- A 14-year-old male presented with dyspnea, respiratory infections, and weakness since birth. Echocardiogram showed severe mitral regurgitation, dilated right heart chambers, and a large atrial septal defect. - He underwent median sternotomy with mitral valve replacement using a 27mm mechanical valve and closure of the atrial septal defect with a pericardial patch. - Postoperative echocardiogram showed normal prosthetic valve function and no residual shunt. Surgical correction effectively treated his congenital mitral valve disease and atrial septal defect.

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