Question Bank

Long Questions (25 Marks)

Cardiac
- Describe the anatomy of ventricular septum of man & what
developmental anomaly may require surgical intervention.
- Role of mitral apparatus in LV contraction various replacement
operations preserving mitral apparatus.
- Causes and mechanism of Thrombosis of prosthetic heart valves and
MV of a patient with thrombosed prosthetic valve.
- Anatomy of MV apparatus and congenital malformation of MV.
- Discuss normal aortic root, what are the structures encountered during
aortic root enlargement.
- Discuss morphology of TV, etiopathology of TR and highlight basic
principles of surgical management.
- Discuss management in of acute MI indicating pros and cons of each
therapeutic procedure.
- Discuss the modification of fontan operation and their application.
- Discuss surgical anatomy of tricuspid valve and management of tricuspid
atresia.
- Discuss variation in the pathological anatomy of TGA which make
diagnosis difficult / impossible.
- Describe the method of detection and prevention of rejection of human
heart transplant.
- Classify supraventricular tachy arrythmias and their surgical
management.
- Classify DORV, diagnostic criteria and surgical management.
- Discuss surgical management of TAPVC in < 6months of age.
- Development of interatrial septum, Classify ASD,Describe surgical
management of Sinus Venosus type of ASD.

808
- Discuss the diagnosis & management of Dissecting Aneurysm of thoracic
aorta.
- Discuss the embryology & anatomy of interventricular septum.
- Describe the course & relations of arch of aorta.
- Discuss the pathology & management of Acute aortic incompetence.
- Discuss the current status of saphenous vein as a coronary artery
bypass graft & the results of redo CABG procedures.
- Describe the anatomy of the fibrous skeleton of the Heart.
- Describe the anatomy of the conduction system of the normal heart &
TOF.
- Describe briefly the embryology & pathological anatomy of the
endocardial cushion defects.
- Describe the anatomy, pathophysiology and surgery for ruptured sinus of
valsalva.
- Describe the morphology of tricuspid valve. Discuss the various causes of
regurgitation & highlight the basic principles of its surgical management.
- Describe the morphology of mitral valve. Discuss the various etiological
causes if regurgitation highlight the various basic principles involved in
the repair of the mitral valve.
- Describe the anatomical development of aortic abscess & mention
various surgical anomalies that can result because of congenital
malformation.
- Etiopathogenesis of pulmonary arterial hepertension and its significance
in cardiac surgery.
- Describe the venous drainage of the heart & explain in detail the clinical
relevance.
- Anatomy of aortic root & various procedures for aortic root enlargement.
- Describe the development of pulmonary artery. Describe the
characteristics of pulmonary blood flow in diminutive or absent central
pulmonary arteries.
809
- Anatomy of mitral complex.
- Describe the anatomy of mitral valve annulus.Describe the various
techniques of mitral valve repair.
- Describe the anatomy of aortic root & discuss the surgical management
of aortic root.
- Classification of tricuspid atresia & surgical procedures.
- Complications of coronary artery disease & its management.
- Discuss in details the anatomy, physiological consequences &
management of hypoplastic left heart syndrome.
- Redocardiac surgery Problems & management.
- Pulmonary embolism & its management.
- Pulmonary thromboendarterectomy.
- Discuss the fibrous skeleton of the heart & its surgical implications.
- Describe the venous drainage of the heart & its applied significance.
- Describe in brief the development of interventricular septum. Describe
various classifications of VSDs and discuss the clinical relavence of each
classification.
- Discuss brain protection during aortic surgery.
- Discuss various techniques of myocardial pretction and their cellular &
molecular basis.
- Describe various causes of right ventricular outflow tract obstruction &
their treatment with surgery.
- Classify complete AV canal defects & describe the principles of surgical
corrections.
- Discuss the anatomy of the mitral valve apparatus & applied
significance.
- Describe the collateral circulation in the coarctation of the aorta below
subclavian artery & its clinical significance.
- Describe the conduction system of the heart & its surgical importance.

810
- Describe the development of pulmonary venous system & left atrium.
Describe briefly anomalies due to maldevelopment.
- Compare off pump CABG with onpump CABG with respect to multivessel
coronary artery disease.
- Discuss bioprosthetic heart valves & their utility in clinical practice.
- Discuss the pathophysiology of chronic constrictive pericarditis & its
surgical management.
- Discuss the Fontan circulation & describe various modifications of
fontan procedure.
- Discuss the indications for Rastelli procedures.
- Give a diagrammatic presentation of various coronary artery patterns in
transposition of great arteries. Discuss the management of a 5 month old
child with d-TGA. What is the only criteria for the correction of
transposition of coronary arteries.
- Describe the clinicopathological difference between pulmonary atresia
with VSD and pulmonary atresia with intact ventricular septum, Discuss
the role of surgery in both of them.
- Describe the causes of difficulties in weaning of CPB following open heart
surgery & its management.
- Discuss the ductus dependant circulation and management of one of
them.
- Describe various indications for CABG and discuss the conduits used for
CABG.
- Discuss surgical management of Atrial fibrillation.
- Describe surgical techniques of cardiac transplantation.
- Techniques of total arterial revascularisation, conduits used & long term
results.
- Discuss the Jones criteria for rheumatic heart disease & current status
of rheumatic prophylaxis.

