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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