Preface - bücher.de · caud ceph FIGURE 14-17. The area of resection is wide to ensure relief of the obstruction. 14-2-1. Anomalous Mitral Valve Papillary Muscle 254 Color Atlas

Preface

Because of the wide variety of anomalies encountered in congenital heartsurgery, a broad understanding of the pathologic anatomy of defects is vitallyimportant to the surgeon. More than in many other fields of surgery, a feel forthree-dimensional spatial relationships of anomalies is helpful in allowing theoperating surgeon to improvise technical details of a procedure. Precisely shapingand sizing an intraventricular baffle or patch, or correctly placing a long intra-atrial suture can make the difference between a successful and an unsuccessfulsurgical outcome.

The congenital heart surgeon is a student during his or her entire careerbecause he or she encounters so many different anomalies. Learning from theexperience of others should always be part of the clinician’s education; this is bestdone by personally observing an operation performed by another. Otherwise, thebest record of a procedure is a good operative photograph.

For over 35 years it has been my practice to photograph most operations.Theseillustrations comprise a valuable part of each patient’s record and are informa-tive as a review of previous surgery and observed anatomy if future surgery isplanned. The illustrations also serve to inform the referring doctor of details ofsurgery and this may also improve patient care.

The photographs have been an invaluable teaching aid for lectures,journal publications, and this book. I hope this atlas will be of interest to full-time or part-time congenital heart surgeons, pediatric and adult cardiologists,intensivists, pediatricians, internists, and all other students of congenital heartdisease.

In this second edition, I have added many new sections, deleted a few obsolete sections, and in some areas changed the format. For example, the atrialswitch operation has been moved to Chapter 16, l-Transposition of the Great Arteries (l-TGA). It is no longer used in the repair of d-transposition ofthe great arteries (d-TGA), but is applicable for the double-switch operation for l-TGA.

Photographs were taken with a Nikon F camera, usually using a Nikon 55-mmmacro lens (Figure P-1). For some close-up pictures of the right and left ventric-ular outflow tracts, a Nikon 100-mm medical lens was used (Figure P-2). Pictureswere taken at f8 to f11 at a distance of 9 to 12 inches from the field.

Lighting for most photographs was augmented with a side-mounted Honey-well Strobonar flash with a wide-angle neutral density filter (Figures P-1, P-2).Using a side-mounted flash, rather than a more traditional ring light (surround-ing the lens), has resulted in some shadows in each picture, which improves theperception of depth of field. More recently, I have used a ring light mounted onthe front of the lens. No special effort has been made to use the operating roomlights or to move them out of the field.

ix

Photographs were taken from behind the patient when surgery was performedthrough a lateral thoracotomy and from the head of the operating room tablefor a median sternotomy.

For orientation, pictures in this atlas are marked with arrows to indicate R,right side of patient; L, left side of patient; Cep, cephalad; Caud, caudad; Ant,anterior; and Post, posterior.

S. Bert Litwin, MD

x Preface

FIGURE P-2. Nikon camera with 100-mm macro lens attached for close-up views. A sportsviewer is used, and the position of the light source is at the side of the lens.

FIGURE P-1. Nikon camera viewer from above. A 5-mm macro lens is attached, and thelight source is positioned to the side of the lens. A waist-level viewer is attached for takingpictures from the head of the operating table.

14 Valvular Stenosis

14-1. Valvular Stenosis

245

unicuspid valve

R L

ceph

caud

FIGURE 14-1. This photograph shows severe valvular stenosis as it occurs in a newborn.There is a unicuspid, horseshoe-shaped leaflet with a single posterior commissure. Leaflettissue is thick, fibrous, and myxomatous. Successful valvotomy can be performed by cre-ating a second commissure. Significant aortic regurgitation is rare due to the fibrous natureof the valve that prevents redundancy. Although typically there is residual stenosis aftersurgery, many infants will do surprisingly well for many years, even though the valveappears severely malformed and incompatible with life. This photograph was taken of apostmortem specimen in a child who died of other causes.

