Supravalvar Stenosis

In the presence of this anomaly, there is usually a severe stenosing ring, at or immediately above the aortic valve commissures. A simple incision across the area of stenosis with patch angioplasty is often inadequate to relieve the obstruction. The stenosing ring must be incised into at least two sinuses of Valsalva. Three effective repair techniques are described.

Figure 14-29. An external view of the heart shows the narrow proximal ascending aorta at the site of supravalvar stenosis.

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Pulmonary Stenosis

supravalvar stenosing ring lower ends of inverted "Y" incision

Figure 14-30. After the cardiopulmonary bypass is established, with moderate hypothermia, aortic cross-clamping, cardioplegic arrest, and profound local cooling, an inverted Y incision is made in the ascending aorta. The stenosing supravalvar ring is seen.

supravalvar stenosing ring lower ends of inverted "Y" incision

Figure 14-30. After the cardiopulmonary bypass is established, with moderate hypothermia, aortic cross-clamping, cardioplegic arrest, and profound local cooling, an inverted Y incision is made in the ascending aorta. The stenosing supravalvar ring is seen.

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Aortic Stenosis Stenotic Ring

area of stenosing ring aortic valve lower ends of inverted "Y" Incision

Figure 14-31. The lower ends of the inverted Y incision are extended into the sinuses of Valsalva of the noncoronary and right coronary cusps, respectively.

area of stenosing ring aortic valve lower ends of inverted "Y" Incision

Figure 14-31. The lower ends of the inverted Y incision are extended into the sinuses of Valsalva of the noncoronary and right coronary cusps, respectively.

steno sing ring
Exposed Arteries

orifice of left coronary artery aortic valve cusp

Figure 14-32. The root of the aorta is exposed after completing the inverted Y incision. The stenosing supravalvar ring is immediately above the valve commissures. Normal valve leaflets are seen, and the orifice of the left coronary artery is located just beneath the ring. In some cases coronary stenosis occurs when fibrous tissue compromises the orifice.

orifice of left coronary artery aortic valve cusp

Figure 14-32. The root of the aorta is exposed after completing the inverted Y incision. The stenosing supravalvar ring is immediately above the valve commissures. Normal valve leaflets are seen, and the orifice of the left coronary artery is located just beneath the ring. In some cases coronary stenosis occurs when fibrous tissue compromises the orifice.

lower points of patch

Figure 14-33. A synthetic patch is tailored so that the lower points of the patch will fit in the opened sinuses of Valsalva.

lower points of patch

Figure 14-33. A synthetic patch is tailored so that the lower points of the patch will fit in the opened sinuses of Valsalva.

area of commissure

lower points of patch

Figure 14-34. The completed repair is seen after the patch is stitched in place with a continuous suture.

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Figure 14-34. The completed repair is seen after the patch is stitched in place with a continuous suture.

Junction Aorta
Figure 14-35. In another baby who has been placed on cardiopulmonary bypass, the area of supravalvar stenosis is in the typical position at the sino-tubular junction.
Aorta And Coronary Orifice

distal ascending aorta steno sing ring

Figure 14-36. The ascending aorta is divided at/or immediately above the stenosing ring. Care must be taken to avoid injury to the coronary artery orifices, which are below the ring.

distal ascending aorta steno sing ring

Figure 14-36. The ascending aorta is divided at/or immediately above the stenosing ring. Care must be taken to avoid injury to the coronary artery orifices, which are below the ring.

Right Coronary Artery

left coronary artery orifice sinus of Valsalva incisions right coronary artery orifice

Figure 14-37. Incisions are made in each of the three sinuses of Valsalva from the ring to near the annulus. The proximity of the coronary artery orifices is seen.

left coronary artery orifice sinus of Valsalva incisions right coronary artery orifice

Figure 14-37. Incisions are made in each of the three sinuses of Valsalva from the ring to near the annulus. The proximity of the coronary artery orifices is seen.

The Names Aortic Valve Leaflets

homograft patches aortic valve leaflets

Figure 14-38. Triangular-shaped tissue patches of homograft pulmonary wall are stitched over incisions in the left and right coronary cusp sinuses. The noncoronary cusp sinus remains open and a patch will be placed here to complete this part of the repair.

caud homograft patches

Figure 14-38. Triangular-shaped tissue patches of homograft pulmonary wall are stitched over incisions in the left and right coronary cusp sinuses. The noncoronary cusp sinus remains open and a patch will be placed here to complete this part of the repair.

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Homograft For Pulmonary Valve

homograft patch aortic anastomosis

Figure 14-39. A direct end-to end anastomosis is performed between the two aortic segments. Counter incisions in the upper aorta may be required due to the disparity in diameter of the two segments caused by adding the homograft patches.

homograft patch

Figure 14-39. A direct end-to end anastomosis is performed between the two aortic segments. Counter incisions in the upper aorta may be required due to the disparity in diameter of the two segments caused by adding the homograft patches.

aortic anastomosis

Pulmonary Artery Stenosis

Figure 14-40. In another infant, after establishing cardiopulmonary bypass with aortic clamping, cardioplegia, and profound local cooling, the supravalvar stenosis is seen at the sinotubular junction.

supravalvar stenosis

Figure 14-40. In another infant, after establishing cardiopulmonary bypass with aortic clamping, cardioplegia, and profound local cooling, the supravalvar stenosis is seen at the sinotubular junction.

Pulmonary Stenosis

Figure 14-41. The ascending aorta has been widely dissected including the arch for mobility because the anastomosis will shorten the ascending aorta. Here, it is divided immediately above the stenotic ring. Care must be taken to avoid injury to the coronary arteries, which originate below the ring.

stenosing ring

Figure 14-41. The ascending aorta has been widely dissected including the arch for mobility because the anastomosis will shorten the ascending aorta. Here, it is divided immediately above the stenotic ring. Care must be taken to avoid injury to the coronary arteries, which originate below the ring.

Figure 14-42. The ring is retracted to expose normal aortic valve leaflets and to view the coronary artery orifices.

aortic valve

Figure 14-42. The ring is retracted to expose normal aortic valve leaflets and to view the coronary artery orifices.

Sinu Valsalva Coronary Artery

sinus of Valsalva incisions caud

Figure 14-43. Incisions are made from the ring into each sinus of Valsalva to near the aortic valve annulus.

caud sinus of Valsalva incisions

Figure 14-43. Incisions are made from the ring into each sinus of Valsalva to near the aortic valve annulus.

incisions in distal aortic segment commissure

Figure 14-44. Longitudinal counter incisions are made in the upper aortic segment, each being opposite an aortic valve commissure.

incisions in distal aortic segment

Figure 14-44. Longitudinal counter incisions are made in the upper aortic segment, each being opposite an aortic valve commissure.

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Pulmonary Artery Segments

incision in distal aortic segment commissure

Figure 14-45. Each commissure will fit in an adjacent upper aortic longitudinal incision.

incision in distal aortic segment commissure

Figure 14-45. Each commissure will fit in an adjacent upper aortic longitudinal incision.

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primary aortic anastomosis

Figure 14-46. A direct end-to-end anastomosis is performed between the two aortic segments. With such, the area of previous stenosis has been opened widely by the incisions into each aortic segment.

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