet through the common semilunar valve annulus without felt pledgets.

aortic valve leaflet

Pulmonary Valve Leaflets

pulmonary valve leaflet

VSD patch

Figure 5-14. Stitches are placed in a Dacron® patch and then tied for repair of the defect. Along the cephalad rim, stitches are placed in the valve annulus so there should be little distortion of the pulmonary valve leaflet.

pulmonary valve leaflet

Figure 5-14. Stitches are placed in a Dacron® patch and then tied for repair of the defect. Along the cephalad rim, stitches are placed in the valve annulus so there should be little distortion of the pulmonary valve leaflet.

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Hypoplastic Pulmonary Valve Annulus

pulmonary valve annulus ventricular septal detect

Figure 5-15. In another patient, the subpulmonary VSD is exposed through a high right ventriculotomy. A dilated and prolapsing aortic valve cusp is present in the upper part of the VSD; this resulted in aortic insufficiency. The VSD is adjacent to the pulmonary valve annulus.

pulmonary valve annulus ventricular septal detect

Figure 5-15. In another patient, the subpulmonary VSD is exposed through a high right ventriculotomy. A dilated and prolapsing aortic valve cusp is present in the upper part of the VSD; this resulted in aortic insufficiency. The VSD is adjacent to the pulmonary valve annulus.

Aortic Valve Regurgitation With Vsd

aortic valve cusp

Figure 5-16. The aortic valve is in the closed position with distention of the aortic root during cardioplegia solution infusion. The distended aortic valve cusp fills much of the VSD, and one can appreciate the mechanism by which aortic insufficiency develops in children with this anomaly. This child underwent concomitant aortic valvuloplasty.

aortic valve cusp

Figure 5-16. The aortic valve is in the closed position with distention of the aortic root during cardioplegia solution infusion. The distended aortic valve cusp fills much of the VSD, and one can appreciate the mechanism by which aortic insufficiency develops in children with this anomaly. This child underwent concomitant aortic valvuloplasty.

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Coronary Cusp Vsd

stretched and insufficient right coronary cusp non coronary cusp left coronary cusp

Figure 5-17. The proximal ascending aorta has been opened. The aortic valve is trileafed with normal left coronary and noncoronary cusps. A blunt sucker tip is placed in the sinus of Valsalva of the right coronary cusp, demonstrating the stretched and prolapsed cusp which allows aortic insufficiency.

stretched and insufficient right coronary cusp non coronary cusp

Figure 5-17. The proximal ascending aorta has been opened. The aortic valve is trileafed with normal left coronary and noncoronary cusps. A blunt sucker tip is placed in the sinus of Valsalva of the right coronary cusp, demonstrating the stretched and prolapsed cusp which allows aortic insufficiency.

caud left coronary cusp

Non Coronary Cusp

redundancy in right leaflet marking stitch in corpora arantil redundancy in right leaflet marking stitch in corpora arantil caud ceph

Figure 5-18. A marking stitch is passed through the corpora arantii of the left and noncoronary cusps. The free margin of the right coronary cusp is pulled toward the right-left cusp commissure to exclude redundancy in the cusp. The marking stitch is passed through the region of the right cusp adjacent to the other two corpora arantii. A second stitch is placed in the right-left cusp commissure, imbricating the redundant right cusp. The right coronary cusp is now supported and should not be insufficient.

Figure 5-18. A marking stitch is passed through the corpora arantii of the left and noncoronary cusps. The free margin of the right coronary cusp is pulled toward the right-left cusp commissure to exclude redundancy in the cusp. The marking stitch is passed through the region of the right cusp adjacent to the other two corpora arantii. A second stitch is placed in the right-left cusp commissure, imbricating the redundant right cusp. The right coronary cusp is now supported and should not be insufficient.

