Total Repair of Simple Tetralogy of Fallot Transventricular

Surgery is carried out with cardiopulmonary bypass, moderate hypothermia, aortic clamping with cardioplegia, and profound local cardiac cooling. Repair of pulmonary stenosis and the ventricular septal defect (VSD) are performed through a short high right ventriculotomy in the infundibulum, which is positioned to avoid division of coronary branches. If the pulmonary valve annulus is restrictive and a transannular patch is anticipated, a longitudinal or oblique ventriculotomy is made that is continuous with the transannular incision.

parieta band muscular

Infundibular floor parietal band septal band caud

Figure 9-14. A high right ventriculotomy is made over the infundibular chamber. The os infundibulum is small, and obstruction is due to prominent parietal and septal bands and a muscular infundibular floor.

Figure 9-15. A right-angle clamp is passed among trabeculations and beneath the parietal band; the band is lifted for improved exposure.

Figure 9-15. A right-angle clamp is passed among trabeculations and beneath the parietal band; the band is lifted for improved exposure.

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Anterior Muscular Vsd

Figure 9-16. The parietal band is excised by sharp dissection.

pari eta band

Infundibular Septum

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Figure 9-17. The septal band is probed and will be excised.

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Figure 9-17. The septal band is probed and will be excised.

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Anterior Inferior Septal Angle

muscular infundibular floor ventricular septal defecl

Figure 9-18. Much of the muscular infundibular floor is excised, and the high VSD is now exposed.

muscular infundibular floor ventricular septal defecl caud

Figure 9-18. Much of the muscular infundibular floor is excised, and the high VSD is now exposed.

Anterior Muscular Vsd

VSD rim near His' bundle anterior leaf of tricuspid valve septal leaf of tricuspid valve

Figure 9-19. Retracting sutures are placed in the septal and anterior leafs of the tricuspid valve. The posterior inferior rim of the VSD adjacent to the His' bundle is exposed.

VSD rim near His' bundle anterior leaf of tricuspid valve septal leaf of tricuspid valve

Figure 9-19. Retracting sutures are placed in the septal and anterior leafs of the tricuspid valve. The posterior inferior rim of the VSD adjacent to the His' bundle is exposed.

Anterior Muscular Vsd

remnant of membranous septum papillary muscle of theconus caud

Tetralogy Fallot Repair

corner stitch

Figure 9-21. The first closure stitch for the VSD repair is placed in the remnant of membranous septum at the posterior inferior corner. If this tissue is not present, the corner stitch is placed superficially in the rim of the VSD.

Interrupted mattress sutures with Teflon® felt pledgets are inserted along the inferior border of the VSD, placing each deeper in the septum on the right ventricular surface as one works more anteriorly and away from the His' bundle region. Stitches are placed similarly along the anterior rim of the VSD, incorporating approximately 50% of the thickness of the septum. Additional stitches are placed in the base of the anterior tricuspid valve leaflet, along the posterior rim of the VSD, and near the tricuspid annulus.

Figure 9-20. The posterior inferior rim of the VSD is probed with a right-angle clamp. A remnant of the membranous septum is present in this child and will be incorporated in the corner VSD closure stitch, which is adjacent to the His' bundle. The papillary muscle of the conus is adjacent to the mid part of the inferior rim of the VSD.

corner stitch caud

Figure 9-21. The first closure stitch for the VSD repair is placed in the remnant of membranous septum at the posterior inferior corner. If this tissue is not present, the corner stitch is placed superficially in the rim of the VSD.

Interrupted mattress sutures with Teflon® felt pledgets are inserted along the inferior border of the VSD, placing each deeper in the septum on the right ventricular surface as one works more anteriorly and away from the His' bundle region. Stitches are placed similarly along the anterior rim of the VSD, incorporating approximately 50% of the thickness of the septum. Additional stitches are placed in the base of the anterior tricuspid valve leaflet, along the posterior rim of the VSD, and near the tricuspid annulus.

Figure 9-20. The posterior inferior rim of the VSD is probed with a right-angle clamp. A remnant of the membranous septum is present in this child and will be incorporated in the corner VSD closure stitch, which is adjacent to the His' bundle. The papillary muscle of the conus is adjacent to the mid part of the inferior rim of the VSD.

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Anterior Muscular Vsd

probe

Dacron patch

Figure 9-22. A knitted Dacron® patch is cut which is slightly larger than the VSD and conforms to its shape. Sutures along three sides of the VSD are placed in the patch and tied. A 1-mm probe is used to gently probe the rim of the VSD from the left ventricular surface to search for residual openings beneath the patch; if these are found, additional repair sutures are placed.

probe

Dacron patch

Figure 9-22. A knitted Dacron® patch is cut which is slightly larger than the VSD and conforms to its shape. Sutures along three sides of the VSD are placed in the patch and tied. A 1-mm probe is used to gently probe the rim of the VSD from the left ventricular surface to search for residual openings beneath the patch; if these are found, additional repair sutures are placed.

Tetralogy Fallot Patch

VSD patch

Figure 9-23. The repair is completed by passing nonfelted mattress sutures through the patch and then through the remaining muscular floor of the infundibulum near the adjacent aortic valve annulus. These stitches are then passed through small felts and tied. The patch is again probed on the right ventricular surface with a 1-mm probe to search for residual openings.

