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Repair of Ruptured Sinus of Valsalva Aneurysm, Ventricular Septal Defect, and Mitral Valve

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posted on 10.12.2021, 18:09 by Abdul Wahid Al Mulla, Hatem, Sarhan, Dina Alwaheidi, Mohamed Elkahlout, Tamer Abdalghafoor, Laith Tbishat, Shady Ashraf, Ali Kindawi

Patient History:

A 30-year-old male patient was admitted for decompensated heart failure. He had a history of a hole in the heart during childhood.
Echocardiography on admission showed left ventricular function, EF 60%, ruptured right coronary sinus of Valsalva aneurysm into the right ventricle, severe mitral regurgitation due to prolapse of P2 segment of the posterior leaflet.
He responded well to anti-failure treatment and was prepared for surgical repair.

Operation :

Patch repair of VSD and right coronary sinus of Valsalva,
Repair of the mitral valve: neochords by PTFE sutures and annuloplasty by 30 mm semirigid ring

Intra-operative findings:

Heart: dilated heart, high pulmonary artery pressure, thick right atrial wall indicating long-standing right heart strain.

Aorta: ruptured aneurysm of the right coronary sinus of Valsalva aneurysm into the right ventricle, consists of a large thin-walled sac with a perforation at the tip. After removing the sac a small infundibular subaortic ventricular septal defect was exposed measuring 5 m in diameter.

Mitral valve: free prolapse of myxomatous P2 segment of the posterior leaflet with elongated thin chorda and one chord-like chordae inserting into the free margin of the middle of P2.

Technique:

Technique General anesthesia, supine position.

Median sternotomy.

The pericardium was opened.
Heparin 3 mg/kg was given and repeated to maintain ACT> 400 sec.

22F aortic cannula, 32 IVC cannula, and 28 SVC cannula were inserted. Coronary sinus catheter was introduced. CPB was started.

Snares of cotton tapes were passed around IVC and SVC.
Aortic X clamp was applied and the heart was arrested by intermittent retrograde cold blood cardioplegia supplemented by antegrade direct right coronary ostial infusion after opening the aorta.

The left atrium was opened laterally through Sodergaards groove and the aorta was opened an inch superior to sino-tubular junction.
The aneurysmal sac of the right coronary sinus of Valsalva was removed. The sub-aortic VSD was closed by a dacron (Hemashield) patch by running 4/0 prolene.

Another elliptical shape Dacron patch was used to close the defect in the right coronary sinus by running 4/0 prolene. The anterolateral margin of the defect was close to the pulmonary valve leaflets and through which pulmonary leaflets were seen. In order to avoid injuring pulmonary leaflets the main pulmonary artery was opened and the leaflets were inspected while closure of the patch was completed.

Next, the mitral valve was exposed. Multiple interrupted 2/0 ethibond sutures were placed in the annulus in a transverse mattress fashion for the annuloplasty ring. Three 4/0 PTFE sutures were placed in the papillary muscles corresponding to left, middle and right segments of P2 in a figure of 8 fashion. The free ends of the sutures were placed in the respective free margin of P2 and locked after adjustment of the length, forming neochords.
A 30 mm semi-rigid complete ring was fixed to the annulus by the interrupted ethibond sutures.
Final adjustment of the neochords was done before tying the knots. Competency of the mitral valve was confirmed by water test.

The left atrial incision was closed by running 3/0 prolene in 2 layers. The aortotomy incision was closed by running 4/0 prolne in 2 layers and finally pulmonary aortotomy was closed by running 5/0 prolene. In the meantime warm blood was infused through the coronary sinus catheter to aid recovery.

Deairing was achieved before tying the knots and via the aortic root vent. Aortic X clamp was removed and the heart recovered in slow junctional rhythm initially followed by sinus rhythm a while later.

After a period of reperfusion, CPB was weaned with minimum inotropic support
TEE showed competent mitral valve with no residual regurgitation, mild aortic incompetence, and no residual shunt across the patches of sinus of Valsalva or VSD.

Protamine was well tolerated while the heart was decannulated.

Hemostasis was achieved by replacing platelet concentrate, fibrinogen, tranexamic acid. and prothrombin complex concentrate
2 RV and 2 RA pacing wires were placed.
2 chest tubes were placed in the pericardium.
The pericardium was closed.
The wound was closed in layers
The patient was transferred to CTICU in stable condition.

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