246 Color Atlas of Congenital Heart Surgery

R L

ceph

caud

FIGURE 14-2. For comparison, this postmortem specimen shows a normal aortic valve inanother newborn infant. There are three cusps and each is thin and pliable.

right coronary cusp

stenotic commissures

non coronary cusp

left coronary cuspR L

caud

ceph

FIGURE 14-3. In this older child with valvular stenosis, the exposure is through a proximalascending aortotomy, with cardiopulmonary bypass, aortic cross-clamping, and cardiople-gia. There are three leaflets that are fibrous and thickened with stenosis primarily of two commissures.

14-2. Subaortic Stenosis: Fibromuscular Obstruction

14 Valvular Stenosis 247

incised commissures

R L

caud

ceph

FIGURE 14-4. Valvotomy is performed by incising stenotic commissures. In some cases, theleaflets are thinned by resecting fibrous tissue.

aortic valve

R L

caud

ceph

FIGURE 14-5. Repair of this anomaly is performed with cardiopulmonary bypass and aorticclamping, cardioplegia, and profound local cardiac cooling, working through a proximalascending aortotomy. Typically, the aortic valve is normal as seen here. There are threeleaflets without commissural stenosis.


fibromuscular ledge

R L

caud

ceph

FIGURE 14-6. With retraction of the valve, a fibromuscular ledge is seen in the left lateralpart of the outflow tract immediately below the valve annulus.

stitch in obstructing muscle ledge

R L

caud

ceph

FIGURE 14-7. A stitch is placed in the middle of the ledge to facilitate grasping it whilethe resection is carried out.


rectangular wedge

R L

caud

ceph

FIGURE 14-8. A rectangular wedge of fibromuscular tissue is resected. It is safe to resecttissue as far anterior as the region beneath the middle of the right coronary cusp. Thebundle of His′ pierces the ventricular septum beneath the noncoronary cusp, after whichthe bundle moves forward in the ventricular septum to the commissure between the non-coronary and right coronary cusps. Tissue is resected to the left and posteriorly as far asthe base of the anterior mitral leaflet, which is located in the posterior wall of the left ven-tricular outflow tract.

R L

caud

ceph

FIGURE 14-9. The resected specimen is seen here.


fibrous collar

R L

caud

ceph

FIGURE 14-10. In another child, a typical fibrous collar is seen in the outflow tract imme-diately below the aortic valve annulus.

area of resection

R L

caud

ceph

FIGURE 14-11. The fibrous collar has been resected along with a wedge of muscle.


aortic valve

R L

caud

ceph

FIGURE 14-12. In another patient, a normal aortic valve is seen.

obstructing muscle ledge

R L

caud

ceph

FIGURE 14-13. The valve cusps are retracted and a fibromuscular obstruction is seen imme-diately below the annulus.


parallel incisions

R L

caud

ceph

FIGURE 14-14. A stitch is placed in the mid part of the ledge for retraction, and parallelincisions are made in the obstructing tissue. The rightward one is below the mid part ofthe right coronary cusp.

muscle ledge to be resected

R L

caud

ceph

FIGURE 14-15. The obstructing muscle ledge is pulled into the field.


FIGURE 14-16. The resected specimen is shown. The obstruction extended deep into thesinus portion of the left ventricle, and the long resected specimen depicts the length ofthe obstructive process.

area of resection

R L

caud

ceph

FIGURE 14-17. The area of resection is wide to ensure relief of the obstruction.

14-2-1. Anomalous Mitral Valve Papillary Muscle


anomalous papillary muscle extension into subaortic area

fibrous extension into base of mitral leaflet

aortic valve leaf

R L

ceph

caud

FIGURE 14-18. After placing another child on cardiopulmonary bypass, an opening is madein the proximal ascending aorta. A trileafed aortic valve is retracted, as is a narrow mem-brane located anteriorly. An obstructing muscle mass is exposed in the posterior left ven-tricular outflow tract. This is an anomalous extension of the mitral valve posterior medialpapillary muscle with a fibrous tissue extension into the base of the anterior mitral leaflet.

right coronary cusp

anomalous papillary muscle extension

fibrous attachment

left coronary cusp

R L

ceph

caud

FIGURE 14-19. The fibrous membrane located beneath the right coronary cusp is excisedand the anomalous muscle bundle is more easily seen.


papillarymuscle excision

mitral valve chords

R L

ceph

caud

FIGURE 14-20. The cephalad 25% of the posteriormedial papillary muscle is excised. The lowerportion of this papillary muscle is left intact andis attached to normal chords. The raw surface ofthe muscle excision is seen.

papillarymuscle excision

mitral valve chords

R L

ceph

caud

FIGURE 14-21. The raw surface of the excised muscle isagain seen and normal mitral valve chords are identi-fied. The lower 75% of the papillary muscle remainsintact with these chords to provide mitral valvesupport. After closing the aorta and removing the childfrom bypass, there was no residual pressure gradient.

