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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4110_Библиотеки_им_академика_М_И_Перельмана
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using a running #6-0 polyproplyene suture. At this point, we then obtained a piece of bovine pericardium and trimmed this
according to the size of the ASD. Next we placed multiple interrupted horizontal mattress sutures going through the tip of the
Gore-Tex patch then through the left-sided AV valve and then through the bovine pericardium. These were then subsequently
tied down thus creating the septum of the heart. We then addressed the cleft in the anterior mitral valve leaflet. This was then
closed using multiple interrupted #6-0 polypropylene sutures. (Note: Make a comment on the appearance and nature of the
cleft and the manner and satisfaction with which it was closed). The valve was then tested and did not appear to be stenotic.
We were able to put a (SIZE) mm Hegar dilator through the orifice. The ASD was then closed using bovine pericardium and a
running #6-0 polypropylene suture. Next we re-approximated the septal leaflet to the septal portion of the patch using a running
#6-0 polypropylene suture in 2 layers (Variation: There was small PFO, which was closed using a running #6-0
polypropylene suture.) The patient was rewarmed.
The right atriotomy was closed using a running #5-0 polypropylene suture. De-airing maneuvers were performed. The aortic
cross-clamp was removed and the patient was subsequently weaned off cardiopulmonary bypass on a (QUANTIFY) amount of
inotropic support and excellent hemodynamics. The patient's LV function was (QUANTIFY). The patient (DID/DID NOT)
have heart block (Note: report the rhythm and rate coming off bypass).
Atrial and ventricular pacing wires were placed (Note: “subsequently atrial/AV pacing was/was not utilized). [Variation: We
did perform modified ultrafiltration for total of (DURATION) minutes with removal of (QUANTIFY) ml of volume taken off].
The protamine was given.
All cannulas were then removed and the purse strings tied and found to be hemostatic. A #19-French Blake drain was placed at
the inferior portion incision and sewn in place with #2-0 silk suture then positioned in the chest and subsequently connected to
Pleur-evac suction. Adequate hemostasis noted. We then re-approximated the sternum using several interrupted #1 stainless
steel wires. The wounds were closed in multiple layers of vicryl followed by monocryl suture followed by benzoin, Steri-
Strips and an occlusive dressing.
Instruments, sponges and needles counts were confirmed to be correct following conclusion of the operation. The patient was
then transferred to the Cardiac Surgery Intensive Care Unit in a stable fashion.
Dr. [BLANK] was present and scrubbed [BLANK] elements of this procedure.
5. Repair of Partial Anomalous Pulmonary Venous Return
Thomas Caranasos MD, Mark Bleiweis MD
University of Florida, Gainesville, FL
Essential Operative Steps
1. Preoperative imaging to determine the type of PAPVR, directing repair.
2. Lines and monitoring.
3. General endotracheal anesthesia.
4. Intraoperative TEE to confirm diagnosis.
5. Median Sternotomy.
6. Pericardial well and harvesting of native pericardium (if elected to use pericardium).
7. Identify and dissect Right Sided Pulmonary Veins.
8. Systemic heparinization.
9. Arterial cannulation.
10. Bicaval venous cannulation (High SVC or Innominate vein and IVC cannulation).
11. Antegrade and/or retrograde cardioplegia (direct cannulation after atriotomy) for myocardial protection.
12. Opening the right atrium to allow for repair.
13. Evaluation of the location of the anomalous pulmonary veins and their draining location.
14. Enlarging the Atrial Septal Defect if needed.
15. Creation of a baffle from the ostia of the anomalous pulmonary veins to the left atrium through the Atrial Septal
Defect or if needed disconnection of the SVC and drainage of the anomalous pulmonary vein through the ASD and
attachment of the SVC to the Right atrium (Warden Procedure).
