DATE OF OPERATION : 07-17-84
PREOPERATIVE DIAGNOSIS : L transposition of the great vessels, dextrocardia, double outlet right ventricle, pulmonary stenosis, atrial septal defect, ventricular septal defect, single coronary artery.
POSTOPERATIVE DIAGNOSIS : Same.
SURGEONS : Peter Mansfield, M.D.; 1st assistant Edward Rittenhouse, M.D.; 2nd assistant Kathryn Batts, Physicians Assistant.
OPERATION : Median sternotomy, cardiopulmonary bypass 2 hours and 45 minutes, body temperature 26°, heart temperature 8°, potassium cardioplegia. Noncoronary perfusion time 2 hours, 19 minutes. Pulmonary arteriotomy, pulmonary valvulotomy (bicuspid, 7mm to 14mm opening). Right ventriculotomy, resection of right ventricular outflow obstructing bands, dacron patch closure of huge ventricular septal defect, right atriotomy (juxtaposed atrial appendages), suture closure atrial septal defect, insertion of temporary pacing wires x 3.
Shaun was brought to the operating room, appropriately premedicated by Doctor Eric Furman. He was anesthetized, intubated, arterial and central venous lines inserted, Foley catheter placed in the bladder, positioned supine, prepped and draped. A median sternotomy was performed. The sternum was bisected in the midline, tissues anterior to the pericardium were divided. The pericardium was opened on the right side, the anterior pericardium reflected, the left side for potential later use and the margins were sutured to the sternal margins. Double concentric pursestrings were placed high in the arch of the aorta. More proximal pursestrings subsequently placed for the cardioplegia line. Pursestrings were placed in the right superior vena cava and the inferior vena cava, which were found to be midline. The atrial appendages were juxtaposed and laid to the left of the ascending aorta. The superior vena cava came down into the pericardium, turned immediately toward the left side, and entered the back wall of the right atrium over the spine. The pulmonary artery lay slightly dorsal and well to the right of the aorta. Subsequent investigation would demonstrate that there was a muscular separation between the pulmonary valve and the aortic valve, a very small, perhaps 1mm, fibrous continuity between the aorta and tricuspid valve, complete fibrous continuity between the mitral and the tricuspid valves, a huge ventricular septal defect, a moderate sized atrial septal defect and severe pulmonary stenosis.
#2 silks were passed around the superior and inferior venae cavae. We heparinized the patient, inserted right angle venous lines into the corresponding cavae, inserted the arterial line, went on bypass, cooling toward an arterial temperature of 17° C. and body temperature of 26°. Tourniquets were cinched down, the cardioplegia line was inserted, the aorta cross clamped after we had reached 17° and the heart was stopped with the cardioplegia solution and iced ringers irrigated externally.
We first opened the main pulmonary artery. We came down on a bicuspid valve that had 7mm orifice and this was incised back on both sides to the point that a 14mm diameter Hegar dilator would pass through the valve retrograde. There were deep enough sinuses that it appeared this wide an opening would still permit the valve to be competent. We passed a right angle clamp through the pulmonary valve and investigated the location of the ventricular septum. Once this was established, we determined location for opening into the ventricle from which the two great vessels arose. This right ventricle was opened in a fashion parallel to the interventricular septum. There were multiple muscle bundles in the way of the right-sided outflow tract and the flow from the left ventricle out to the aorta. These were resected and then we could see the anatomy. There was a large aortic valve which overrode the ventricular septum either 100% or perhaps as little as 60%, depending upon the angle that you took from the septum up to the cranial aspect of the heart. We found a very large ventricular septal defect, no evidence of significant obstruction below the pulmonary valve, and complete fusion between the tricuspid and mitral valves. It was possible to place stitches right down this fusion between the valves and we used horizontal mattress interrupted sutures all the way around the ventricular septal defect in the muscular areas. We stayed well away from the ventricular septum where the bundle might be, although it was not possible to avoid coming close where we moved from the tricuspid valve to the ventricular wall.
With these preplaced sutures, we used Blue Cross dacron patch material and tied these sutures down in place. We passed three sutures trough the most superior aspect of this and out through the anterior muscle of the heart just below the aortic valve, which were later tied down. In the meantime we could use right angle clamp into the aorta to facilitate repeat cardiopledias.
We then opened the right atrial appendage, staying away from the body of the atrium, and through that closed with running 4-0 prolene the atrial septal defect that lay between the right and left atria. We carefully defined that each had an AV valve going to the appropriate ventricle before this atrial septal defect was closed. The atrium was then closed with running 5-0 prolene.
The main pulmonary artery was closed with a running 5-0 prolene as well. The right ventriculotomy was closed with interrupted sutures of 4-0 prolene carefully placed to avoid any of the branches of the single coronary artery present in this patient. The patient was tipped in steep Trendelenburg, left ventricular vent had been inserted through the left ventricular apex. I should mention that we did locate the small ventricular septal defect which was toward the apex by placing a light in through the left ventricular apical vent site, and by running it along the ventricular septum located the opening. The light was then passed through it and a single suture backed with Teflon pledgets was placed all the way around this opening and tied down. This should reduce if not close the flow through this particular VSD.
We placed the root cannula on suction and with the patient tipped in the steep Trendelenburg we released the superior and inferior venae cavae and ultimately slowly released the ascending aortic clamp. No air was seen after the aortic cross clamp had been opened and with the heart filled and the lungs ventilated, we ultimately removed the left ventricular vent after the heart was beating satisfactorily. It had spontaneously gone into a normal sinus rhythm. We maintained root suction for the next 20 minutes while we were rewarming and there was cardiac output. During that time we placed right angle chest tube in the mediastinum, a straight chest tube in the left hemithorax and atrioventricular and reference electrodes. At that point we removed the rot suction line and tied down the pursestring. We came off bypass without difficulty and without the need for pressor agents. The patient was decannulated without incident. Protamine was administered to reverse the heparin previously given.
We measured pressures in the right ventricle about 30 minutes off bypass and found them to be 46/6 with arterial pressures of 104/65.
Hemostasis was secured within the mediastinum. The sternum was approximated with #20 wires. The anterior fascia with #2-0 Mersilene, the subcutaneous tissues with Vicryl and skin with subcuticular pullout prolene. Steri-Strips were applied. Dry sterile dressings were applied.
Sponge counts were reported as correct by the nurse in charge on two occasions. Urine output before, during and after bypass was excellent. The patient left the operating room in good condition after the orotracheal tube was changed to a nasotracheal tube, and transported to the Intensive Care Unit.
Peter B. Mansfield, M.D.; Attending