This is a long note for just a little verbiage for the cath. It is at the very end of the report. Thank you.
PREOPERATIVE DIAGNOSIS
TRANSPOSITION OF THE GREAT ARTERIES, STATUS POST BALLOON SEPTOSTOMY
POSTOPERATIVE DIAGNOSIS
TRANSPOSITION OF THE GREAT ARTERIES, STATUS POST BALLOON SEPTOSTOMY
OPERATION
ARTERIAL SWITCH OPERATION
ATRIAL SEPTAL DEFECT PRIMARY CLOSURE
PLACEMENT OF TRANSTHORACIC RIGHT ATRIAL BROVIAC CATHETER
PLACEMENT OF PERITONEAL DRAINAGE CATHETER
ECMO SUPPORT
INDICATIONS FOR THE PROCEDURE
Newborn infant with transposition of the great arteries
who comes to the OR for surgical repair. I was called urgently to the room
because of the patient being hypotensive and requiring CPR.
OPERATIVE FINDINGS
The patient had normal coronary anatomy. There was a lot of blood and clot in
the right pleural space upon opening. No clear site of bleeding was
identified. There was a large atrial septal defect.
DESCRIPTION OF THE PROCEDURE
I arrived to the room and Anesthesia was performing CPR. After a few seconds,
the patient again had a pressure thus, we proceeded to prep and drape
relatively quickly. A median sternotomy incision was then performed and the
chest retractor was in place and opened. Upon entering, I noted that there was
a lot of blood and clots in the right pleural space. The blood and clots were
drained and removed. I could not identify any obvious source of bleeding. The
pericardial space was then opened and a segment of pericardium was harvested
and placed in glutaraldehyde. Pursestring sutures were placed in the distal
ascending aorta, and the SVC, and the IVC. Intravenous heparin was given. The
branch pulmonary arteries and the PDA were carefully dissected. The pulmonary
end of the PDA was encircled with a 5-0 Prolene suture. The patient was noted
to have normal coronary anatomy. The heart was then cannulated and
cardiopulmonary bypass was instituted. The patient was cooled down to 32�C.
The PDA was ligated. A second ligature was then placed in the PDA and the PDA
was transected. Tourniquets were placed around both caval cannulas. The
ascending aorta was carefully dissected from the underlying pulmonary artery.
An LV vent was placed through the right superior pulmonary vein. An antegrade
cardioplegic catheter was placed in the proximal ascending aorta. The aorta
was then crossclamped and the heart arrested using cold antegrade blood
cardioplegia. The cardioplegia was given approximately every 20 minutes during
the crossclamp period. The mid ascending aorta was transected. The main
pulmonary artery was then transected proximal to the bifurcation. The LeCompte
maneuver was then performed by bringing the pulmonary arteries anterior to the
distal aorta. The native pulmonary trunk was then anastomosed to the distal
aorta using 7-0 Prolene in a running fashion. Both coronary buttons were then
harvested from the native aorta and the coronary buttons were extensively
mobilized. Cardioplegia was then delivered into the empty neoaortic root in
order to dilate the sinuses. Oblique incisions were made in the left and the
right facing sinus with the left coronary button was reimplanted using 7-0
Prolene in a running fashion. There was excellent coronary flow while giving
cardioplegia. Oblique incision was made in the left facing sinus more
superiorly where the right coronary button was reimplanted in a similar
fashion. I then proceeded to open the right atrium and the atrial septal
defect was closed primarily using a 5-0 Prolene in a two-layer fashion. The
atriotomy was then closed using a 5-0 Prolene suture. I then proceeded to
reconstruct the neopulmonary trunk using a patch of autologous pericardium.
The patch was sewn in place using 6-0 Prolene in a running fashion. The
posterior neopulmonary commissure was resuspended to the patch using 5-0
Prolene suture. The neopulmonary trunk was then anastomosed to the central
pulmonary arteries using 7-0 Prolene in a running fashion. The patient was
placed in the Trendelenburg position. The antegrade cardioplegia catheter was
used as an aortic root vent. CoSeal glue was then applied to all suture lines.
The aortic crossclamp was then removed. The heart resumed normal sinus rhythm.
There was clearly some dysfunction of the left ventricle. We attempted to come
off bypass but clearly, the patient was hypotensive and there was significant
left ventricular dysfunction. I therefore proceeded to go on ECMO support. An
ECMO circuit was prepared and we then proceeded to disconnect from the
cardiopulmonary bypass circuit and reconnect to the ECMO circuit. We had
excellent flow through the ECMO circuit. Careful hemostasis was obtained by
giving some intravenous protamine. A mediastinal chest tube was placed.
Temporary atrial and ventricular pacing wires were also placed. A peritoneal
drainage catheter was also placed. A transthoracic right atrial Broviac
catheter was also inserted. The chest was closed using a patch of Silastic
material.