surgical correction of ASD with MR in a child

1. Surgical correction of ASD with MR in
a child
DR. ASRAFUL HOQUE SIUM
MBBS,MS(CV&TS)
UNIT CHIEF-9
ASSISTANT PROFESSOR
CARDIAC SURGERY, NICVD.

2. 14 years, male
 History of dyspnoea and respiratory tract infections since birth
 Symptoms would exacerbate with exertion and relieved by rest
 Weakness and lethargy
 No associated chest pain, palpitations, orthopnea, dependant oedema, or
loss of consciousness

3. On examination
 Ill-looking, less than average body built
 Pectus excavatum
 Wide and fixed splitting of second heart sound
 Pansystolic murmur in mitral area radiating to left axilla

4. Chest X-ray
 Enlarged Cardiac Shadow
 Plethoric lung fields.

5. Echocadiogram
 Prolapse of anterior mitral leaflet
 Mitral regurgitation grade IV
 Grossly dilated Right atrium and ventricle
 Interatrial septal defect of 43mmx46mm size in
secundum part. Postero superior and postero
inferior rim of IAS almost absent. Left-right shunt

6. Cont…
Measurement by 2D
LA 18mmx39mm
LVIDd 29mm
LVIDs 18mm
LVEF 68%
MV
annulus
25mm
Doppler measurements
Parameter Velocity Peak gradient
Mitral valve 1.3m/s 7.4 mmHg
PASP= 67 mmHg PADP=28 mmHg

7. MVR with pericardial patch closure of
ASD
 Median sternotomy
 Standard CPB
 del Nido cardioplegia
 Peroperatively severely dilated LA, RA and ventricles were noted
 Right atriotomy done

8. Cont…
 Large ASD of 45mm x 50 mm
 Anterior mitral leaflet prolapsed
 Elongated chordae
 Attempt for repair using 4/0 pledgeted prolene suture but
failed

9. Cont…
 Mitral valve replacement with 27mm ATS bileaflet mechanical
valve, using interrupted stitch technique.
 ASD closed with gluteraldehyde treated pericardial patch
 CPB weaned
 Postoperative period uneventful

10. Echocardiogram: Postoperative
 Normal prosthetic valve leaflet motion
 Velocity: 1.2m/s

11. Discussion

12. Discussion: Epidimiology
 Congenital mitral valve disease : 0.21% to 0.42% of clinical cases
(Kirklin/Barratt-Boyes Cardiac Surgery, 4th Edition, pg1816)
 Among clinical cases: 25% coexist with ASD
 In adults 37 to 70% of ASD patients have mitral prolapse 5% clinically severe
(Betriu A, Wigle ED, Felderhof CH, McLoughlin MJ: Prolapse of the posterior leaflet of the mitral valve associated with
secundum atrial septal defect. Am J Cardiol 35, 363 (1975))
 First valve repair by open approach using CPB; 1957 by Lillehei and
colleagues

15. Discussion: Techniques
Fig: Commissuroplasty with ring annuloplasty
Fig: Sliding plasty
Fig: Anterior leaflet
prolapse repair

16. Limitations
 Expensive Carpentier-Edwards or similar anuloplasty ring
 Peroperative TEE or Epicardial Echo required
 Redo surgery not feasible for failed repair

17. Take home message
 Repair, if feasible
 Replacement more effective