16. Closure of the right atriotomy.
17. Rewarming, Warm blood cardioplegia “hot shot”.
18. Deairing of the left side of the heart.
19. Removal of the aortic cross-clamp.
20. Hemostasis of the atriotomy and/or SVC to Right Atrial connection.
21. Pacer wire placement.
22. Separate from CPB.
23. Venous decannulation.
24. Protamine administration.
25. Aortic decannulation.
26. Chest tube drainage.
27. Hemostasis and sternotomy closure.
Potential Complications and Pitfalls
1. Stay midline during sternotomy.
2. Cannulation catastrophe (aortic dissection/bleeding).
3. Insufficient myocardial protection (inappropriate aortic cross clamp, AI, insufficient venous drainage, persistent
LSVC)
4. Coronary sinus injury with retrograde cardioplegia cannulation.
5. Improper visualization of the draining veins.
6. Small ASD limiting flow and creation of a pressure gradient.
7. Improper size of the baffle limiting flow.
8. Patency of the SVC to right atrial connection.
9. Improper deairing.
10. Bleeding from atriotomy.
11. Inadequate control of hemostasis prior to sternal closure.
12. Late obstruction of the pulmonary venous circulation, pulmonary hypertension.
13. Post Operative arrhythmia.
Template Dictation
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Preoperative Diagnosis:
1. Partial anomalous pulmonary venous drainage of the right pulmonary veins to the right atrium.
2. Oval fossa atrial septal defect.
Postoperative Diagnosis: Same
Procedure(s) Performed:
1. Repair of partial anomalous pulmonary venous drainage by tunnel repair of the right pulmonary veins through the
atrial septal defect using autologous pericardium.
2. Closure of atrial septal defect.
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT – e.g. - newly
discovered partial anomalous pulmonary venous drainage of the right pulmonary veins on imaging.] She has evidence of
drainage of all the right pulmonary veins directly into the right atrium. There is also a small atrial septal defect. She has a
history of polysplenia and developmental delay.
Description of Procedure: After informed consent and patient identification, the patient was brought to the operating room and
placed in the supine position. After single lumen general endotracheal tube anesthesia appropriate monitoring lines were
placed. Patient was then prepped and draped in the usual sterile fashion.
A median sternotomy incision was made, and dissection carried down to the level of the pericardium. The thymus was
subtotally resected. The pericardium was then opened on the left side to preserve the pericardium for baffle repair if
necessary. The aorta was separated from the pulmonary artery. The superior vena cava was dissected. A large azygous vein
was identified which came in relatively close to the innominate vein. There were no pulmonary veins draining into the superior
vena cava. We could identify the right pulmonary veins and they appeared to be in normal position, however they entered the
right atrium proper. The patient had one episode of rapid supraventricular arrhythmia and synchronized cardioversion was
necessary. The patient resumed a sinus rhythm at that point. Heparin was administered. After placing appropriate pursestring
sutures, aortic and superior vena caval cannulation was performed. Cardiopulmonary bypass was instituted and an inferior
vena caval cannula was added. An antegrade cardioplegia cannula was placed in the ascending aorta and this was also used as
a root vent later in the case. The patient was allowed to drift to a low temperature of 34 degrees centigrade. The aorta was then
cross clamped and a smooth diastolic cardiac arrest was achieved using antegrade cold potassium blood cardioplegia. Both
caval snares were then applied.
An oblique right atriotomy was made. The retrograde cardioplegia cannula was placed directly into the coronary sinus os and
held in place with polypropylene pursestring.
The retrograde cardioplegia was administered every 15-20 minutes during the cross clamp time. The pulmonary venous
drainage from the right lung was noted to be to the right atrium. We also ensured that there were no other veins draining on the
right side. The left veins drained normally into the left atrium. Since there was a small oval fossa defect, the remaining oval
fossa tissue was excised. This produced a widely patent atrial septum. A patch of untreated pericardium was fashioned for
baffling of the veins to the left atrium. This was then sutured in place using continuous fine polypropylene suture. The left side
of the heart was de-aired prior to tying the knot.