VSD patch

Figure 9-23. The repair is completed by passing nonfelted mattress sutures through the patch and then through the remaining muscular floor of the infundibulum near the adjacent aortic valve annulus. These stitches are then passed through small felts and tied. The patch is again probed on the right ventricular surface with a 1-mm probe to search for residual openings.

9-2-1. Total Repair of Tetralogy of Fallot - Transatrial

I was originally interested in this technique of tetralogy repair for use in patients with an anomalous left anterior descending coronary artery that arose from the right coronary system and traversed the infundibular surface: however it is now easy to recognize there are many advantages of this exposure for use in all tetralogy repairs. The VSD is easily seen which expedites repair. Injury to the right ventricular outflow tract is less and the surgeon can more accurately gauge the size of the infundibulum to define obstructing muscle bundles while inspecting it from above. Even when a transannular patch is required, the ventriculotomy can be shorter and avoid injury to the anomalous coronary vessel. I now prefer this approach for repair of all patients with tetralogy of Fallot regardless of patient size and it is used in over 95% of repairs.

Figure 9-24. In this patient, the external appearance of the size of the pulmonary valve area indicated the annulus is normal; however, the main pulmonary artery is hypoplastic.

Pulmonary Valve Annulus

main pulmonary artery pulmonary valve annulus

Figure 9-24. In this patient, the external appearance of the size of the pulmonary valve area indicated the annulus is normal; however, the main pulmonary artery is hypoplastic.

main pulmonary artery pulmonary valve annulus

Figure 9-25. After establishing bypass and car-dioplegic arrest, the right atrium is open. The tricuspid valve is retracted and the obstructing muscle bundles in the floor and roof as well as the parietal band region are exposed.

Hypoplastic Muscle

muscle roof and parietal band muscle floor anterior tricuspid valve leaf

Figure 9-25. After establishing bypass and car-dioplegic arrest, the right atrium is open. The tricuspid valve is retracted and the obstructing muscle bundles in the floor and roof as well as the parietal band region are exposed.

muscle roof and parietal band muscle floor anterior tricuspid valve leaf

Septal Band Right Ventricle

ventricular septal delect caud

Figure 9-26. Obstructing muscle bands are grasped and excised.

ventricular septal delect caud

Figure 9-26. Obstructing muscle bands are grasped and excised.

Ventricular Septal Defect Repair

ventricular septal defect

Figure 9-27. The VSD is in the perimembranous position.

ventricular septal defect

Figure 9-27. The VSD is in the perimembranous position.

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Anterior Muscular Vsd

anterior leaf web of septal tissue in posterior inferior corner septal leaf

Figure 9-28. The web of septal tissue in the posterior inferior corner of the VSD is exposed. This will be used in repair of the defect in order to avoid placing deep stitches in this area which might damage the His' bundle.

anterior leaf web of septal tissue in posterior inferior corner septal leaf caud

Figure 9-28. The web of septal tissue in the posterior inferior corner of the VSD is exposed. This will be used in repair of the defect in order to avoid placing deep stitches in this area which might damage the His' bundle.

Tetralogy Fallot Patch

anterior leaf

Figure 9-29. Multiple stitches are placed in the rim of the VSD and these are attached to a Dacron® patch. Along the posterior rim of the VSD, stitches are passed through the base of the anterior tricuspid valve leaflet.

anterior leaf

Figure 9-29. Multiple stitches are placed in the rim of the VSD and these are attached to a Dacron® patch. Along the posterior rim of the VSD, stitches are passed through the base of the anterior tricuspid valve leaflet.

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Transatrial Vsd Closure

Figure 9-30. All stitches are tied to secure the Dacron® patch.

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Figure 9-30. All stitches are tied to secure the Dacron® patch.

Transannular Patch Fallot

Figure 9-31. An incision is made in the main pulmonary artery from distally to the valve annulus proximally. Pulmonary valve leaflets are thickened and there is commissural stenosis.

pulmonary valve

Figure 9-31. An incision is made in the main pulmonary artery from distally to the valve annulus proximally. Pulmonary valve leaflets are thickened and there is commissural stenosis.

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Strata Shunt Valve

valve leaf annulus

Figure 9-32. A large pulmonary valve leaflet is exposed for a commissurotomy.

valve leaf annulus caud

Figure 9-32. A large pulmonary valve leaflet is exposed for a commissurotomy.

Stenotic Pulmonary Valve Annulus

commissure

Figure 9-33. The commissurotomy is complete.

commissure caud

Figure 9-33. The commissurotomy is complete.

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Complete Repair Tetralogy Fallot

septal band and floor muscle

Figure 9-34. Through this exposure, additional muscle in the infundibulum is identified and resected.

septal band and floor muscle caud

Figure 9-34. Through this exposure, additional muscle in the infundibulum is identified and resected.

Infundibulum Artrie

Figure 9-35. A widely patent infundibulum is seen.

infundibulum

Figure 9-35. A widely patent infundibulum is seen.

Double Chamber Right Ventricle Repair
Figure 9-36. The outflow tract is viewed again through the tricuspid valve as a final check for obstructing muscle bundles. The main pulmonary artery is then reconstructed with a patch and the atriotomy closed to complete the repair.
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