14-3. Modified Konno Procedure

In some patients, the left ventricular outflow tract is narrow and local tissue resec-tion alone is inadequate to relieve the obstruction. A modified Konno procedurecan be used in this diverse group of patients, which includes tunnel-like stenosis,stenosis in patients after total repair of complete atrio-ventricular (AV) canal,and some cases of hypertrophic cardiomyopathy. The geometry of the outflowtract is altered by full thickness resection of the ventricular septum workingthrough a right ventriculotomy and an aortotomy. The left ventricular outflowtract is further augmented by ventricular septal defect (VSD) patch closure,placing the patch on the right ventricular surface of the septum. If that patchencroaches on the right ventricular outflow tract, an additional patch can beplaced in the ventriculotomy.When the right ventricular outflow tract is not com-promised by the intracardiac patch, the repair can be performed working throughan aortotomy and an adjacent right atriotomy.


right ventricle outflow tract

aortic valve

R L

ceph

caud

FIGURE 14-22. The child has been placed on cardiopulmonary bypass and the proximalascending aorta opened. A normal aortic valve is identified and severe long segmentsubaortic stenosis seen.

ventriculotomy

ventricular septum

R L

ceph

caud

FIGURE 14-23. A ventriculotomy is made in the region of the right ventricular outflowtract.


aortotomy

tip of right angle clamp in VSD

R L

ceph

caud

FIGURE 14-24. An oblique incision is made in the ventricular septum starting immediatelybelow the aortic valve and extending caudad toward the patient’s left side (starting at orto the left of corpora arantii of the right coronary cusp to avoid the His′ bundle). To iden-tify this region, a right-angle clamp is passed through the aortic valve to protrude in theregion of the septum to be incised.

iatrogenic VSD

R L

ceph

caud

FIGURE 14-25. The large ventriculotomy is seen and through this region obstructing tissuein the left ventricle can be excised. If ventricular septal tissue is to be removed, this shouldbe toward the patient’s left in order to avoid the region of the bundle of His′.


VSD

R L

ceph

caud

FIGURE 14-26. Multiple felted mattress sutures are placed around the right ventricularsurface of the VSD.

patch

R L

ceph

caud

FIGURE 14-27. A Dacron® patch is used to close the VSD positioning the patch on theright ventricular surface of the septum.


outflow tract patch

R L

ceph

caud

FIGURE 14-28. The right ven-triculotomy is closed with atissue patch to enlarge the rightventricular tract; the aortotomyhas been closed.

14-4. Supravalvar Stenosis

In the presence of this anomaly, there is usually a severe stenosing ring, at orimmediately above the aortic valve commissures. A simple incision across thearea of stenosis with patch angioplasty is often inadequate to relieve the obstruc-tion.The stenosing ring must be incised into at least two sinuses of Valsalva.Threeeffective repair techniques are described.

ascending aorta

supravalvarstenosis

R L

ceph

caud

FIGURE 14-29. An externalview of the heart shows thenarrow proximal ascendingaorta at the site of supravalvarstenosis.


supravalvar stenosing ring

lower ends of inverted “Y” incision

R L

ceph

caud

FIGURE 14-30. After the cardiopulmonary bypass is established, with moderate hypother-mia, aortic cross-clamping, cardioplegic arrest, and profound local cooling, an inverted Yincision is made in the ascending aorta. The stenosing supravalvar ring is seen.

area of stenosing ring

aortic valve

lower ends of inverted “Y” incision

R L

ceph

caud

FIGURE 14-31. The lower ends of the inverted Y incision are extended into the sinuses ofValsalva of the noncoronary and right coronary cusps, respectively.


stenosing ring

orifice of left coronary artery

aortic valve cusp

R L

ceph

caud

FIGURE 14-32. The root of the aorta is exposed after completing the inverted Y incision.The stenosing supravalvar ring is immediately above the valve commissures. Normal valveleaflets are seen, and the orifice of the left coronary artery is located just beneath the ring.In some cases coronary stenosis occurs when fibrous tissue compromises the orifice.