[Variation: For Warden Procedure: A superior vena caval snare was placed above the level of the azygous. The azygous
vein was controlled with a neurovascular clip. Clamps were placed at the SVC-RA junction. The patient remained in sinus
rhythm. The superior vena cava was divided above the level of the pulmonary veins. The cardiac side was over sewn using a
continuous polypropylene suture, in two layers, first a running horizontal mattress suture followed by simple continuous
technique. The sutures were tied before releasing the clamp to prevent the pursestring effect. This was noted to be hemostatic.
Next the aortic cross-clamp was applied, and a smooth diastolic cardiac arrest was achieved using a single dose of antegrade
cold potassium blood cardioplegia. The inferior caval snare was applied. An oblique right atriotomy was made, avoiding the
right atrial appendage. Superior sinus venosus defect was identified and defect was opened inferiorly and enlarged. We then
ran a polypropylene suture to endothelialize the cut surface. Next a patch of autologous untreated pericardium was fashioned
for the patch closure of the sinus venosus atrial septal defect and baffling of the pulmonary veins to the left atrium. This was
sutured in placed using continuous 5-0 polypropylene suture. The left side of the heart was deaired through this site before
tying the suture. Then the aortic cross-clamp was removed and deairing was performed via the root vent. Patient resumed
normal sinus rhythm spontaneously. Right atrial appendage was opened at its tip. The pectinate muscles were excised to ensure
that the right atrial opening was widely patent. The anastomosis between the SVC and the right atrial appendage was
constructed using continuous 5-0 polyproplyene suture. The anastomosis appeared to be widely patent and it was suture was
tied this over a 10 mm dilator, which was the size of the vena cava. The right atriotomy was closed in two layers. Caval snares
were removed and the patient was adequately rewarmed].
A hot shot was initiated in retrograde fashion. During this time, the left side of the heart was deaired. Next we completed the
hot shot in an antegrade fashion and removed the retrograde catheter. The right atrial closure was initiated with continuous
horizontal mattress polypropylene suture. Caval snares were then removed, the hot shot was completed, and the aortic cross
clamp was removed. The right atrial closure was completed with a simple continuous technique. The patient resumed a normal
rhythm spontaneously. He/She was rewarmed to normothermia.
An adequate deairing in the heart was ensured by the transesophageal echo. A double lumen right atrial catheter was tunneled
from the upper abdomen. It was placed it in the right atrium and fixed in place using two pursestring polypropylene sutures.
Patient was successfully weaned from the cardiopulmonary bypass. Post repair transesophageal echocardiogram revealed
good biventricular function and no pulmonary venous obstruction.
Modified ultrafiltration was then performed (Optional). The patient was decannulated while heparin was reversed with
protamine sulfate. Atrial and ventricular pacing wires were placed. A right pleural drain was placed. A mediastinal chest
drain was added. Excellent hemostasis was assured prior to closure. The sternum was reapproximated using interrupted #4
wires.
The presternal fascial, subcutaneous and cutaneous tissue layers were approximated with continuous absorbable sutures.
Sterile dressings were applied. Sponges, needles and instruments counts were correct. The patient was taken to the intensive
care in a stable condition. Cardiopulmonary bypass time was [BLANK] minutes and total clamp time was [BLANK] minutes.
Dr. [BLANK] was present and scrubbed [BLANK] elements of this procedure.
