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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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slide1

Centro Cardiovascular Pediátrico

Clínica Santa María

Santiago Chile

Dr Luis León M.

Dr Stephan Haecker D.

Dr Daniel Pérez I.

www.cardiopatiascongenitas.cl

slide2

VSD PATCH ANNULOPLASTY

FOR

COMPLETE

ATRIOVENTRICULAR

SEPTAL DEFECT

¿ which goals does

a good surgical technique

achieve ?

slide3

CAVSD:

Inlet VSD

Primum ASD

Common AV valve

slide4

Type A CAVSD:

Common AV valve with chordae inserting on the VSD crest,

and divided leaflets

slide5

Type C CAVSD:

Common AV valve with anterior and posterior bridging leaflets

slide10

SURGICAL ISSUES

Distortion of the mitral valve

slide11

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.

slide13

The area where leaflets become in contact with each other

is the coaptation zone

also called the “kissing edge”

slide14

Floating leaflets reach into each other and

touch in the coaptation zone, in red

This makes a competent mitral valve

slide15

¿ how does surgery alter the mitral valve ?

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

of valve tissue

slide17

A VSD patch which is higher than the valve uses more

valve tissue and shortens both hemileaflets even more

slide19

Again, a high VSD patch tethers the leaflet tissue and

loses the coaptation border as shown

slide20

An excessively long VSD patch brings the hemileaflets apart

valve area is larger

hemileaflets lose their coaptation border along the

mitral cleft

slide22

Leaflets will be subject to greater tension

due to a larger annulus

They will lose mobility

slide25

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

slide27

SURGICAL ISSUES

Distortion of the coaptation border

slide30

Floating shows the divided leaflets in good contact

A wide coaptation border results in a competent mechanism

slide31

suturing the free border of the mitral cleft

distorts normal function

and puts tension on the subvalvar chordae

this is not an uncommon mistake

slide32

CHANGES OCCURRING

IN THE

BEATING HEART

slide33

The

Common AV valve in motion

slide41

SURGICAL ISSUES

The surgically created mitral ring

slide43

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

slide44

In the cardioplegic heart the patch looks centered

The new mitral ring is outlined in white

slide45

¿ 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

slide46

¿ what have we produced ?

¡ an entirely new mitral ring geometry !

slide47

Hemileaflets are pulled to the right side

Hemileaflets lose their coaptation with the mural leaflet

slide48

Having said all this:

MY FAVORED

SURGICAL

TECHNIQUE

slide49

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

slide50

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

slide52

Step Two: achieving kissing point marks

This is the key issue towards obtaining a perfect mitral valve

slide54

I float and check my marks

I can pass a second sitch improving on my first one

slide59

Step Three:

Mitral annuloplasty with the VSD patch

Here the issue is obtaining the:

BEST POSSIBLE GEOMETRY

OF THE

MITRAL RING

DURING SYSTOLE

slide60

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

slide61

The glutaraldehyde fixed pericardial patch is cut

to the right height

and the right length and shape

slide63

…and now we will proceed to reduce its length

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

but not its height !

slide66

a standard patch results in abnormal geometry

of the mitral ring during systole

slide67

therefore requiring active annulus reduction in

the usual fashion

¿ does this look familiar to you ?

slide68

Septal reduction annuloplasty

with the VSD patch

Achieves the best possible mitral ring geometry

in the beating heart

slide69

In 70% of cases floating reveals a perfectly competent

Mitral valve

ASD closure is completed with a second patch

reinforcing the patch/valve suture

slide70

Goals achieved:

Keeps it simple

Adequate for small babies

Short operating times

Best postoperative course and survival

Good intermediate term results

slide71

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.

slide72

Centro Cardiovascular Pediátrico

Clínica Santa María

Santiago Chile

Dr Luis León M.

Dr Stephan Haecker D.

Dr Daniel Pérez I.

www.cardiopatiascongenitas.cl