Total Repair

Median Sterotomy Aortic

atretic outflow tract atretic outflow tract

ventricular septal defect caud

Figure 11-1. Working through a median sternotomy, cardiopulmonary bypass is established. Repair is carried out with aortic clamping, cardioplegia, and profound local cardiac cooling. A high longitudinal right ventriculotomy is made extending cephalad into the outflow tract chamber which is atretic at its upper end. The ventricular septal defect (VSD) is subcristal and nonrestrictive.

caud ventricular septal defect

Figure 11-1. Working through a median sternotomy, cardiopulmonary bypass is established. Repair is carried out with aortic clamping, cardioplegia, and profound local cardiac cooling. A high longitudinal right ventriculotomy is made extending cephalad into the outflow tract chamber which is atretic at its upper end. The ventricular septal defect (VSD) is subcristal and nonrestrictive.

aortic valve anterior leaf of tricuspid valve anterior leaf of tricuspid valve ceph caud

Figure 11-2. The VSD is retracted anteriorly, and the aortic valve is seen. Typically, this valve is equally related to right and left ventricles. Multiple interrupted felted mattress sutures are placed around the rim of the VSD. Stitches in the posterior inferior corner of the defect are placed superficially in the rim to avoid damage to the His' bundle. With location of the aortic valve partly over the right ventricle, the distance between the posterior inferior corner of the VSD and the cephalad margin of the aortic valve is great and requires multiple sutures to close the VSD with the Dacron® baffle.

Figure 11-2. The VSD is retracted anteriorly, and the aortic valve is seen. Typically, this valve is equally related to right and left ventricles. Multiple interrupted felted mattress sutures are placed around the rim of the VSD. Stitches in the posterior inferior corner of the defect are placed superficially in the rim to avoid damage to the His' bundle. With location of the aortic valve partly over the right ventricle, the distance between the posterior inferior corner of the VSD and the cephalad margin of the aortic valve is great and requires multiple sutures to close the VSD with the Dacron® baffle.

Stitch Close Vsd

ceph

Stitch Close Vsd

Figure 11-3. Stitches are placed in a rectangular-shaped patch of knitted Dacron® and tied. The length of the patch is in the transverse plane and creates a tunnel or baffle that connects the left ventricle to the aortic valve.

anterior leaf of tricuspid valve

Figure 11-3. Stitches are placed in a rectangular-shaped patch of knitted Dacron® and tied. The length of the patch is in the transverse plane and creates a tunnel or baffle that connects the left ventricle to the aortic valve.

Pulmonary Infundibulum

main pulmonary artery region of outflow tract atresia infundibulum

Figure 11-4. There is tissue continuity between the infundibulum and the main pulmonary artery. The right ventriculotomy is extended across the area of outflow tract atresia and onto the proximal main pulmonary artery.

main pulmonary artery region of outflow tract atresia

Figure 11-4. There is tissue continuity between the infundibulum and the main pulmonary artery. The right ventriculotomy is extended across the area of outflow tract atresia and onto the proximal main pulmonary artery.

infundibulum caud

Pulmonary Infundibulum

pericardial patch

Figure 11-5. Vascular continuity between the right ventricle and main pulmonary artery is established by placing a pericardial outflow tract patch over the high ventriculotomy, the area of atresia, and the proximal main pulmonary artery. Pericardium is used here because of its hemostatic qualities. A patch of Gore-Tex® or homograft pulmonary artery wall may be used and avoids the risk of late development of a pericardial patch aneurysm.

pericardial patch caud

Figure 11-5. Vascular continuity between the right ventricle and main pulmonary artery is established by placing a pericardial outflow tract patch over the high ventriculotomy, the area of atresia, and the proximal main pulmonary artery. Pericardium is used here because of its hemostatic qualities. A patch of Gore-Tex® or homograft pulmonary artery wall may be used and avoids the risk of late development of a pericardial patch aneurysm.

Pericardial Hood

Dacron cover

Figure 11-6. A Dacron® patch cover is stitched over the pericardial outflow tract patch. Dense scar tissue will eventually engulf the Dacron® and form a supporting buttress over the pericardial patch. This technique is used to avoid late patch aneurysm formation.

Dacron cover

Figure 11-6. A Dacron® patch cover is stitched over the pericardial outflow tract patch. Dense scar tissue will eventually engulf the Dacron® and form a supporting buttress over the pericardial patch. This technique is used to avoid late patch aneurysm formation.

Pericardial Hood Patch

ascending aorta main pulmonary artery

Figure 11-7. In another patient, there is proximal atresia and severe hypoplasia of the main pulmonary artery.

ascending aorta main pulmonary artery

Figure 11-7. In another patient, there is proximal atresia and severe hypoplasia of the main pulmonary artery.

Atresia Pulmonary Artery

ventriculotomy

Figure 11-8. An oblique high right ventriculotomy is made in a location to avoid injury to surrounding coronary arteries. Hypertrophied myocardium at the ventriculotomy is excised.

Pulmonary Arteries Location

ventricular septal defect

Figure 11-9. A large VSD is exposed.

ventriculotomy ventricular septal defect

Figure 11-9. A large VSD is exposed.