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6. Supra-Cardiac Total Anomalous Pulmonary Venous Return
(TAPVR)
Juan M. Lehoux, MD and Carlos M. Mery, MD, MPH
Texas Children’s Hospital/Baylor College of Medicine, Houston, TX
Essential Operative Steps
1. Lines and Monitoring.
2. General endotracheal anesthesia.
3. Median sternotomy.
4. Perform partial thymectomy.
5. Open pericardium and set up pericardial well on stay sutures.
6. Dissect out the aorta, ligamentum arteriosum/PDA, SVC, and identify vertical vein.
7. Systemic heparinazation.
8. Bi-caval cannulation (may use single right atrial cannula).
9. Confirm ACT (>400).
10. Start cardiopulmonary bypass.
11. Ligate ligamentum arteriosum/PDA.
12. Cool to 18 degrees.
13. Dissect out the vertical vein.
14. Place apical stitch to aid in retraction of the heart.
15. Dissect out pulmonary venous confluence.
16. Cross clamp the aorta and instill cardioplegia once at desired temperature.
17. Start circulatory arrest.
18. Ligate the vertical vein.
19. Open the venous confluence widely with a longitudinal incision (may extend the incision into the vertical vein)
without entering the pulmonary vein orifices.
20. Inspect the pulmonary venous orifices.
21. Note: The rest of the procedure may be performed with a combination of circulatory arrest, low-flow
cardiopulmonary bypass, and full cardiopulmonary bypass if bicaval cannulation, or under circulatory arrest if
single venous cannulation.
22. Snare IVC and SVC if bicaval cannulation; remove atrial cannula if single atrial cannulation.
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23. Oblique right atriotomy.
24. Identify ASD.
25. May enlarge the ASD in order to inspect the left atrium and choose the best site for anastomosis.
26. Make incision on the posterior wall of left atrium corresponding to the incision on the pulmonary venous
confluence (may include the left atrial appendage depending on the size and lie of the left atrium).
27. Perform anastomosis between pulmonary venous confluence and left atrium with 8-0 polypropylene in running
fashion.
28. Close the ASD using either a patch or primary closure of the septum primum.
29. If single venous cannulation, close the right atriotomy, replace the cannula, and restart CPB.
30. Start rewarming.
31. De-air the left sided chambers.
32. Remove the aortic cross-clamp.
33. Vent the left heart via the left atrial appendage (if not included in the anastomosis) or the patch (prior to
complete closure) until the left ventricle regains adequate function.
34. Close the right atriotomy (if bicaval cannulation).
35. May insert LA line through the left atrial appendage (if not included in the anastomosis). May insert PA line if
patient had significant obstruction and there are concerns for pulmonary hypertension.
36. Resume ventilation.
37. Wean from cardiopulmonary bypass.
38. Sequential decannulation.
39. Place mediastinal tubes
40. May place peritoneal dialysis catheter to aid in postoperative fluid management
41. Sternal closure.
Potential Complications and Pitfalls
1. Avoid phrenic nerve injury during thymectomy.
2. Do not place too much tension on pericardial well in order to avoid worsening obstruction of the pulmonary
veins.
3. Do not ligate vertical vein until in circulatory arrest or after the pulmonary venous confluence is open in order to
avoid worsening pulmonary venous congestion.
4. Avoid right phrenic nerve injury when dissecting out the SVC.
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5. Completely dissect SVC in order to avoid missing entry of a separate pulmonary vein
6. Make pericardiotomy towards the left side to allow for harvesting of patch material if autologous pericardium is
to be used.
7. Limit incision to the venous confluence. Avoid manipulating pulmonary veins.
8. Avoid twisting/kinking of anastomosis.
9. Make anastomosis as wide as possible.
10. Do not allow the left ventricle to distend. Vent heart thru left atrial appendage if possible.
11. LA and/or PA lines may help for postoperative monitoring.
12. Peritoneal dialysis catheter may facilitate postoperative fluid management.
Template Dictation
Preoperative Diagnosis: Obstructed supra-cardiac total anomalous venous return (TAPVR)
Postoperative Diagnosis: Same
Procedure(s) Performed: Repair of obstructed supra-cardiac total anomalous venous pulmonary return via direct
anastomosis.
