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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. VSD PATCH ANNULOPLASTY. FOR COMPLETE ATRIOVENTRICULAR SEPTAL DEFECT. ¿ which goals does a good surgical technique achieve ?.

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cardiopatiascongenitas.cl

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  1. Centro Cardiovascular Pediátrico Clínica Santa María Santiago Chile Dr Luis León M. Dr Stephan Haecker D. Dr Daniel Pérez I. www.cardiopatiascongenitas.cl

  2. VSD PATCH ANNULOPLASTY FOR COMPLETE ATRIOVENTRICULAR SEPTAL DEFECT ¿ which goals does a good surgical technique achieve ?

  3. CAVSD: Inlet VSD Primum ASD Common AV valve

  4. Type A CAVSD: Common AV valve with chordae inserting on the VSD crest, and divided leaflets

  5. Type C CAVSD: Common AV valve with anterior and posterior bridging leaflets

  6. In type C bridging leaflets are surgically divided

  7. The inlet VSD is occluded with a properly shaped patch

  8. Leaflets are sutured to the upper border Of the VSD patch

  9. A second patch closes the atrial septal defect

  10. SURGICAL ISSUES Distortion of the mitral valve

  11. 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.

  12. Floating shows us the diastolic geometry of the mitral valve

  13. The area where leaflets become in contact with each other is the coaptation zone also called the “kissing edge”

  14. Floating leaflets reach into each other and touch in the coaptation zone, in red This makes a competent mitral valve

  15. ¿ how does surgery alter the mitral valve ? Suturing the leaflets to the VSD patch uses 2 or 3 mm of valve tissue

  16. Floating will show minor leaking along the mural border

  17. A VSD patch which is higher than the valve uses more valve tissue and shortens both hemileaflets even more

  18. There is more leaking along the mural border and central area

  19. Again, a high VSD patch tethers the leaflet tissue and loses the coaptation border as shown

  20. An excessively long VSD patch brings the hemileaflets apart valve area is larger hemileaflets lose their coaptation border along the mitral cleft

  21. Suturing the mitral cleft becomes mandatory

  22. Leaflets will be subject to greater tension due to a larger annulus They will lose mobility

  23. and they will cover less area

  24. Again this will result in incompetence due to loss of coaptation zone

  25. 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

  26. SURGICAL ISSUES Distortion of the coaptation border

  27. Dividing the anterior bridging leaflet in type C CAVSD leaves us with two hemleaflets

  28. And two more after divididing the posterior bridging leaflet

  29. Floating shows the divided leaflets in good contact A wide coaptation border results in a competent mechanism

  30. suturing the free border of the mitral cleft distorts normal function and puts tension on the subvalvar chordae this is not an uncommon mistake

  31. CHANGES OCCURRING IN THE BEATING HEART

  32. The Common AV valve in motion

  33. In the normal heart mitral and tricuspid valves have independent valve rings

  34. During ventricular systole both AV valves will close

  35. Valve rings are dilated in diastole

  36. And they become smaller in systole

  37. there is a common AV valve ring in CAVSD whether type A or C

  38. The common AV ring is dilated in diastole

  39. But it becomes smaller in systole

  40. SURGICAL ISSUES The surgically created mitral ring

  41. 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

  42. In the cardioplegic heart the patch looks centered The new mitral ring is outlined in white

  43. ¿ 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

  44. ¿ what have we produced ? ¡ an entirely new mitral ring geometry !

  45. Hemileaflets are pulled to the right side Hemileaflets lose their coaptation with the mural leaflet

  46. Having said all this: MY FAVORED SURGICAL TECHNIQUE

  47. 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

  48. 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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