Smaller skin incision from sternal angle – if so, free up some soft tissue superiorly.

Clear the pericardium of fat and layers using a dry swab after removing the thymus before opening the pericardium.

Use scissors to open pericardium to get cleaner edges. Leave the right pleura closed till the end to avoid the lungs getting in the way.

Pericardium hitched on the opposite side on clips – so it can be brought down to start patching if necessary. (don’t make the distance too wide between the stays for the patch; usually bottom half on the left side, but ?upper half is quicker – especially if making the pericardial window to the left at the same time?)

Mosquito to retract aorta. Straight to aortic purse-strings x2. Make first one/inside purse-string towards assistant.

Dissect the pericardium off the SVC using scissors – check for anomalous veins/large SVC. Place purse-string on the medial aspect of the SVC so cannulation can happen without assistant. (?snug SVC purse-string)

[circulating; stop circulating; wait for clamped here] Divide lines, secure with clips, cannulate aorta. Adjust cannula to correct height. Allow assistant to snug, then snug own, and tie silk around only assistant’s purse-string with cannula. Pull out the trocar, clamp, remove the cap/trocar. Place swab on top of the cannula with the luer lock up. Unclamp and deair. Connect up to the tubing. [through to you, give 10] Place both snuggers on own side, place folded towel over them, stretch out the cannula and place a silk suture to hold the cannula on the top drape.

Asst to hold hand-held pump sucker in right hand and retract the RA with the left hand. Cannulate SVC (no stretching needed with GOSH cannula). Snug, tie, [go on bypass, one pipe]. Secure the SVC cannula in position with Kelly. Place purse-string on the IVC (horizontal mattress with open end toward own). Cannulate IVC. Snug, tie, [two pipes, cool to 36, (or 34, 35), full flow, lungs off]. (No vent needed for ASD – Purse-string on RUPV/leave blood behind/cannulate for vent). Snare SVC (ratchetless), snare IVC (right-angle DB).

Purse-string for plegia (simple u-stitch with U towards operator). Place root cannula, remove needle, flow down, trickle, cardioplegia, XC, flow back up, give cardioplegia. Slush. Get patch ready during cardioplegia delivery.

At 2min – Open RA (using scissors) with suckers inside (right up on suckers, yellow to assistant outside, blue to surgeon inside the atrium), continuing with plegia. Place RA closure suture as one of retraction sutures on a shod. Place ticron stays on both sides (2x) with wide bites so it is easier to cut the suture later.

At 3min – Examine septum, valve, coronary sinus, SVC, and pulmonary veins. Excise any fenestrations.

At 5 min – Start suturing (forehand outside in on the septum, forehand inside out on the patch) on the rightward aspect. After a few, cut the patch (don’t make it too big), cut one of the stays, hold the other stay and parachute the patch, assistant pulling on the other end. Bottom half first (so deairing is through top/medial half), coming to the top. (24 bites, 10s/bite, total 4 mins). Rewarm.

At 8min – Get additional 5-0 singles ready (x2-3 for the other corners.), get lungs ready. LA vent off, allowing some blood behind to collect.

At 9 min (before tying), deair – blows on the lungs, deair the aorta (root vent connected) tie the running suture.

At 10 min – ensure root vent working, flow down, clamp off. Place 3 interrupted sutures on the suture line.

Cut the atrial stay to the right and retract the other one to the top. Start closing the atrium (2 layers, partial/equal thickness, forehand). Cardiology/TOE/echo/Ventilate.

CPB wean – SVC clamp. Check for air – remove root vent. Cardiology to check for residual/TR/AR. Protamine.

Drains x2, pacing wires.

Decannulate. Check purse-strings, pack, right window.

Wires, remove packs.