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT – e.g. - acute
desaturations into the 70’s soon after birth.] Patient was started on non-invasive respiratory support with no improvement. He
was emergently intubated and transferred to the NICU. An Echocardiogram was performed which revealed supra-cardiac total
anomalous pulmonary venous return with an obstructed vertical vein. Patient was taken urgently to the operating room for
repair.
Description of Procedure [using bicaval cannulation]: The patient was brought to the operating room and placed on the
operating table in the supine position. General anesthesia was induced. Monitoring lines were placed. The patient was
prepped and draped in the usual fashion.
A median sternotomy was performed. A subtotal thymectomy was performed. The pericardium was opened and set on stays to
create the pericardial well. A piece of autologous pericardium was harvested for future use. Dissection was performed around
the aorta, superior vena cava and the ductus arteriosum. The aorta, superior and inferior vena cava were cannulated for
cardiopulmonary bypass. After confirmation of adequate ACT, bypass was initiated. The ductus arteriosus was ligated. The
patient was cooled to 18 degrees. During cooling, the vertical vein was identified entering the innominate vein. The vertical
vein was dissected and followed inferiorly towards the pulmonary venous confluence. The confluence was dissected out by
incising the posterior pericardium. Once the patient was at 18 degrees, the aorta was cross-clamped and antegrade
cardioplegia was given. Smooth cardiac arrest was quickly achieved.
A pledgeted 6-0 polypropylene was placed on the apex of the heart to facilitate retraction upwards and rightwards. The
dissection of the pulmonary venous confluence was then completed. Circulatory arrest was started and the vertical vein was
ligated and divided at its entry point into the innominate vein. The venous confluence was incised longitudinally with care not
to incise the individual pulmonary orifices. The veins were individually inspected.
Cardiopulmonary bypass was re-started. The SVC and IVC were snared, the right atrium was incised in the usual fashion. A
large secundum ASD was identified. The left atrium was inspected through the ASD. The ideal area for the anastomosis was
identified by lining up the left atrial wall to the previously made confluence incision. Special care was taken to avoid torsion
at the site of the anastomosis by visualizing the area of the anastomosis from both inside and outside the heart.
The posterior wall of the left atrium was incised longitudinally up to the left atrial appendage mirroring the incision made in
the pulmonary venous confluence. Using a combination of circulatory arrest and low-flow cardiopulmonary bypass, the
anastomosis was performed between the pulmonary venous confluence and left atrium with 8-0 polypropylene suture in running
fashion. After completion of the anastomosis, all 4 pulmonary veins were probed through the ASD and were found to be
patent. Full cardiopulmonary bypass was restarted and the patient was rewarmed.
The ASD was closed (primarily/with a patch) using a running [Blank] polyproplyene (The left atrial appendage was incised to
vent the left heart.). After de-airing, the cross-clamp was removed. The patient regained a spontaneous sinus rhythm. The
right atriotomy was closed with running 6-0 polypropylene (Optional: A left atrial line was placed through the left atrial
appendage in the usual fashion. A pulmonary arterial line was placed in the main pulmonary artery for pressure monitoring).
Once the patient was warm, ventilation was re-started. Cardiopulmonary bypass was weaned with (careful assessment of left
atrial and pulmonary arterial pressures and) very judicious volume monitoring. The venous cannulas were removed. After
confirmation of adequate hemodynamics, protamine was given. The aortic cannula was the removed.
A temporary peritoneal catheter and mediastinal tube were inserted. After confirmation of hemostasis, the patient’s sternum
was closed with steel wire in the usual fashion. The fascia, subcutaneous planes, and skin were closed in layers. The patient
tolerated the procedure without complications and transported to the Pediatric Cardiac Intensive
Care Unit in a satisfactory condition. Sponge, needle and instrument counts were correct.
Cardiopulmonary bypass time was [BLANK] minutes. Hypothermic circulatory arrest time was [BLANK] minutes and cardiac
ischemia time of [BLANK] minutes.
Dr. [BLANK] was present and scrubbed [BLANK] elements of this procedure.
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