Before CPB

Harvest the pericardium as a large patch as usual (ticrons on four corners with enough length to move within the field, save in moist saline gauze sandwich).

Dissect as usual – aorta, PAs to hilum, duct, PA, SVC, IVC. Can desaturate when mobilising the PDA/PAs. Double-sloops around the PAs to carry out the Lecompte later on. 2x ticron to go around the duct and ready to ligate, and leave them long on clips. Place a long length of prolene on the LA appendage and place it under the heart and the end on a rubber-shod on the bottom of the wound.

32C.

Before XC

Go on CPB. Lungs off after doubly tying off the duct. 6-0 prolene to transfix the aortic end and cut this suture. (Careful of friable duct tissue from aorta, can lead to bleeding).

Mobilise LPA and RPA to their first divisions to allow Lecompte. Visualise and mark with a 7/0 prolene the site for coronary transfer.

Cauterise a small spot on the ascending aorta for the cardioplegia cannula. Place the U-stitch for the CP cannula, and place the cannula.

XC

X-clamp ensuring it does not catch the PAs. Give cardioplegia. Remove the tape around the aorta. Snare the venacava. Open the right atrium and place a vent through the ASD into the left side. Remove the CP cannula (give the little rubber back) and replace with an olive-tipped cannula for selective ostial injection for the next dose.

Coronary harvest

Transect the aorta. Place 3 stays (prolene) on the aortic wall (not full thickness) above the commissure (in-out, or out-in) and place them on rubber-shod mosquitos. Use the mosquitos and assistant (rough sucker and forceps) to keep the sinus stretched out to visualise coronary ostia and leaflets.

Dissect out the left coronary button with Jameson fine scissors to go down the sides., leave the tall length of the commissural post. Use 90-deg castro scissors to dissect near the annulus, or continue with Jameson scissors. Use the coronary probe to work out the direction of the LAD/LCx. Use diathermy on 10 (or 8 if very close to the coronary) to dissect a bit further from the myocardium, and free from the adventitia. Repeat the same for the right coronary button. Use the mobility of the harvested buttons to see the stretch and lie to the neo-aorta (previously marked sutures).

If the coronaries come off a single ostium, judge the distance between the two to see if enough rim can be left on both coronaries when splitting them into two separate coronaries.

If there is an intramural portion, unroof the intramural portion.

Neo-PA sinus reconstruction

Adjust the commissural retraction sutures to lay open the sinuses for patching. Place the previously harvested autologous pericardial patch on the superior left-hand side keeping it stretched, and the smooth surface facing up (i.e. to go inside the neo-PA).

Use 7-0 prolene to start suturing the patch to create the neo-pulmonary sinuses. Start FH out-in on the patch (where ‘in’ is the smooth surface), and place a rubber-shod on the left side to keep it stretched. Then FH in-out on the neo-pulmonary edges. Small bites close together. Continue all the way towards the nadir and up the other side towards the operator.

Once near the commissure again, make a slit on the pericardium for the commissure. Continue with the same stitch to the top of the commissure on the operator side. Tie off the end with a loop (use a half-silk to make the tying easier if not enough length). Take the other end of the suture and continue up over the commissure and tie off again similarly with a loop for one of the hands.

Once completed, place all the stays of the neo-PA at the bottom of the field to make room. Give cardioplegia (selective ostial).

MPA transection + Coronary re-implantation

Transect the MPA near its bifurcation near the previously placed marking stitch. Use the Jameson scissors pointing inferiorly. Stays to the neo-aortic valve commissures. Cut out a L or J-shaped incision for the LCA, and a straight slit for the RCA.

8-0 prolene from right to left around the coronary button to the neo-aorta. Similarly 8-0 around the right coronary button. Switch from inside-edges together to outside edges together when coming up on the other side of the coronary button, always checking if the valve or the ostium has been caught.

Lecompte + Ascending aorta reconstruction

Mobilise LPA and fix the sloop to the left side of the patient. Same for the RPA. Lecompte manouevre by moving the sloops above the transected ascending aorta. Neo-aortic root (with the coronaries already implanted) to the ascending aorta using 7-0 prolene.

ASD closure + XC off

Open the RA. Use assistant with pump sucker and forceps to see the ASD. (Look out for large Eustachian valve or remnants of the balloon septostomy). 6-0 to close the ASD. 6-0 to close the RA. Deair. Clamp off. Tie down ASD stitch to close. Check the coronaries for lie, stretch, filling, air.

Neo-MPA reconstruction

Place vent in the RA-RV. Adren 0.05 Milrinone 0.3 Rewarm Neo-PA to bifurcation anastomosis with 7-0 prolene. 6-0 single layer for RA closure. Place pacing wires. LA line.