Figure 11-8. An oblique high right ventriculotomy is made in a location to avoid injury to surrounding coronary arteries. Hypertrophied myocardium at the ventriculotomy is excised.

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Cardio Patch Dacron

Dacron patch

Figure 11-10. Repair sutures are placed in a rectangular-shaped Dacron® patch.

Dacron patch caud

Figure 11-10. Repair sutures are placed in a rectangular-shaped Dacron® patch.

Figure Arteries
Figure 11-11. Stitches are tied orienting the length of the rectangular patch transversely to connect the left ventricular flow tract to the aortic valve.
Figure Arteries
Figure 11-12. Ventricular septal defect closure is completed by passing additional stitches through the upper rim of the patch and then through the floor of the outflow tract.

homograft wall patch left pulmonary-artery main pulmonary artery

Pulmonary Artery

homograft wall patch left pulmonary-artery main pulmonary artery

Figure 11-13. In this patient, there is stenosis of the proximal left pulmonary artery. An incision is made across the area of stenosis and a homograft wall patch is applied to this area.

Figure 11-13. In this patient, there is stenosis of the proximal left pulmonary artery. An incision is made across the area of stenosis and a homograft wall patch is applied to this area.

homograft wall patch

Homograft Valve Conduit

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Figure 11-14. Sutures have been placed in the triangular-shaped homograft wall patch to cover the incision in the left pulmonary artery.

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Figure 11-14. Sutures have been placed in the triangular-shaped homograft wall patch to cover the incision in the left pulmonary artery.

Homograft Valve Conduit

homograft wall patch left pulmonary artery homograft wall patch left pulmonary artery

Homograft Valve Conduit
Figure 11-15. There is adequate relief of the area of stenosis after placement of the patch.

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Pulmonary Homograft Images

homograft conduit homograft valve posterior suture

Figure 11-16. To establish vascular continuity from the right ventricle to the pulmonary artery, a valved aortic homograft with attached ascending aorta and mitral leaflet is used. The homograft is oriented so that the mitral leaflet of the graft is placed anteriorly. Graft placement is begun by stitching the posterior muscle bar below the homograft valve annulus to the native right ventricular outflow tract.

homograft conduit homograft valve posterior suture caud

Figure 11-16. To establish vascular continuity from the right ventricle to the pulmonary artery, a valved aortic homograft with attached ascending aorta and mitral leaflet is used. The homograft is oriented so that the mitral leaflet of the graft is placed anteriorly. Graft placement is begun by stitching the posterior muscle bar below the homograft valve annulus to the native right ventricular outflow tract.

Mitral Kapak Anterior Posterior

anterior mitral leaf of homograft posterior suture

Figure 11-17. The posterior muscle bar suture line is completed and tied at each corner.

anterior mitral leaf of homograft posterior suture

Figure 11-17. The posterior muscle bar suture line is completed and tied at each corner.

Valved Aortic Homograft Conduit

reconstructed left pulmonary artery distal suture homograft conduit

Figure 11-18. The homograft conduit is positioned with the curve of the homograft extending toward the left chest. The inner curve of the conduit hugs the lateral border of the heart. The distal conduit is cut to an appropriate length. Before this final tailoring maneuver, it is advantageous to momentarily release the aortic cross-clamp to allow the ascending aorta and the coronaries to fill. At this point, one can more accurately determine the correct length of conduit needed. The distal suture line is placed within the distal main pulmonary artery but proximal to the pulmonary artery branches.

reconstructed left pulmonary artery distal suture caud homograft conduit

Figure 11-18. The homograft conduit is positioned with the curve of the homograft extending toward the left chest. The inner curve of the conduit hugs the lateral border of the heart. The distal conduit is cut to an appropriate length. Before this final tailoring maneuver, it is advantageous to momentarily release the aortic cross-clamp to allow the ascending aorta and the coronaries to fill. At this point, one can more accurately determine the correct length of conduit needed. The distal suture line is placed within the distal main pulmonary artery but proximal to the pulmonary artery branches.

homograft conduit

anterior mitral leaf of homograft

Figure 11-19. The anterior part of the distal suture line is placed on the anterior surface of the pulmonary artery to avoid narrowing of the distal anastomosis.

anterior mitral leaf of homograft

Figure 11-19. The anterior part of the distal suture line is placed on the anterior surface of the pulmonary artery to avoid narrowing of the distal anastomosis.

Pulmonary Homograft Images

homograft conduit anterior mitral leaf of homograft

Figure 11-20. The anterior mitral leaf of the homograft conduit is stitched to the anterior rim of the ventriculotomy, creating a hood that allows the homograft valve to assume a natural position. This helps to avoid homograft valve annulus distortion and valve regurgitation postoperatively.

homograft conduit anterior mitral leaf of homograft

Figure 11-20. The anterior mitral leaf of the homograft conduit is stitched to the anterior rim of the ventriculotomy, creating a hood that allows the homograft valve to assume a natural position. This helps to avoid homograft valve annulus distortion and valve regurgitation postoperatively.

Tetralogy Fallot Repair
Figure 11-21. After completing homograft conduit placement, the left pericardium may be opened to allow the conduit to rest in the left chest. This avoids compression of the conduit by the sternum when the latter is closed.
Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

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