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Centro Cardiovascular Pediátrico Clínica Santa María Santiago Chile Dr Luis León M. Dr Stephan Haecker D. Dr Daniel Pérez I. www.cardiopatiascongenitas.cl. VSD PATCH ANNULOPLASTY. FOR COMPLETE ATRIOVENTRICULAR SEPTAL DEFECT. ¿ which goals does a good surgical technique achieve ?.

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Cardiopatiascongenitas cl

Centro Cardiovascular Pediátrico

Clínica Santa María

Santiago Chile

Dr Luis León M.

Dr Stephan Haecker D.

Dr Daniel Pérez I.

www.cardiopatiascongenitas.cl


Cardiopatiascongenitas cl

VSD PATCH ANNULOPLASTY

FOR

COMPLETE

ATRIOVENTRICULAR

SEPTAL DEFECT

¿ which goals does

a good surgical technique

achieve ?


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CAVSD:

Inlet VSD

Primum ASD

Common AV valve


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Type A CAVSD:

Common AV valve with chordae inserting on the VSD crest,

and divided leaflets


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Type C CAVSD:

Common AV valve with anterior and posterior bridging leaflets


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In type C bridging leaflets are surgically divided


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The inlet VSD is occluded with a properly shaped patch


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Leaflets are sutured to the upper border

Of the VSD patch


A second patch closes the atrial septal defect

A second patch closes the atrial septal defect


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SURGICAL ISSUES

Distortion of the mitral valve


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After the VSD is closed the new mitral valve has three leaflets:

a mural leaflet

and two hemi bridging leaflets

Syringe flushing of saline will float these leaflets

to a closed position. This isn´t the same as in

a beating heart, since it is in a cardioplegic state.


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Floating shows us the diastolic geometry of the mitral valve


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The area where leaflets become in contact with each other

is the coaptation zone

also called the “kissing edge”


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Floating leaflets reach into each other and

touch in the coaptation zone, in red

This makes a competent mitral valve


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¿ how does surgery alter the mitral valve ?

Suturing the leaflets to the VSD patch uses 2 or 3 mm

of valve tissue


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Floating will show minor leaking along the mural border


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A VSD patch which is higher than the valve uses more

valve tissue and shortens both hemileaflets even more


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There is more leaking along the mural border

and central area


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Again, a high VSD patch tethers the leaflet tissue and

loses the coaptation border as shown


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An excessively long VSD patch brings the hemileaflets apart

valve area is larger

hemileaflets lose their coaptation border along the

mitral cleft


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Suturing the mitral cleft becomes mandatory


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Leaflets will be subject to greater tension

due to a larger annulus

They will lose mobility


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and they will cover less area


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Again this will result in incompetence due to loss of

coaptation zone


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In the end leaflets will need to be approximated

by means of additional commisuroplasties

This is like using the accelerator,

and then applying your brakes to save the situation


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SURGICAL ISSUES

Distortion of the coaptation border


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Dividing the anterior bridging leaflet in type C CAVSD

leaves us with two hemleaflets


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And two more after divididing the posterior bridging leaflet


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Floating shows the divided leaflets in good contact

A wide coaptation border results in a competent mechanism


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suturing the free border of the mitral cleft

distorts normal function

and puts tension on the subvalvar chordae

this is not an uncommon mistake


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CHANGES OCCURRING

IN THE

BEATING HEART


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The

Common AV valve in motion


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In the normal heart mitral and tricuspid valves have

independent valve rings


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During ventricular systole both AV valves will close


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Valve rings are dilated in diastole


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And they become smaller in systole


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there is a common AV valve ring in CAVSD

whether type A or C


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The common AV ring is dilated in diastole


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But it becomes smaller in systole


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SURGICAL ISSUES

The surgically created mitral ring


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Let us look at mitral ring geometry

after our intervention

We have placed our VSD patch to the right

of the ventricular septum and given some more

valve tissue to the mitral valve


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In the cardioplegic heart the patch looks centered

The new mitral ring is outlined in white


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¿ what about systole ?

In the beating heart the mitral annulus acquires

a new geometry

It shortens along the ventricular wall

but it bulges along the septum


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¿ what have we produced ?

¡ an entirely new mitral ring geometry !


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Hemileaflets are pulled to the right side

Hemileaflets lose their coaptation with the mural leaflet


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Having said all this:

MY FAVORED

SURGICAL

TECHNIQUE


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Both cavae are cannulated so as to have the right atrium

fully exposed

The often patent duct is always dissected and interrupted

on bypass, an LV vent is placed in the LA away from

the common AV valve


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Step One: asigning valve tissue to mitral and tricuspid valves

the VSD patch will be placed to the right side of the septum,

the valve is floated and a division line is proposed


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The kissing points of the anterior and posterior bridging leaflets

are then marked


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Step Two: achieving kissing point marks

This is the key issue towards obtaining a perfect mitral valve


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marking the kissing points with a closed valve

requires some patience


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I float and check my marks

I can pass a second sitch improving on my first one


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Fine traction sutures are placed on the tricuspid side


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Step Three:

Mitral annuloplasty with the VSD patch

Here the issue is obtaining the:

BEST POSSIBLE GEOMETRY

OF THE

MITRAL RING

DURING SYSTOLE


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The kissing points stitch is taken a few milimeters wider

so as to increase the coaptation border

and slightly reduce the valve free border length


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The glutaraldehyde fixed pericardial patch is cut

to the right height

and the right length and shape


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This is the usual shape


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…and now we will proceed to reduce its length

by 25%, that is 2 or 3 milimeters on each side,

but not its height !


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Thus reducing the mitral ring in the septum only


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Thus reducing the mitral ring in the septum only


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a standard patch results in abnormal geometry

of the mitral ring during systole


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therefore requiring active annulus reduction in

the usual fashion

¿ does this look familiar to you ?


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Septal reduction annuloplasty

with the VSD patch

Achieves the best possible mitral ring geometry

in the beating heart


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In 70% of cases floating reveals a perfectly competent

Mitral valve

ASD closure is completed with a second patch

reinforcing the patch/valve suture


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Goals achieved:

Keeps it simple

Adequate for small babies

Short operating times

Best postoperative course and survival

Good intermediate term results


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Very Early Surgical Repair in Complete Atrioventricular Septal Defect

METODOLOGY: A descriptive and retrospective study. Between January 2006 and December 2008, 24 patients with Complete AVSD underwent definitive repair. One exception had PA banding, then subsequent OHS. In this series, one patient with Heterotaxy Syndrome and two patients with AVSD and Fallot was excluded.


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Centro Cardiovascular Pediátrico

Clínica Santa María

Santiago Chile

Dr Luis León M.

Dr Stephan Haecker D.

Dr Daniel Pérez I.

www.cardiopatiascongenitas.cl


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