Repair of Atrioventricular Septal Defect Associated With Tetralogy of Fallot or Double- Outlet Right Ventricle: 30 Years of Experience Jeremy Ong, BMedSci,

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Repair of Atrioventricular Septal Defect Associated With Tetralogy of Fallot or Double- Outlet Right Ventricle: 30 Years of Experience Jeremy Ong, BMedSci, Christian P. Brizard, MD, Yves d'Udekem, MD, PhD, Robert Weintraub, MBBS, Terry Robertson, MBBS, Michael Cheung, MBBS, Igor E. Konstantinov, MD, PhD The Annals of Thoracic Surgery Volume 94, Issue 1, Pages 172-178 (July 2012) DOI: 10.1016/j.athoracsur.2012.02.070 Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Heart morphology. (A) Normal heart. Inlet and outlet of the right ventricle (RV) are approximately equal in length. (B) Complete atrioventricular septal defect. The inlet of the RV is approximately half the length of its outlet. (C) Complete atrioventricular septal defect with tetralogy of Fallot. The aorta is in continuity with a common atrioventricular valve and overrides the ventricular septum by the subaortic extension of the ventricular septal defect. The dotted line demonstrates extent of resection of the subpulmonary muscular obstruction. (D) After complete resection of subpulmonary obstruction, a patch with generous subaortic extension is used to prevent subaortic obstruction. (AoV = aortic valve; PV = pulmonary valve; TV = tricuspid valve.) The Annals of Thoracic Surgery 2012 94, 172-178DOI: (10.1016/j.athoracsur.2012.02.070) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Flowchart shows patient distribution. (CAVSD = complete atrioventricular septal defect; DORV = double-outlet right ventricle; TOF = tetralogy of Fallot.) The Annals of Thoracic Surgery 2012 94, 172-178DOI: (10.1016/j.athoracsur.2012.02.070) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Technique of the superior bridging leaflet detachment: (A) The incision begins at the base of the lateral leaflet of the right atrioventricular valve component and extends onto the base of the superior bridging leaflet. (B) The aortic valve is visualized and detachment of the superior bridging leaflet is performed under direct vision to avoid damage of the aortic valve. (C) Subaortic extension of the ventricular septal defect (B1 and B2) can be approached through this incision and closed with a patch (C1 and C2) before (D) reattachment of the superior bridging leaflet. (AoV = aortic valve; CS = coronary sinus; LV = left ventricle; RV = right ventricle.) The Annals of Thoracic Surgery 2012 94, 172-178DOI: (10.1016/j.athoracsur.2012.02.070) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Kaplan-Meier curve shows 20-year actuarial survival. The Annals of Thoracic Surgery 2012 94, 172-178DOI: (10.1016/j.athoracsur.2012.02.070) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Kaplan-Meier curve shows 20-year freedom from reoperation. The Annals of Thoracic Surgery 2012 94, 172-178DOI: (10.1016/j.athoracsur.2012.02.070) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions