Surgical treatment of congenital heart defects

Repair of pulmonary valve stenosis

Surgical intervention for this pathology aims to restore normal vessel lumen and ensure adequate cardiac output. The operation is performed with the heart excluded from circulation, using a mandatory CPB machine.

The baseline approach for this surgery is a median sternotomy, which provides a wide exposure of the anterior surface of the heart and great vessels.

Steps of the surgical procedure:

1. The surgeon makes a longitudinal incision in the pulmonary trunk.
2. The edges of the resulting wound are gently retracted to visualize the intravascular structures.
3. An inspection of the fused semilunar valves is performed, which in this pathology visually acquire a characteristic cone shape.
4. Commissurotomy is performed: using a scalpel, the physician precisely dissects the pathological adhesions (commissures) between the cusps.
5. The final stage is the hermetic closure of the pulmonary artery wall. For reliability, a double-row suture is applied, representing a combination of horizontal mattress and continuous locking sutures.

Closure of atrial septal defect (ASD)

Interventions on the atrial septum have their own topographical features. Unlike operations on the ventricles or the pulmonary trunk, the optimal approach here is a right-sided lateral thoracotomy, performed strictly via the 4th intercostal space.

Course of the surgical procedure:

• A wide incision of the pericardium is made, the edges of which are immediately secured with special traction sutures for fixation.
• Cannulation and connection of the cardiopulmonary bypass (CPB) machine are performed.
• The right atrium is opened in the space between the placed venous catheters.
• Direct defect repair is carried out. For this, the opening is closed with a reliable double-row continuous suture.

General principles of septal repair: In cases where the defect cannot or should not be closed directly, patches are used. They are tailored from the patient's own tissues (pericardium) or synthetic materials are used. Fixation of such a patch, for example, in a secundum ASD, is performed using a continuous suture.

Suture of ventricular septal defect (VSD)

VSD repair operations require direct access to the ventricular cavities. As with pulmonary stenosis, the surgical approach of choice is median sternotomy. Life support for the patient during the opening of the heart chambers is maintained by CPB.

Surgical technique:

1. A longitudinal incision of the right ventricular wall is performed. It is extremely critical to make the incision in the so-called avascular zone to avoid damaging the coronary arteries.
2. The edges of the myocardial wound are retracted using surgical hooks for adequate visualization of the defect.
3. The choice of repair method directly depends on the anatomical shape of the opening:
4. Slit-like defect is repaired relatively simply — its edges are approximated and closed with interrupted horizontal mattress sutures.
5. Round defect requires patch placement. Felt Teflon is used as the material, which is securely fixed around the perimeter with horizontal mattress sutures.

Also, within intracardiac interventions, transventricular mitral commissurotomy may be performed. During this manipulation, a special instrument (dilator) is passed through the ventricular wall, and upon opening its blades, the narrowed left venous opening is dilated.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Topographical anatomy of the avascular zones of the right ventricle
• Principles of tailoring and preparing an autopericardial patch
• Features of applying double-row continuous and horizontal mattress sutures to vessels
• Technique of transventricular mitral commissurotomy and dilator operation

Other topics in the section "Operations on the Chest Wall and Thoracic Organs"

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