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Anatomic Correction of the Syndrome of Aortic Valve Cusp Prolapse and Subaortic VSD via Vertical Right Axillary Thoracotomy

Tuesday, June 4, 2024

Estafanos M, Rose A, Essa Y, M. Said S. Anatomic Correction of the Syndrome of Aortic Valve Cusp Prolapse and Subaortic VSD via Vertical Right Axillary Thoracotomy. June 2024. doi:10.25373/ctsnet.25968118

A seven-month-old, 8.5 kg infant was followed clinically for a large ventricular septal defect (VSD) until an echocardiographic evaluation raised concerns regarding aortic valve (AV) regurgitation secondary to a new prolapse of the aortic cusps into the large defect.

The combination of a large subaortic VSD, AV cusp (especially the right and/or non-coronary cusps) prolapse, and dilated associated sinus of Valsalva often present together and occur as a result of loss of continuity between the media and annulus of the AV, which results in sagging of the aortic annulus into the VSD. The repair in this video is done through a transaortic approach and results in an anatomic correction of all the components of the syndrome without using a prosthetic material.

Beginning the procedure with a vertical right axillary thoracotomy, surgeons entered the right chest through the right fourth intercostal space. After retraction of the right lung, the pericardial space was entered anterior to the right phrenic nerve. Heparin was administered systemically, and cardiopulmonary bypass (CPB) was initiated via central aortic and bicaval cannulation. After application of the aortic cross clamp (AXC), a hockey-stick aortotomy was made toward the middle of the noncoronary sinus of Valsalva of the aortic root and cardioplegic arrest was achieved via direct administration of cardioplegia into the coronary ostia. The large VSD was easily visualized via the aortic valve. A series of multiple interrupted 6-0 polypropylene sutures supported with bovine pericardial pledgets were placed in a horizontal mattress fashion passing through the crest of the interventricular septum and the aortic annulus, thus closing the defect, plicating the dilated sinus of Valsalva, and correcting the cusp prolapse. This addressed all the components of the syndrome.

The aortotomy was then closed in a two-layer fashion, the heart was deaired, and AXC was removed. The patient was weaned off CPB and post bypass transesophageal echocardiogram confirmed excellent repair with trace AV regurgitation, no prolapse, and no significant residual ventricular level shunt. The patient was then decannulated, heparin was reversed, and the incision was closed in the standard fashion. The AXC and CPB times were 68 and 91 minutes, respectively.

The patient was extubated in the operating room, received no transfusions, and the rest of the postoperative course was uneventful. He was discharged 48 hours later and continued to do well during his follow up with trivial aortic regurgitation.


  1. Yacoub MH, Khan H, Stavri G, Shinebourne E, Radely-Smith R. Anatomic correction of the syndrome of prolapsing right coronary aortic cusp, dilation of the sinus of Valsalva, and ventricular septal defect. J Thorac Cardiovasc Surg 1997; Feb 113(2): 253-60
  2. Said SM, Greathouse KC, McCarthy CM, Brown N, Kumar S, Salem MI, Kloesel B, Sainathan S. Safety and efficacy of right axillary thoracotomy for repair of congenital heart defects in children. World J Pediatr Congenit Heart Surg 2023 Jan; 14(1): 47-54


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Dr. Said, quite enjoyed this videos and all your submissions. Please keep up the hard work! Yacoub's technique was reviewed in 2010 from Green Lane/Starship hospital. This repair although has nice initial results, the incidence of progressive aortic regurgitation is not insignificant. Preferably, patch closure through the right atrium or pulmonary valve (sewing to the musclular rims of the defect or the pulmonary valve annulus), supports the sinus and prevents the leaflet prolapse. Below is the reference: " Midterm Results of Repair of Perimembranous or Conal Ventricular Septal Defects Using the Transaortic Direct Suture Technique" Suresh Babu Kale,Kirsten Finucane, Tee-ling Chan,Elizabeth Rumball, and Tom Gentles. Annals of Thoracic Surgery. Volume 89 (4), 2010. pp1244-49
Thank you, Dr. Artrip for your insightful comments and glad that you enjoy our submissions. As you expect the main goal of this video is to demonstrate the feasibility of the technique and the safety and excellent outcomes of the right axillary approach. In terms of the repair technique itself, I agree with you that life-long follow-up of these cases is critical to watch for recurrent aortic regurgitation. Now, in terms of whether using the standard trans-atrial approach with patch, I think if you don't correct the aortic prolapse at the first encounter, there is always a chance of progression and recurrence of aortic regurgitation whether you have a patch or not. In the study you cited, 9 patients had moderate or severe aortic regurgitation prior to surgery (unclear if this was all due to simple prolapse of the cusp or not), two patients had early failure while they were in the hospital and required early reoperation (I assume 2 out of those 9) and it is unclear to me if there was total correction of the aortic valve cusp prolapse post-repair or not? (the authors did not describe the echocardiographic findings post-repair in terms of total correction of the prolapse or not and if there was residual aortic regurgitation or not) and also unclear what was the mechanism of recurrent aortic regurgitation, was there a residual shunt that continued to create the Venturi like effect on the cusp etc...? Also was these with the conal vs the perimembranous VSDs? I think these are all important factors to consider. I also quote the authors of this study " Alternative surgical techniques for dealing with this problem, including simple patch closure, may not prevent the onset or progression of AR". and also "severity of preoperative AR strongly predicted the need for reoperation. This association has been described previously in the context of patch closure of VSD, as has older age. Others have found that grades of AR greater than moderate may be progressive despite surgical intervention".. At the end, I believe we understand more now about aortic regurgitation and the techniques of repair compared to the past and I believe you have no prolapse post repair and adequate coaptation length, the chance of recurrence will be minimal regardless of the technique used. Thank you again for the stimulating conversation and for providing the reference.

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