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PREOPERATIVE DIAGNOSIS
HIGH BILATERAL GLENN PRESSURES
PULMONARY INSUFFICIENCY
RIGHT PULMONARY ARTERY STENOSIS
STATUS POST COMPLETE REPAIR OF UNBALANCED AV CANAL DEFECT WITH BILATERAL
BIDIRECTIONAL GLENN
POSTOPERATIVE DIAGNOSIS
HIGH BILATERAL GLENN PRESSURES
PULMONARY INSUFFICIENCY
RIGHT PULMONARY ARTERY STENOSIS
STATUS POST COMPLETE REPAIR OF UNBALANCED AV CANAL DEFECT WITH BILATERAL
BIDIRECTIONAL GLENN
OPERATION
REDO STERNOTOMY WITH LYSIS OF ADHESIONS AND REMOVAL OF DEEP-SEATED STERNAL
WIRES
TAKEDOWN OF RIGHT BIDIRECTIONAL GLENN WITH RIGHT SVC TO RA ANASTOMOSIS
RIGHT PULMONARY ARTERY PATCH AUGMENTATION
PLACEMENT OF 14-MM RV-TO-PA PULMONARY HOMOGRAFT
PARTIAL CLOSURE OF LEFT PULMONARY ARTERY ORIGIN
INDICATIONS FOR THE PROCEDURE
-------- is a complex unbalanced AV canal patient who had a one-and-one-half
ventricle repair approximately a year ago. He subsequently had balloon
dilatation of his AV valves because of stenosis. He remains with significant
diuretic management because of elevated Glenn pressures. He was recently
presented in a combined cardiovascular conference, we agreed to proceed with
takedown of the right Glenn, banding of the proximal LPA, and placement of
RV-to-PA conduit because of severe pulmonary insufficiency.
OPERATIVE FINDINGS
The patient had bilateral bidirectional Glenn. There was RPA stenosis at the
level proximal to the right bidirectional Glenn.
DESCRIPTION OF PROCEDURE
With the patient in supine position under excellent general anesthesia, the
chest and abdomen were prepped and draped in the standard fashion. The chest
was entered through the previous median sternotomy incision. The previous
sternal wires were deeply embedded in the sternum. The wires were cut and
removed. The sternum was then divided using the oscillating saw. The
undersurface of each hemisternum was then carefully dissected from the
underlying mediastinal structures. The chest retractor was then placed and
opened. The epicardium of the heart was then carefully dissected from the
pericardium circumferentially. The right bidirectional Glenn was carefully
dissected. Both branch pulmonary arteries were extensively mobilized.
Pursestring sutures were placed in the distal ascending aorta, proximal right
SVC, and in the IVC. Intravenous heparin was given. The heart was then
cannulated in the standard fashion. Cardiopulmonary bypass was instituted and
the patient was cooled down to 35�C. A tourniquet was placed around the LSVC.
I first proceeded to divide the right superior vena cava as it entered the
right pulmonary artery. I then extended the incision in the right pulmonary
artery proximally past the area of narrowing. The RPA was then augmented using
a patch of Gore-Tex material which was sewn in place using 6-0 Prolene in a
running fashion. I then proceeded to clamp the right atrial appendage and a
longitudinal arteriotomy was made in the right atrium. The right SVC was then
anastomosed to the right atrium using a lateral patch of Gore-Tex material in
order to augment the anastomosis. I then proceeded to open the right
ventricular outflow tract where there was minimal pulmonary valve tissue. I
then was able to identify the proximal aspect of the right and left pulmonary
arteries. I proceeded to place a Gore-Tex patch at the mouth of the left
pulmonary artery just proximal to where the left Glenn anastomosis entered. It
became quite clear that a proximal LPA band was impossible to perform because
of the closeness of the Glenn anastomosis to the most proximal aspect of the
LPA. After closing the mouth of the LPA, I proceeded to make a hole in the
middle of the Gore-Tex tube to allow antegrade flow into the LPA but in a
restrictive fashion. The hole probably measured approximately 3 mm to 4 mm. I
then proceeded to place a 14-mm pulmonary homograft in the RV-to-PA position
to provide pulmonary valve competency. Distally, the conduit was sewn to the
central pulmonary arteries using 5-0 Prolene in a running fashion. Proximally,
it was sutured in a similar fashion. We then started to rewarm. On the
transesophageal echocardiogram there was good biventricular function. The
patient was then weaned from cardiopulmonary bypass without any difficulty.
Modified ultrafiltration was performed. The heart was then decannulated. The
pursestring sutures were tied and the cannulation sites reinforced using 5-0
Prolene suture. Careful hemostasis was obtained. A mediastinal chest tube was
placed. The incision was then closed in layers. A sterile dressing was
applied.
