Common Arterial Trunk and Complete Atrioventricular Septal Defect Repair

Operation performed:

1. Repair of type 1 common arterial trunk - bovine pericardial baffle (VSD patch) from inlet VSD to truncal valve and placement of 12 mm Hancock RV to PA Conduit.
2. Repair of complete atrioventricular septal defect - Rastelli type C with 2 patch (VSD patch and ASD patch 1/primum patch) technique using bovine pericardium and closure of left AV valve cleft.
3. Creation of left SVC to secundum ASD tunnel with bovine pericardium (ASD patch 2/secundum and LSVC tunnel patch). This step both facilitated closure of an additional secundum atrial septal defect as well as ensured drainage of the left superior caval vein to the right atrium.
4. Patch closure of coronary sinus atrial septal defect with bovine pericardium (ASD patch 3/coronary sinus defect patch).
5. Removal of bilateral PABs and bovine pericardial patch augmentation of the left pulmonary artery.

Operative Steps:

Cannulation required high aortic cannulation for the repair of the truncus and right, left, and inferior vena cavae cannulation given the large left SVC and absence of a bridging vein. In this case, the authors cooled to 28 degrees centigrade given the anticipated length of the operation. Mobilization of the branch pulmonary arteries from hilum to hilum was performed and the bilateral pulmonary artery bands were removed.

Prior to cross clamp, the coronary artery anatomy was carefully inspected. The coronary crossing the right ventricular outflow tract was marked along its course with sutures so as to clearly mark its course in order to safely select the site for the ventriculotomy later in the operation. After arrest, the artery would be much more difficult to identify.

After cross clamp and arrest, caval veins were snared, and a right atriotomy was made and a vent was placed across the secundum ASD into the left atrium. The authors then floated the valve and marked the top of the left AV valve cleft. This step was performed at this point in order to pressurize the valve for proper assessment prior to the ventriculotomy.

The truncal artery was incised in order to separate the pulmonary arteries. The truncal valve and coronary ostia were inspected. The truncal artery was closed primarily as it was felt it could be done safely and effectively and given a primary closure would provide more room for the RV to PA conduit.

Antegrade cardioplegia was administered again at this point which allowed the authors to test the truncal valve for competence after the truncal artery repair, and it also allowed them to assess the VSD component and what approach would be necessary for closure. While the truncal valve was pressurized, it became clear that they would not be able to adequately create the baffle from the VSD to the truncal valve only through the right atrium and AV valve. Therefore, they proceeded with the ventriculotomy, which was placed more caudal than would be typical in order to avoid injury to the coronary artery crossing the RVOT. A bovine pericardial patch (VSD patch) was cut so as to provide a flat edge for the portion between the AV valve and with large teardrop to baffle over to the truncal valve. The VSD patch was started through the right atrial approach for which the portion dividing the AV valve and the right and left ventricles could be completed and then the ventriculotomy site was used to complete the baffle (VSD patch) to the truncal valve.

Subsequently, the right atrial approach was again used to attach the VSD patch to the AVV and the ASD patch (a separate bovine pericardial patch-ASD patch 1/primum patch) which was then brought down and secured to the superior margin of the VSD patch.

Again, the atrial septum had three defects (a small primum component of the complete canal, a separate secundum defect, and a coronary sinus defect). In order to gain adequate exposure to the left AVV valve, the limbus bridging the secundum component and coronary sinus defect was divided {4:34:55}. This band formed the inferior margin of the secundum defect and superior margin of the coronary sinus defect.

The orifice of the left SVC was identified draining into the roof of the left atrium. A tunnel was created to direct drainage into the right atrium by inverting a portion of the left atrial appendage and augmenting it with a separate pericardial patch (ASD patch 2/secundum and LSVC tunnel patch). (Eventually, the limbus/septal tissue divided for exposure would be reattached to the posterior septum. Again, this band formed the inferior margin of the secundum defect and superior margin of the coronary sinus defect. The patch augmenting the LSVC tunnel (ASD patch 2/secundum and LSVC tunnel patch) would be attached to the superior margin of this limbus, effectively closing the secundum defect and completing the tunnel channeling the LSVC drainage to the right atrium. This final step, however, was completed after repair of the left AV valve cleft, which was followed by closure of the primum defect with the ASD patch 1/primum patch.)

Next, the left AV valve cleft was closed followed by closure of the primum defect with ASD patch 1/primum patch. The limbus the authors had divided was then put back together by reattaching it to the posterior portion of the atrial septum and the ASD patch 2/secundum and LSVC tunnel patch was attached to the superior margin of this band of tissue, which effectively closed the secundum defect and completed and the tunnel for the LSVC drainage to the right atrium. A temporary suture was then used to close the ventriculotomy in order to assess the right AV valve. Then, the coronary sinus defect was closed with a separate a bovine pericardial patch (ASD patch 3/coronary sinus defect patch) and a vent was placed through the middle of this patch to vent the left atrium. At this point, re-warming was initiated and the cross clamp was removed after de-airing. The pulmonary arteries were sized and the left pulmonary artery was small and required patch augmentation. The distal anastomosis of the RV to PA conduit was completed first. A 12 mm Hancock valved conduit had been selected and the authors removed the exterior metal ring. The conduit was left long so as not to compress the left anterior descending coronary artery traveling under it. The proximal anastomosis being performed with the heart beating also allowed an added opportunity to assess for potential coronary artery injury while completing that suture line. Finally, the right atrium was closed and the LA vent was removed.

He was weaned from bypass without difficulty. Postoperative TEE demonstrated normal biventricular function, trivial truncal valve insufficiency, no residual VSD, mild left and right AV valve insufficiency and mild right or left AV valve stenosis, no RVOT obstruction or pulmonary artery stenosis, and laminar low velocity flow through the LSVC tunnel.

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