lower points of patch

R L

ceph

caud

FIGURE 14-33. A synthetic patch is tailored so that the lower points of the patch will fitin the opened sinuses of Valsalva.


area of commissure

lower points of patch

R L

ceph

caud

FIGURE 14-34. The completed repair is seen after the patch is stitched in place with a con-tinuous suture.

supravalvarstenosis

R L

ceph

caud

FIGURE 14-35. In another baby who has been placed on cardiopulmonary bypass, the areaof supravalvar stenosis is in the typical position at the sino–tubular junction.


distal ascending aorta

stenosing ring

R L

ceph

caud

FIGURE 14-36. The ascending aorta is divided at/or immediately above the stenosing ring.Care must be taken to avoid injury to the coronary artery orifices, which are below thering.

left coronary artery orifice

right coronary artery orifice

sinus of Valsalva incisions

R L

ceph

caud

FIGURE 14-37. Incisions are made in each of the three sinuses of Valsalva from the ringto near the annulus. The proximity of the coronary artery orifices is seen.


homograft patches

aortic valve leaflets

R L

ceph

caud

FIGURE 14-38. Triangular-shaped tissue patches of homograft pulmonary wall are stitchedover incisions in the left and right coronary cusp sinuses. The noncoronary cusp sinusremains open and a patch will be placed here to complete this part of the repair.

homograft patch

aortic anastomosis

R L

ceph

caud

FIGURE 14-39. A direct end-to end anastomosis is performed between the two aortic seg-ments. Counter incisions in the upper aorta may be required due to the disparity in diam-eter of the two segments caused by adding the homograft patches.


supravalvar stenosis

R L

ceph

caud

FIGURE 14-40. In another infant, after establishing cardiopulmonary bypass with aorticclamping, cardioplegia, and profound local cooling, the supravalvar stenosis is seen at thesinotubular junction.

stenosing ring

R L

ceph

caud

FIGURE 14-41. The ascending aorta has been widely dissected including the arch for mobil-ity because the anastomosis will shorten the ascending aorta. Here, it is divided immedi-ately above the stenotic ring. Care must be taken to avoid injury to the coronary arteries,which originate below the ring.


aortic valve

R L

ceph

caud

FIGURE 14-42. The ring is retracted to expose normal aortic valve leaflets and to view thecoronary artery orifices.

sinus of Valsalva incisions

R L

ceph

caud

FIGURE 14-43. Incisions are made from the ring into each sinus of Valsalva to near theaortic valve annulus.


incisions in distal aortic segment

commissure

R L

ceph

caud

FIGURE 14-44. Longitudinal counter incisions are made in the upper aortic segment, eachbeing opposite an aortic valve commissure.

incision in distal aortic segment

commissure

R L

ceph

caud

FIGURE 14-45. Each commissure will fit in an adjacent upper aortic longitudinal incision.

14-5. Aortic Root Enlargement Procedures

14-5-1. Posterior Root Enlargement


primary aortic anastomosis

R L

ceph

caud

FIGURE 14-46. A direct end-to-end anastomosis is performed between the two aortic seg-ments. With such, the area of previous stenosis has been opened widely by the incisionsinto each aortic segment.

aortic valve cusps

L R

caud

ceph

FIGURE 14-47. With cardiopulmonary bypass, aortic clamping, and cardioplegia with pro-found local cardiac cooling, a proximal ascending aortotomy is made. A bicuspid stenoticand dysplastic valve is seen. After it is determined that valvuloplasty is not possible, thevalve leaflets are excised.


anterior mitral leaflet

extended aortotomy

annulus

L R

caud

ceph

FIGURE 14-48. The aortotomy is extended caudad and posteriorly through the valveannulus to the base of the anterior mitral leaflet. With this technique, the annulus can beenlarged by up to 4 to 5mm.

treated pericardial patch

L R

caud

ceph

FIGURE 14-49. Glutaraldehyde-treated pericardium is stitched over the lower aortotomy extension.


pericardial patch

L R

caud

ceph

FIGURE 14-50. The pericardial patch is retracted anteriorly and seen from outside theaorta.

prostheticvalve

valve stitches in patch

pericardial patch

L R

caud

ceph

FIGURE 14-51. A prosthetic valve is implanted at the level of the native aortic valveannulus, and the pericardial patch now comprises part of that annulus. To complete therepair, the remaining pericardial patch is stitched over the aortotomy.

