surgical techniques aimed at avoiding damage to the conduction system in manipulations mainly on the cardiac surgery

1. conducting system of heart
during cardiac surgery

2. Directed by
DR.Karar .A.Ali
department of cardiothoracic surgery
kararbenign@gmail.com

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16. • Figure 2: Representative angiographic images of
the SNA (arrows) demonstrating the general
feasibility of its visualization.
• (A) a normal SNA; (B) SNA with a focal stenosis
(arrowhead); (C) diffuse atherosclerotic disease
involving also the SNA; (D) stenosis of the main
left coronary artery upstream the SNA
(arrowhead).

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This heart with tetralogy of Fallot shows the
typical devia- tion of the outlet septum and
the overriding aorta. The yellow line depicts
the position of the atrioventricular conduction
tissues on the posteroinferior border of the
ventricular septal defect.

25. •
Schematic representation of the
atrioventricular conduction tissues
in the presence of a
perimembranous ventricular septal
defect. The bundle usually lies on
the left ventricular aspect of the
posteroinferior border of the defect.
The star marks the position of the
atrioventricular node. Modified,
adapted, and used with permission
from Davies et al. 9

26. • Right ventricular view of the atrioventricular
transition, showing a perimembranous ventricular
septal defect (VSD) extending slightly to the outlet.
The yellow line shows the location of the
atrioventricular conduction axis.

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These two hearts opened through the right ventricle show muscular
ventricular septal defects (VSD) positioned in different parts of the
septum (trabecular and inlet). The yellow lines indicate the location
of the conduction axis, running posteroinferiorly or anterocephalad
relative to the VSD.

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30. • These two hearts with atrioventricular septal defect
were dissected differently. The upper panel shows a
view of the common atrioventricular junction and the
aorta (Ao) displaced anterosuperiorly. The lower
panel demonstrates a heart opened through the right
ventricular chambers. The atrioventricular node is
displaced posteroinferiorly due to the deficiency of
the atrioventricular septation. The initial part of the
nonbranching bundle is usually covered by the inferior
bridging leaflet but the anterior part lies on the bare
surface of the crest of the ventricular septum.

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32. • The left-sided panel shows a heart with
atrioventricular septal defect with two valvar
orifices due to the fusion of the bridging leaflets.
Such tissue fusion protects the long
atrioventricular conduction axis from surgical
damage during defect correction. The right panel
shows in a histological section the presence of a
bundle branch hidden by the leaflet tissues.

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34. • Opened right atrium
in a case of absent
right atrioventricular
connection. The star
shows the anticipated
site of the
atrioventricular node
on the floor of the
atrium. ICV indicates
inferior caval vein.

35. • Opened right atrium
showing the tricuspid
valvar orifice overriding
the inlet ventricular
septum. The anomalous
node is located at the
site where the
ventricular septum
reaches the inferior
right atrial wall. The
atrioventricular bundle
runs on the bare surface
of the ventricular crest.

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39. • Different surgical techniques for correction of an
AVSD. Single patch correction (A), double patch
correction (B) and modi fi ed single patch (C) where
the valve is attached to the ventricular septum are
shown. In all techniques closure of the so-called cleft
in the left atrioventricular valve (LAVV) is performed
(1) and often approximation of the septal parts of the
right atrioventricular valve (RAVV) (2) and
approximation of the 2 left lateral commissures of the
LAVV (3) are performed. RA = right atrium, LA = left
atrium, RV = right ventricle, LV = left ventricle.

55. triangle of Koch

62. (A) Main panel shows a heart cut in
a plane simulating transesophageal
view with the superior vena cava
(SVC) at 11 O'clock position. The
circles mark the leaflet commissures
and the white lines trace the
segments of the hinge line. Note the
smooth wall vestibule of atrial wall
leading to the valve orifice. The
smaller panels taken from random
specimens demonstrate the
thinness of the vestibular wall and
variations in relationship of the
hinge line (arrows), depth of fat-
filled atrioventricular groove, and
location of right coronary artery(*)
at the numbered segments.