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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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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 ?


CAVSD:

Inlet VSD

Primum ASD

Common AV valve


Type A CAVSD:

Common AV valve with chordae inserting on the VSD crest,

and divided leaflets


Type C CAVSD:

Common AV valve with anterior and posterior bridging leaflets






SURGICAL ISSUES

Distortion of the mitral valve


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.


Floating shows us the leaflets:diastolic geometry of the mitral valve


The area where leaflets become in contact with each other leaflets:

is the coaptation zone

also called the “kissing edge”


Floating leaflets reach into each other and leaflets:

touch in the coaptation zone, in red

This makes a competent mitral valve


¿ how does surgery alter the mitral valve ? leaflets:

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

of valve tissue



A VSD patch which is leaflets: higher than the valve uses more

valve tissue and shortens both hemileaflets even more



Again, a high VSD patch tethers the leaflet tissue and leaflets:

loses the coaptation border as shown


An leaflets:excessively long VSD patch brings the hemileaflets apart

valve area is larger

hemileaflets lose their coaptation border along the

mitral cleft



Leaflets will be subject to greater tension leaflets:

due to a larger annulus

They will lose mobility




In the end leaflets will need to be approximated leaflets:

by means of additional commisuroplasties

This is like using the accelerator,

and then applying your brakes to save the situation


SURGICAL ISSUES leaflets:

Distortion of the coaptation border


Dividing the anterior bridging leaflet in type C CAVSD leaflets:

leaves us with two hemleaflets



Floating shows the divided leaflets in good contact leaflets:

A wide coaptation border results in a competent mechanism


suturing the free border of the mitral cleft leaflets:

distorts normal function

and puts tension on the subvalvar chordae

this is not an uncommon mistake


CHANGES OCCURRING leaflets:

IN THE

BEATING HEART


The leaflets:

Common AV valve in motion






there is a common AV valve ring in CAVSD leaflets:

whether type A or C




SURGICAL ISSUES leaflets:

The surgically created mitral ring


Let us look at leaflets: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


In the cardioplegic heart the patch looks centered leaflets:

The new mitral ring is outlined in white


¿ what about systole ? leaflets:

In the beating heart the mitral annulus acquires

a new geometry

It shortens along the ventricular wall

but it bulges along the septum


¿ what have we produced ? leaflets:

¡ an entirely new mitral ring geometry !


Hemileaflets are pulled to the right side leaflets:

Hemileaflets lose their coaptation with the mural leaflet


Having said all this: leaflets:

MY FAVORED

SURGICAL

TECHNIQUE


Both cavae are cannulated so as to have the right atrium leaflets:

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


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



Step Two: achieving kissing point marks leaflets

This is the key issue towards obtaining a perfect mitral valve


marking the kissing points with a closed valve leaflets

requires some patience


I float and check my marks leaflets

I can pass a second sitch improving on my first one



Step Three: leaflets

Mitral annuloplasty with the VSD patch

Here the issue is obtaining the:

BEST POSSIBLE GEOMETRY

OF THE

MITRAL RING

DURING SYSTOLE


The kissing points stitch is taken a few milimeters wider leaflets

so as to increase the coaptation border

and slightly reduce the valve free border length


The glutaraldehyde fixed pericardial patch is cut leaflets

to the right height

and the right length and shape



…and now we will proceed to reduce its length leaflets

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

but not its height !




a standard patch results in abnormal geometry leaflets

of the mitral ring during systole


therefore requiring active annulus reduction in leaflets

the usual fashion

¿ does this look familiar to you ?


Septal reduction annuloplasty leaflets

with the VSD patch

Achieves the best possible mitral ring geometry

in the beating heart


In 70% of cases floating reveals a perfectly competent leaflets

Mitral valve

ASD closure is completed with a second patch

reinforcing the patch/valve suture


Goals achieved: leaflets

Keeps it simple

Adequate for small babies

Short operating times

Best postoperative course and survival

Good intermediate term results


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.


Centro Cardiovascular Pediátrico Septal Defect

Clínica Santa María

Santiago Chile

Dr Luis León M.

Dr Stephan Haecker D.

Dr Daniel Pérez I.

www.cardiopatiascongenitas.cl


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