14-5-2. Konno Procedure with a Prosthetic Valve


aortic valve cusps

L R

caud

ceph

FIGURE 14-52. The aortotomy is made in a longitudinal direction and to the left of theright coronary artery orifice. The severely scarred valve cusps are beyond repair, and it isdecided to proceed with valve replacement and anterior root enlargement.

aortotomy

right ventriculotomy

ventricular septum

R L

ceph

caud

FIGURE 14-53. An adjacent incision is made in the anterior wall of the right ventricularoutflow tract to expose the septum.


valve leaflet

ventricular septal incision

R L

ceph

caud

FIGURE 14-54. The aortic valve annulus is incised by working to the left of the right coro-nary orifice. The incision extends into the upper part of the ventricular septum cephaladto the His′ bundle. Valve leaflets are excised in preparation for valve replacement.

patch in ventricular septal defect

R L

ceph

caud

FIGURE 14-55. A woven Dacron® patch is tailored to conform to the iatrogenic VSD andadjacent aortotomy. The lower part of the patch is placed over the VSD with interruptedfelted mattress sutures, placing the patch on the left ventricular surface of the septum.


native valve annulus

ventricular septal defect patch

R L

ceph

caud

FIGURE 14-56. The patch is retracted anteriorly and interrupted valve sutures are placedin the native valve annulus. Additional anterior valve sutures pass through the patch.

prosthetic valve

R L

ceph

caud

FIGURE 14-57. After the valve orifice is sized, an appropriate prosthetic valve is stitchedin place in the subcoronary position. At least 60% of the valve annulus should be placedin the native annulus. Significant enlargement of the left ventricular outflow tract is accom-plished, allowing for placement of a larger prosthesis.


annulus of valve

patch over ventricular septal defect

R L

ceph

caud

FIGURE 14-58. The upper segment of the Dacron® patch is stitched to the aortotomy witha continuous suture. Felt pledgets of valve sutures are seen and the repaired VSD is caudadto the valve annulus.

pericardial patch over right ventricular outflow area

patch covering aortic wall patch

R L

ceph

caud

FIGURE 14-59. A pericardial patch is stitched over the right ventriculotomy and extendsin continuity across the surface of the Dacron® patch. Blood that leaks from the Dacron®patch is collected beneath the pericardial patch and drains to the right ventricle.

14-5-3. Konno Procedure with a Homograft Valve


ascending aorta

right coronary artery

R L

ceph

caud

FIGURE 14-60. The right coronary artery is in the usual anterior aortic root location.

aortotomy to left of right coronary artery


aortic valve cusps


R L

ceph

caud

FIGURE 14-61. A longitudinal incision in the proximal aorta is directed to the left of theright coronary artery orifice. An adjacent right ventriculotomy is made, and the aorticvalve annulus is incised, extending this incision into the ventricular septum.


mitral leafletof homograftpatch

homograft to native annulus stitch


R L

ceph

caud

FIGURE 14-62. Native aortic valve cusps are excised.An aortic valve homograft is tailored,leaving a large patch of homograft wall anteriorly. The homograft is positioned so that itsmitral leaflet is located anteriorly. The homograft is stitched to the native valve annuluswith a continuous monofilament suture, placing this stitch immediately below the homo-graft valve annulus.

mitral leaflet of homograft

ventricular septum

R L

ceph

caud

FIGURE 14-63. The homograft mitral leaflet is used to close the VSD with interruptedfelted mattress sutures. These stitches are passed from the left ventricular surface of theseptum and then through the adjacent homograft mitral leaflet. Pledgets are used on bothsurfaces of the septum.


aortotomy

posterior homograft to native aorta suture

anterior wall of homograft

R L

ceph

caud

FIGURE 14-64. Homograft aortic wall is removed from two posterior sinuses of Valsalvaof the graft. The central homograft commissure is in the midline, and the upper rim of thehomograft is stitched to the posterior wall of the native ascending aorta.

anterior homograft wall to native aorta suture


homograft mitral leaflet stitched to ventricular septum

R L

ceph

caud

FIGURE 14-65. The anterior homograft aortic wall is stitched to the aortotomy of the nativeaorta.