Kinematic Redundancy

two mattress stitches in redundant cusp competent right coronary cusp felted stitch on top of new commissure two mattress stitches in redundant cusp competent right coronary cusp

Figure 5-19. Two pledgeted mattress sutures are passed through the redundant right cusp tissue and through the aortic wall, firmly pressing the redundant tissue against the aortic wall. A third pledgeted mattress suture is placed over the top of the new right-left commissure. One arm of this mattress stitch passes through the right and left cusps, respectively, at the commissure. The other arm of the stitch passes to the child's left, through the full thickness of the aorta in the right cusp sinus of Valsalva at the commissure. It is passed through a second felt pledget and then from outside to within the aorta in the left cusp sinus of Valsalva at the commissure. Both arms of this stitch are then passed through the end of the original felt pledget that is used in the mattress suture. When it is tied, this stitch forms a buttress or support with the pledget on top of the new commissure. This prevents blood from dissecting behind the valve repair during diastole. The right coronary cusp is again probed with a blunt sucker tip to demonstrate its competency following obliteration of the prolapse.

The aorta is closed and attention is turned to repair of the VSD. The competency of the aortic valve can be observed while cardioplegia solution is injected in the aortic root and the aortic valve is viewed through the VSD. Later, during rewarming, when the aortic clamp has been removed, left ventricular vent return is again measured to determine presence or absence of significant aortic insufficiency.

felted stitch on top of new commissure

Sub Pulmonic Vsd

marking stitch in corpora arantii redundancy of left coronary cusp ceph caud

Figure 5-20. In another patient, the proximal ascending aorta has been opened. The aortic valve has three leaflets with distention and stretching of the left coronary cusp. A marking stitch is placed in the corpora arantii of the right and noncoronary cusps. The left cusp is pulled toward the patient's left and redundancy in this leaflet is seen at the right-left cusp commissure. The corpora arantii marking suture is then placed additionally in the adjacent region of the new left coronary cusp.

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aortic wall felted imbricating sutures

Figure 5-21. Two felted mattress sutures are placed in the redundant portion of the left coronary cusp. These are placed through the wall of the aorta and supported with additional pledgets before tying them outside the aorta. With such, the redundant portion of the leaflet is excluded from the valve apparatus and attached to the lateral aortic wall. The left coronary cusp is now the same size as the other two leaflets.

aortic wall felted imbricating sutures caud

Figure 5-21. Two felted mattress sutures are placed in the redundant portion of the left coronary cusp. These are placed through the wall of the aorta and supported with additional pledgets before tying them outside the aorta. With such, the redundant portion of the leaflet is excluded from the valve apparatus and attached to the lateral aortic wall. The left coronary cusp is now the same size as the other two leaflets.

felted stitch on top of commissure

Figure 5-22. A felted mattress suture is placed on top of the new left-right cusp commissure to prevent blood from dissecting behind the valve repair during diastole.

felted stitch on top of commissure

Figure 5-22. A felted mattress suture is placed on top of the new left-right cusp commissure to prevent blood from dissecting behind the valve repair during diastole.

Right Coronary Cuspid Valve

right coronary cusp

"wind sock" and fenestration

Figure 5-23. In another patient, the aortic valve is viewed through a proximal ascending aortotomy. A 1-mm probe is passed into the dilated central portion of the right coronary cusp. There is a discrete fenestration in the end of this wind sock.

right coronary cusp

Figure 5-23. In another patient, the aortic valve is viewed through a proximal ascending aortotomy. A 1-mm probe is passed into the dilated central portion of the right coronary cusp. There is a discrete fenestration in the end of this wind sock.

"wind sock" and fenestration

Fenestration Aortic Valve

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Figure 5-24. The valve cusp is lifted and the fenestration at the end of the wind sock in the right coronary cusp is seen.

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Figure 5-24. The valve cusp is lifted and the fenestration at the end of the wind sock in the right coronary cusp is seen.

Pledget Sutures
Figure 5-25. The cusp is repaired with a single pledgeted mattress suture placed across the fenestration on the upper surface of the right coronary cusp.
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Responses

  • d
    What is subpulmonary vsd?
    8 years ago
  • Thomas Ingram
    Where is the position of vsd that damages the aortic valve?
    8 years ago
  • Dominique
    What is subpulmonary defect?
    3 years ago
  • ambrogio
    What is pulmonary articlur ventrical septum defect?
    7 months ago

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