PREOPERATIVE DIAGNOSIS
HIGH BILATERAL GLENN PRESSURES
PULMONARY INSUFFICIENCY
RIGHT PULMONARY ARTERY STENOSIS
STATUS POST COMPLETE REPAIR OF UNBALANCED AV CANAL DEFECT WITH BILATERAL
BIDIRECTIONAL GLENN
POSTOPERATIVE DIAGNOSIS
HIGH BILATERAL GLENN PRESSURES
PULMONARY INSUFFICIENCY
RIGHT PULMONARY ARTERY STENOSIS
STATUS POST COMPLETE REPAIR OF UNBALANCED AV CANAL DEFECT WITH BILATERAL
BIDIRECTIONAL GLENN
OPERATION
REDO STERNOTOMY WITH LYSIS OF ADHESIONS AND REMOVAL OF DEEP-SEATED STERNAL
WIRES
TAKEDOWN OF RIGHT BIDIRECTIONAL GLENN WITH RIGHT SVC TO RA ANASTOMOSIS
RIGHT PULMONARY ARTERY PATCH AUGMENTATION
PLACEMENT OF 14-MM RV-TO-PA PULMONARY HOMOGRAFT
PARTIAL CLOSURE OF LEFT PULMONARY ARTERY ORIGIN
INDICATIONS FOR THE PROCEDURE
-------- is a complex unbalanced AV canal patient who had a one-and-one-half
ventricle repair approximately a year ago. He subsequently had balloon
dilatation of his AV valves because of stenosis. He remains with significant
diuretic management because of elevated Glenn pressures. He was recently
presented in a combined cardiovascular conference, we agreed to proceed with
takedown of the right Glenn, banding of the proximal LPA, and placement of
RV-to-PA conduit because of severe pulmonary insufficiency.
OPERATIVE FINDINGS
The patient had bilateral bidirectional Glenn. There was RPA stenosis at the
level proximal to the right bidirectional Glenn.
DESCRIPTION OF PROCEDURE
With the patient in supine position under excellent general anesthesia, the
chest and abdomen were prepped and draped in the standard fashion. The chest
was entered through the previous median sternotomy incision. The previous
sternal wires were deeply embedded in the sternum. The wires were cut and
removed. The sternum was then divided using the oscillating saw. The
undersurface of each hemisternum was then carefully dissected from the
underlying mediastinal structures. The chest retractor was then placed and
opened. The epicardium of the heart was then carefully dissected from the
pericardium circumferentially. The right bidirectional Glenn was carefully
dissected. Both branch pulmonary arteries were extensively mobilized.
Pursestring sutures were placed in the distal ascending aorta, proximal right
SVC, and in the IVC. Intravenous heparin was given. The heart was then
cannulated in the standard fashion. Cardiopulmonary bypass was instituted and
the patient was cooled down to 35�C. A tourniquet was placed around the LSVC.
I first proceeded to divide the right superior vena cava as it entered the
right pulmonary artery. I then extended the incision in the right pulmonary
artery proximally past the area of narrowing. The RPA was then augmented using
a patch of Gore-Tex material which was sewn in place using 6-0 Prolene in a
running fashion. I then proceeded to clamp the right atrial appendage and a
longitudinal arteriotomy was made in the right atrium. The right SVC was then
anastomosed to the right atrium using a lateral patch of Gore-Tex material in
order to augment the anastomosis. I then proceeded to open the right
ventricular outflow tract where there was minimal pulmonary valve tissue. I
then was able to identify the proximal aspect of the right and left pulmonary
arteries. I proceeded to place a Gore-Tex patch at the mouth of the left
pulmonary artery just proximal to where the left Glenn anastomosis entered. It
became quite clear that a proximal LPA band was impossible to perform because
of the closeness of the Glenn anastomosis to the most proximal aspect of the
LPA. After closing the mouth of the LPA, I proceeded to make a hole in the
middle of the Gore-Tex tube to allow antegrade flow into the LPA but in a
restrictive fashion. The hole probably measured approximately 3 mm to 4 mm. I
then proceeded to place a 14-mm pulmonary homograft in the RV-to-PA position
to provide pulmonary valve competency. Distally, the conduit was sewn to the
central pulmonary arteries using 5-0 Prolene in a running fashion. Proximally,
it was sutured in a similar fashion. We then started to rewarm. On the
transesophageal echocardiogram there was good biventricular function. The
patient was then weaned from cardiopulmonary bypass without any difficulty.
Modified ultrafiltration was performed. The heart was then decannulated. The
pursestring sutures were tied and the cannulation sites reinforced using 5-0
Prolene suture. Careful hemostasis was obtained. A mediastinal chest tube was
placed. The incision was then closed in layers. A sterile dressing was
applied.