14-5-4. Ross–Konno Procedure


anterior wall of homograft stitched to native aorta

harvested homograft patch in right ventricular outflow R L

ceph

caud

FIGURE 14-66. A homograft aortic wall patch that was harvested in the tailoring processis used to reconstruct the right ventricular outflow tract. The homograft aortic wall patchcovers the ventriculotomy and is stitched to the anterior homograft valve annulus.

aortotomy

autograft explant site in right ventricular outflow


autograft

R L

ceph

caud

FIGURE 14-67. After establishing cardiopulmonary bypass with moderate hypothermia,aortic clamping, cardioplegic arrest, and profound local cooling, the pulmonary autograftis harvested. The main pulmonary artery has been divided proximal to the branches andthe proximal vessel with the valve was harvested from the right ventricule. A circumfer-ential 0.5-cm muscle bar was taken with the graft. Here, the ascending aorta has beenopened in a longitudinal direction, extending this excision across the aortic valve annulus into the ventricular septum. This relieves the left ventricular outflow tractobstruction.


muscle ridge

autograft leaflets

R L

ceph

caud

FIGURE 14-68. Prior to implantation, the autograft leaflets are inspected and found to benormal.

annulus

marking stitches

ventricular septal defect

explant site

R L

ceph

caud

FIGURE 14-69. Aortic valve leaflets are excised, leaving a 1-mm segment of leaflet attachedto the native annulus. The new left ventricular outflow tract opening is marked with threetrifurcating stitches. These are placed opposite the native sinuses of Valsalva and will beinserted near the middle of each autograft sinus of Valsalva.


autograft

stitches for ventricular septal defect closure

R L

ceph

caud

FIGURE 14-70. The trifurcating stitches are placed in the proximal autograft muscle bar,opposite the mid part of each autograft leaflet. Multiple interrupted felted stitches arepassed through the ventricular septum from left ventricle into right ventricle in prepara-tion for closing the VSD.

autograft

anterior muscle bar

VSD patch

R L

ceph

caud

FIGURE 14-71. A Dacron® patch is placed over the VSD utilizing previously insertedstitches. The autograft will be attached to the native aortic valve annulus with multipleinterrupted fine polypropylene sutures. In situ the graft fits well. The VSD patch will beattached to the anterior muscle bar with additional interrupted sutures.


native aorta

autograft

VSD patch


R L

ceph

caud

FIGURE 14-72. Working inside the native aorta, the posterior wall of the graft sinuses ofValsalva is tailored and then the graft is stitched to the posterior native aorta below andaround the coronary orifices. The posterior graft commissure is also attached to the pos-terior native aorta. The anterior wall of the autograft is stitched to the opening in thenative aorta.

pulmonary homograft

anterior muscle bar

ventriculotomy

R L

ceph

caud

FIGURE 14-73. A pulmonary valve homograft with attached main pulmonary artery is used for reconstruction of the right ventricular outflow tract. Its muscle bar is stitched to the posterior right ventricle and the anterior graft muscle bar is stitched to the ventriculotomy.

14-6. Apical Left Ventricle to Ascending Aorta Conduit

In small infants, when an apical–aortic conduit is required, there may be inade-quate space in which to work to attach the conduit to the descending aorta whenworking through a median sternotomy. Here the conduit is attached to theascending aorta.


main pulmonary artery

ascending aorta

R L

ceph

caud

FIGURE 14-74. Through a median sternotomy, a small ascending aorta is seen. The proce-dure is performed with cardiopulmonary bypass, moderate hypothermia, aortic clamping,and cardioplegic arrest plus profound local cooling.

left apical ventriculotomy

R L

ceph

caud

FIGURE 14-75. A left apicalventriculotomy is made,and a button of ventricularwall is removed.


conduit valve

R L

ceph

caud

FIGURE 14-76. A porcine-valved conduit (12mm in this case) is beveled and stitched tothe ventriculotomy with a continuous monofilament suture. The conduit valve is placednear the ventriculotomy.

ascending aorta

R L

ceph

caud

FIGURE 14-77. A longitudinal ascending aortotomy is made to accept the distal end of theconduit.


