Open the pericardium to the right, so a piece of pericardium may be harvested if needed later to augment the SVC-PA anastomosis.

Place stay sutures as usual.

Start with the aorta (mosquito) and place a sling.

Free the adventitia from the aorto-pulmonary area on the RPA and the LPA. Mobilise the PAs enough to get mobility for a side-biting clamp. Snare them in elastic loops.

Dissect the SVC from the pericardium using scissors (to avoid phrenic nerve injury) and diathermy where needed. Dissect as far as the azygos. Go around the azygos by going around the SVC on either side of the azygos. Ligate using 5/0 prolene away from the SVC-azygos junction, and leave it in continuity.

Place a marking suture on the mid-point of the anterior aspect of the SVC to get the correct orientation of the SVC, to prevent torque on the forthcoming anastomosis.

Purse-strings and snares around the SVC and IVC as usual. Place the superior purse-string at the SVC/innominate junction in order to get maximum length on the SVC.

Cannulate normally (aorta, IVC onto CPB at 34C, SVC).

Snare the SVC cannula. Use forceps to fold the SVC in half at the marking suture, and place a cross-clamp as distally as possible. Place another cross-clamp on the SVC above the SA node. 5/0 prolene to oversew (back and forth) and release the clamp.

Hold either side of the top of the RPA, and open the PA with a blade (11 or 15). Use scissors to open it to a slightly larger size than the SVC opening.

Use 6/0 PDS to start on the SVC (start anteriorly to go around the left angle and end up doing the backwall). Take very small bites on the SVC (depth and width) as it is very elastic. Avoid handling the PA. Make a small slit in the SVC on the anterior wall to avoid kinking. Release the PA snares to de-air and tie the anastomosis.

For atrial septectomy, X-clamp/give cardioplegia, snare the cavae, open the RA, visualise the fossa and cut the edges into the interatrial folds, staying away from the tricuspid valve/conduction system/CS.

Release clamp/off bypass/echo/pacing wires (ventricular only), drain (x1).

No need for anticoagulation. Can extubate early.