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Ann Thorac Surg 2000;69:291-292
© 2000 The Society of Thoracic Surgeons

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How to Do It

Improved exposure of isolated perimembranous ventricular septal defects

^a Department of Cardiac Surgery, B.M. Birla Heart Research Centre, Calcutta, India

Address reprint requests to Dr Kapoor, Department of Cardiac Surgery, B.M. Birla Heart Research Centre, 1/1 National Library Ave, Calcutta 700 027, India
e-mail: lkapoor{at}vsnl.com

	Abstract

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We describe an alternative step in the transatrial approach to the repair of ventricular septal defects. We temporarily detach the chorda of the obscuring tricuspid valve from its attachment to the septum to expose the ventricular septal defect.

	Introduction

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Increasing experience over the past two decades has led to standardization of the transatrial approach to the repair of ventricular septal defects (VSD). Occasionally the VSD is hidden awkwardly under the septal leaflet of the tricuspid valve, making exposure difficult. Temporary detachment of the septal leaflet of the tricuspid valve, at its base, is the method routinely used to tackle this situation. However, we have been using an alternative method to expose the VSD whereby we temporarily detach the leaflet from its attachment to the septum.

	Technique

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Aortobicaval hypothermic cardiopulmonary bypass with cold crystalloid cardioplegic arrest is established. The right atrium is opened parallel to the atrioventricular (AV) groove and stay sutures are placed. The left atrium is vented through the interatrial septum as the delivery of cardioplegia is completed. The VSD is assessed by gently retracting and everting the septal leaflet of the tricuspid valve. Often it is clearly seen and a patch can be sutured in place without much trouble. Sometimes the approach is made difficult by the presence of the chordae tendinae of the septal leaflet of the tricuspid valve (Fig 1). In this situation we detach the obstructing chorda from its insertion onto the septum, just below the VSD margin. The detached chorda is then turned upward, folding the leaflet upon itself, to reveal the VSD hiding under it (Fig 2). The upturned leaflet itself helps to further retract the tricuspid orifice, clearly displaying the VSD (even more so in the awkward VSDs of the tetralogy of Fallot).

View larger version (21K): [in this window] [in a new window]   Fig 1. Transatrial view of the ventricular septal (VSD), partially covered by the leaflet and chordae tendinae of the septal leaflet of the tricuspid valve.

View larger version (21K): [in this window] [in a new window]   Fig 2. The chordae tendinae are detached at the junction with the septum and flipped upward to expose the ventricular septal defect.

View larger version (30K): [in this window] [in a new window]   Fig 3. The ventricular septal defect (VSD) patch is in place and the chordae tendinae of the septal leaflet are reattached to the septum with a pledget using 5-0 Prolene stitch.

We have performed this procedure in 39 of 158 VSD closures (including 11 cases of tetralogy of Fallot). Postoperative echocardiography showed grade 2 tricuspid regurgitation (TR) in 4 patients. Of these, 1 patient had had grade 2 TR preoperatively as well. One patient who had had grade 2 TR preoperatively, subsequently had grade 3 TR at 6 months follow-up.

	Comment

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Repair of a VSP, either isolated or in association with other cardiac anomalies, is the most common operation in the surgery of congenital heart defects. Successful closure requires good visualization and avoidance of the conduction tissue, especially at the posteroinferior margin.

Techniques of surgical management of VSDs have now been standardized. The approaches described for repair are through either the right atrium, the pulmonary artery, the aorta, or the ventricle [1]. Left ventriculotomy provides a good view, unobscured by trabecular bands or papillary muscles, of the rare apical and muscular VSDs [2, 3]. Although the choice depends upon the exact location of the VSD, the right atrial route is the most commonly used.

Exposure of VSDs through the right atrium is simple and often provides an adequate view of the margins of the defect. Sometimes the chordae tendinae of the septal leaflet of the tricuspid valve interfere with visualization, and also with the placement of important sutures beyond the posteroinferior margin. The technique described to address this situation advocates detachment of the tricuspid leaflet from the annulus. This allows repair of the VSD, and is followed by reattachment of the septal leaflet in its original position [1, 4, 5], and is reported to be safe as assessed by postoperative echocardiography [6].

However, when using the conventional procedure, we found that suturing the upper edge of the VSD patch to the base of the tricuspid leaflet is sometimes made awkward by the shortened residual tag of the leaflet, upon which one also subsequently has to suture the remaining leaflet itself. Also, exposure of a VSD extending to the outlet septum still requires retractors to be placed under the tricuspid orifice. The procedure does not address the issue of a chordal attachment at the all-important posteroinferior margin of the VSD, which interferes with suturing of the VSD patch away from the edge.

The maneuver we described addresses both these issues: exposure and the posteroinferior margin. Additionally, the upturned leaflet helps to retract the tricuspid orifice further, improving exposure. Avoiding a VSD retractor under the septal leaflet also frees the assistant’s right hand, and gives the surgeon more room to work in. Also, because the leaflet is now completely free it is easy to accurately place the upper sutures in the base of the leaflet. The posteroinferior margin lying freely exposed, after detachment of the chorda, permits easy and accurate suturing of the patch. Reattaching the chorda either to its original position or onto the VSD patch is a minor additional step.

We believe that this modification is a useful addition to the armamentarium of the pediatric cardiac surgeon.

	Acknowledgments

 
We acknowledge Dr Devi Prasad Shetty, ex-Chief Cardiac Surgeon, B.M. Birla Heart Research Centre, Calcutta.

	References

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1. McGrath L.B. Methods for repair of simple isolated ventricular septal defect. J Card Surg 1991;6:13-23.[Medline]
2. Misumi H., Sakata K., Hayashi K., Masuda T., Kobayashi Y., Tanimoto Y. Left ventricular approach for muscular ventricular septal defects in infant. Nippon Kyobu Geka Gakkai Zasshi 1992;40:1803-1807.[Medline]
3. Zavenella C., Matsuda H., Jara F., Subramanian S. Left ventricular approach to multiple ventricular septal defects. Ann Thorac Surg 1977;25:537-543.
4. Mullen J.C., Lemermeyer G., Schipper S.A., Bentley M.J. Perimembranous ventricular septal defect repair. Can J Cardiol 1996;12:817-821.[Medline]
5. Frenckner B.P., Olin C.L., Bomfim V., Bjarke B., Wallgren C.G., Bjork V.O. Detachment of the septal tricuspid leaflet during transatrial closure of isolated ventricular septal defect. J Thorac Cardiovasc Surg 1981;82:773-778.[Abstract]
6. Bol-Raap G., Bogers A.J., Boersma H., De Jong P.L., Hess J., Bos E. Temporary tricuspid valve detachment in closure of congenital ventricular septal defect. Eur J Cardiothorac Surg 1994;8:145-148.[Abstract]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Lalit Kapoor Mohan Dattatrya Gan Mrinal Bandhu Das Srirup Chatterjee Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kapoor, L. Articles by Chatterjee, S. Search for Related Content PubMed PubMed Citation Articles by Kapoor, L. Articles by Chatterjee, S.