R L

ceph

caud

FIGURE 14-78. The completed aortic anastomosis is shown and the conduit lies along theleft heart border.

7 Pulmonary Stenosis

Pulmonary stenosis can occur at one or more sites from the proximal right ven-tricular outflow tract to the peripheral pulmonary arteries.Valvar obstruction andperipheral pulmonary stenosis are usually treated by closed balloon angioplasty;however, surgical repair is performed in many patients, especially those in whomoperation is carried out for associated anomalies.

Narrowing of the main pulmonary artery and/or the proximal right and leftbranches is most commonly associated with tetralogy of Fallot and will be dis-cussed in Chapter 9.

7-1. Valvular Pulmonary Stenosis

Pulmonary valvotomy is performed using cardiopulmonary bypass, including leftventricular venting and aortic cross-clamping; although in unusual circumstances,as in very small neonates, it is most expeditious to avoid the use of a left ven-tricular vent. In these cases, care must be taken not to allow air from the openedright heart to enter the left heart through an intracardiac communication as apatent foramen ovale. Aortic clamping may also be optional but its use helps inreducing blood flow from the coronary sinus into the right ventricle and the oper-ative field. An alternative method to reduce blood flow into the operative fieldwhen not using aortic cross-clamping is the use of a single right atrial cannulathat the drains coronary sinus as well as caval return. In this instance, the tricus-pid valve must remain competent during bypass or otherwise excessive air willenter the venous return line to the pump.

129


incised commissures

R L

ceph

caud

FIGURE 7-2. All commissures are incised to the annulus.

leaflets

R L

ceph

caud

FIGURE 7-1. After the cardiopulmonary bypass is established, the proximal main pul-monary artery is opened transversely or longitudinally.Three commissures of the trileafedpulmonary valve are stenotic, and there is mild thickening of the leaflets.

7-2. Infundibular Stenosis and Double Chamber Right Ventricle

Repair is performed with cardiopulmonary bypass, aortic clamping, cardioplegicarrest, and profound local cardiac cooling.

7 Pulmonary Stenosis 131

mainpulmonaryartery

valve

R L

ceph

caud

FIGURE 7-3. In this patient, after cardiopulmonary bypass is established, a proximal mainpulmonary arteriotomy is made. There are three leaflets with stenotic commissures, andthe valve is dysplastic. All leaflets are fibrous with limited mobility. Incising the stenoticcommissures alone will not relieve the obstruction, because the leaflets are bulky and willnot adequately move out of the stream of blood during systole. Part or all of the leafletswill be resected to avoid residual obstruction.

septal band

parietal band

os infundibulum

anterior wall extensionof obstructing parietalband

R L

ceph

caud

FIGURE 7-4. After the child is placed on cardiopulmonary bypass, a high right ventriculo-tomy is made. Obstruction at the os infundibulum is identified. There are large muscleridges in the region of the parietal and septal bands extending to the anterior wall of theright ventricle. Fibrous tissue surrounds the os.


os infundibulum

tricuspid valvepapillary muscle

R L

ceph

caud

FIGURE 7-5. Obstructing muscle and fibrous tissue has been resected, and the tricuspidapparatus below this area is seen.

parietalband

moderatorband

FIGURE 7-6. Double-chambered right ventricle is a form of infundibular pulmonary steno-sis caused by muscle obstruction that is primarily in the area of the moderator band, asseen on this right ventriculogram.

7 Pulmonary Stenosis 133

parietalband

moderatorband

tricuspidvalveleaflets

R L

ceph

caud

FIGURE 7-7. In this patient with double chamber right ventricle the exposure is througha right atriotomy while the tricuspid valve is retracted.The hypertrophied moderator bandforms the major blockage, although an obstructing parietal band is also seen.

parietalband

VSD

R L

ceph

caud

FIGURE 7-8. An associated membranous ventricular septal defect (VSD) is located medialto the parietal band.


os infundibulum

VSD patch

R L

ceph

caud

FIGURE 7-9. The parietal and moderator bands are resected, and the os infundibulum isnow open. The VSD is closed with multiple interrupted mattress sutures and a Dacron®patch.

Documents

Preface - bücher.de · caud ceph FIGURE 14-17. The area of resection is wide to ensure relief of the obstruction. 14-2-1. Anomalous Mitral Valve Papillary Muscle 254 Color Atlas