Muscular VSD Repair With PA Band Removal and PA Plasty

Case Presentation 

This video presents the case of a 6-year-old female with a history of a larger posterior muscular ventricular septal defect and a previous placement of a pulmonary artery band at six weeks of age. 
 
Six years later, the patient was experiencing exercise intolerance and exhibiting signs of progressive cyanosis. 
 
A preoperative transesophageal echocardiogram demonstrated a 9 mm ventricular septal defect (VSD) with bidirectional shunting, a fenestrated atrial septal defect (ASD), a mildly dilated and hypertrophied right ventricle, and a pulmonary band gradient of 83 mmHg with a peak systolic velocity of 2.5 m/s. 
 
Due to the progressive cyanosis, bidirectional shunting of the VSD, and increased pulmonary band gradient, the cardiothoracic surgical team elected to proceed with closing the VSD and debanding the patient. 
 
Surgery 

The patient was first heparinized and cannulated bicavally. Cardiopulmonary bypass commenced in the standard fashion, with 15 mL/kg of antegrade del Nido cardioplegia administered.  
 
Attention was then directed to the right atrium. An oblique right atriotomy incision was created to visualize the large muscular VSD. The septal and moderator muscle bands were noted, along with partial obstruction from the papillary muscle and secondary chords. 
 
CorMatrix was brought into the surgical field, and 5-0 Prolene sutures were used to close the VSD in a running fashion.  
 
Care was taken to ensure no trapping or injury to the tricuspid valve chordal apparatus.  
 
Saline was then used to ensure complete septal closure. Attention was then drawn to the atrial septum, which demonstrated a large fenestrated atrial septal defect. This was further closed with CorMatrix and 5-0 Prolene sutures in a running fashion. The surgeon then focused on the removal of the previously placed pulmonary artery band. 
 
Following band removal, suitably sized dilators were unable to pass beyond the scar tissue of the previously placed band. For this reason, Metzenbaum scissors were utilized for a vertical pulmonary arteriotomy superior to the banding site, which was extended toward the pulmonary valve.  
 
CorMatrix was used as a pulmonary artery patch plasty and secured into place using 5-0 Prolene sutures in a running fashion. 
 
Following completion of the patch, dilators were passed antegrade through the pulmonary artery with no signs of obstruction.  
 
After deairing, the cross-clamp was removed, the patient was separated from cardiopulmonary bypass and was closed in the standard fashion. 
 
Postoperation 

The postoperative transesophageal echocardiogram demonstrated excellent biventricular function and no evidence of residual VSD, ASD, or trivial tricuspid valve regurgitation, with a 24 mmHg gradient at the level of the pulmonary artery plasty. The patient was discharged on postoperative day four. 

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