No Ventricular Septal Defect Patch Atrioventricular Septal Defect Repair  Carl L. Backer, MD, Osama Eltayeb, MD, Michael C. Mongé, MD, John M. Costello, MD  Operative Techniques in Thoracic and Cardiovascular Surgery  Volume 20, Issue 3, Pages 279-292 (September 2015) DOI: 10.1053/j.optechstcvs.2016.02.006 Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 1 The child has been placed on cardiopulmonary bypass with venous cannulae in the superior and inferior vena cava. The aorta has been cross-clamped and cold blood cardioplegia delivered. The dotted line shows the incision to be made for exposure in the right atrium. Note the atrial incision is carried medial to the inferior vena cava, which allows the visualization of the AV valve to be substantially improved. This “unhinges” the right atrium from the ventricle for excellent exposure of the atrioventricular valve. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 279-292DOI: (10.1053/j.optechstcvs.2016.02.006) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 2 (A) The right atrium has been opened and retracted showing the Rastelli classification type A. Note that the superior bridging leaflet is divided and attached to the crest of the ventricular septum. Inset shows a suture used to mark the approximation of the superior and interior bridging leaflets leading to separate right and left atrioventricular valves. (AV = atrioventricular). Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 279-292DOI: (10.1053/j.optechstcvs.2016.02.006) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 2 (Continued) (B) Rastelli classification C. The superior bridging leaflet is not divided and is not attached to the ventricular septum. This has also been referred to as a “free-floating leaflet.” Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 279-292DOI: (10.1053/j.optechstcvs.2016.02.006) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 3 (A) demonstrates bulb irrigation of the common atrioventricular valve in Rastelli A. The dotted line indicates where a proposed line of separation of the right and left atrioventricular valves would occur with placement of the sutures. Inset (B) shows bulb insufflation of the common AV valve in a patient with Rastelli type C. (L = left; R = right). Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 279-292DOI: (10.1053/j.optechstcvs.2016.02.006) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 4 A series of pledgetted horizontal mattress sutures have been placed on the right ventricular side of the ventricular septum. They have then been passed through the appropriate site on the common AV valve for a patient with Rastelli type A. The sutures are also shown as they pass through the pericardial patch. A rubber-shod clamp is shown holding a single suture which demonstrates where the superior and inferior bridging leaflets are to be brought together to begin the closure of the zone of apposition. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 279-292DOI: (10.1053/j.optechstcvs.2016.02.006) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 5 (A) shows the completed ventricular element closure in a patient with Rastelli type A. The pledget-based sutures have been passed through the ventricular septum, through the AV valve, and have been tied. Note that the sutures are only passed through the left AV valve portion of the superior bridging leaflet at this point. AV = atrioventricular. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 279-292DOI: (10.1053/j.optechstcvs.2016.02.006) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 5 (Continued) (B) The anatomy of a patient with Rastelli type C classification. Note that the superior bridging leaflet portion of the right and left AV valves is completed, because of the patient anatomy. AV = atrioventricular. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 279-292DOI: (10.1053/j.optechstcvs.2016.02.006) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 6 Relationship of the pledget to the crest of the ventricular septum, the AVvalve tissue, and the pericardial patch. AV = atrioventricular; LV = left ventricle; RA = right atrium; RV = right ventricle. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 279-292DOI: (10.1053/j.optechstcvs.2016.02.006) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 7 The pericardial patch has been reflected anteriorly. We are looking directly down at the left AV valve. The zone of apposition has been closed with multiple interrupted prolene sutures. AV = atrioventricular. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 279-292DOI: (10.1053/j.optechstcvs.2016.02.006) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 8 (A) Rastelli A. The superior bridging leaflet of the right AV valve must now be suspended to the pericardial patch. This is illustrated with running prolene suture. In addition the superior and inferior bridging leaflets of the right AV valve have been approximated closing the zone of apposition of the right AV valve. This usually requires only 2 or 3 sutures. AV = atrioventricular. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 279-292DOI: (10.1053/j.optechstcvs.2016.02.006) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 8 (Continued) (B) Rastelli type C. Note that the superior bridging leaflet of the right AV valve has already been attached to the pericardial patch. This illustration shows the sutures being placed to close the zone of apposition of the right AV valve, and the suture used to close the atrial component of the defect. ASD = atrial septal defect; AV = atrioventricular; IBL = inferior bridging leaflet; SBL = superior bridging leaflet. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 279-292DOI: (10.1053/j.optechstcvs.2016.02.006) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 9 Rastelli A, the atrial portion of the defect is being closed with a running suture technique using the autologous pericardial patch. Typically, 2 suture lines are created which then join in the middle to complete the closure. Note the AV node position at the apex of the triangle of Koch adjacent to the coronary sinus. The sutures adjacent to the AV node are placed very superficially and are closer to the left AV valve. This is typically a fine prolene suture, either 6.0 or 5.0 prolene. Care is taken not to grasp this area with a pickup or injure this area with any type of instrument such as a cardiotomy sucker. AV = atrioventricular. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 279-292DOI: (10.1053/j.optechstcvs.2016.02.006) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 10 Completed procedure in a cut-a-way view. The common AV valve has been separated into left and right AV valves. The zone of apposition of both AV valves has been closed. The ventricular element of the defect has been eliminated by the compression of the crest of the ventricular septum to the common AV valve and the autologous pericardial patch. AV = atrioventricular. Operative Techniques in Thoracic and Cardiovascular Surgery 2015 20, 279-292DOI: (10.1053/j.optechstcvs.2016.02.006) Copyright © 2016 Elsevier Inc. Terms and Conditions