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21st World Congress of the World Society of Cardio-Thoracic Surgeons

Image of the Week: Jan. 26, 2006 -- Sinoatrial Artery

18 year old girl with rheumatic mitral disease (MS + MR) with Afib LA size 6.8- underwent a mitral valve replacement (attempted repair but valve was too badly deformed and so was replaced) + electrocautery maze. She is in sinus rhythm now. She had a particularly large sinoatrial artery crossing over the dome of the Left atrium.

Patient had a fixed orifice which causes stenosis and regurgitation. Trial commissurotmy showed a plastered PML subvalvar apparatus (you can see the white wall of subvalvar tissue. You can also see that the PML motion is totally restricted thus not allowing the leaflet to move up despite traction by two forceps.

The posteromedial commissure shows division of the fibrosed subvalvar apparatus into two halves to allow it to be shared on both sides of the commissure.

I initially tried to divide some posterobasal chordae and tried to fenestrate the subvalvar and tried to delamellate it from the posterior LV wall.But since everything was so fused I really could not free the PML to my liking. I did a trial Panneth Burr annuloplasty to see the intermediate result which I felt was pretty bad because the PML was still tethered.

I was planning to detach the whole PML from its subvalvar and replace them with Goretex chords but I chose to back out based on the patients general condition. I don't think she would tolerate two CPB runs easily if the repair failed.

I also want to emphasize the traction suture that I use (for students) that enables the mitral valve to virtually come up to the incision enabling precise repairs.

Submitted by:

Dr. Prasanna Simha M
Sri Jayadeva Institute of Cardiology
Bangalore, India


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