811
 - Defie renovascular hypertension . Describe its pathophysiology &
treatment modalities.
- Discuss the role of transthoracic & transesophageal echocardiography in
cardiac surgery.

Thoracic
- Surgical anatomy of thymus & pathogenesis of myasthenia gravis.
- Classify carcinoma of lung discuss various treatment procedures of small
cell Carcinoma of the lung.
- Describe anatomy of lower end of oesophagus and management of reflux
oesophagitis.
- Discuss various treatment modalities used in post thoracotomy pain
management.
- Describe the etiopathogenesis & diagnosis of bronchopleural
fistula.Discuss the management of bronchopleural fistula.
- Development of diaphragm and surgical treatment of diaphragmatic
hernia.
- Describe the Bronchopulmonary segments & discuss the aetiology &
management of Bronchiactesis.
- Describe the congenital tracheoesophageal fistula & discuss the
management.
- Discuss the pathogenesis, investigations & surgical management of
recurrent hemoptysis.
- Describe the anatomy of the mediastinum & discuss the anterior
mediastinal tumours.
- Describe the anatomy of bronchopulmonary segments & its surgical
significance.
- Describe the pathophysiology of pulmonary sequestration & its surgical
management.
- Describe the pathophysiology & management of Bronchiectesis.
812
 - Describe the pathology of mediastinal tumours.
- Describe the surgical anatomy & management of congenital atresia of the
oesophagus.
- Describe the anatomy of thymus & discuss the pathogenesis and various
modes of management of myasthenia gravis.
- Discuss the pathology of Carcinoma of the lung and the principles in
management.
- Anatomy of Trachea. Indications of tracheal surgery & the procedures of
tracheal resections.
- Discuss the anatomy of diaphragm with special reference to different
diaphragmatic hernias.
- Discuss Pulmonary function parameters in relation to cardiothoracic
surgery.
- Anantomy of oesophagus & its lymphatic drainage.
- Discuss the various types of carcinoma of oesophagus & their
management.
- Describe etiology of stricture oesophagus & its treatment.
- Explain the lung volume & discuss various pulmonary function tests &
their clinical application.
- Discuss the surgical anatomy of the mediastinum with special reference
to mediastinal tumours.
- Discuss various endoscopic diagnostic procedures for the diagnosis of
thoracic diseases of surgical importance.
- Discuss the lymphatic drainage of the lungs with reference to
Bronchogenic carcinoma.
- Describe the various fungal infections of lungs & heart which are of
interest to cardiothoracic surgeon and their treatment.

Vascular

813
 - Embryology of carotid arterial system of brain & discuss management of
ICA stenosis.
- Anatomy of radial artery & the tests performed to evaluate the adequacy
of blood flow through the hand.
- Surgical anatomy of aortic root, Pathology and management of annulo
aortic ectasia.
- Discuss clinical features and management of chronic atherosclerotic
aorta iliac obstruction.
Miscellaneous
- Schematic representation of coagulation cascade, evaluation &
management of bleeding disorders after Open heart surgery.
- Etio-pathology & management of Acute renal failure after open heart
surgery.
- Activated clotting time.
- Factors affecting blood loss during open heart surgery & detailed
methods of management to minimize the same.
- Describe the cardiovascular reserves in health & post op cardiac surgery.
How can you manipulate them in post op period in order to achieve
successful result.
- What is Low cardiac output ,Investigations & management modalities of
Low cardiac output
- Discuss the methods in use for blood conservations in open heart
surgery.
- Describe the physiology of Cardiopulmonary bypass.
- Describe various factors contributing to the pathophysiological changes
associated with cardiopulmonary bypass.
- Describe the pathophysiology of hypothermia with reference to open
heart surgery.
- Discuss the consequences of reduced core temperature below 36 degree
centigrade.
814
 - Describe the factors affecting cardiac output & its pharmacologic
manipulations.
- Discuss the cardiopulmonary bypass setup for infant cardiac surgery.
- Describe the recent advances in myocardial protection for cardiac
surgery.
- Discuss the coagulation cascade & outline the mechanism of action of
various anticoagulant & pro coagulant medications.
- What are the various organisms for nosocomial infections in recovery
rooms & intensive care units? Describe methods of preventing them.
- What perfusion strategies you will adopt for the aneurysm of the arch of
aorta? Discuss the technique.
- A 45 year old person came up for double valve replacement. What would
be your preferred method of myocardial management?
- Discuss in brief stem cell therapy in peripheral & myocardial
angiogenesis with reference to source of stem cells, its route of
administration, advantage & disadvantage.
- Discuss the scope & indications of robotics in cardiac surgery.
- When is myocardial viability is assessed? Discuss current modalities
available to assess myocardial viability.
- Describe the concept of tissue engineered heart valve. Discuss in brief
current status of heart valve banking & heart valve substitute in India.
- Describe principles & various uses of PET in cardiac evaluation.

Short Questions (10 Marks)

Cardiac
- Surgery of PDA with PAH.
- COA of aorta .
- Unroofed CS.
- Double aortic arch.
815
- Classification of aortic arch dissection.
- Complete common AV canal.
- Extra cardiac conduits.
- Scimatar syndrome.
- Discuss blood supply of SA node & its surgical importance.
- Coronary sinus type of TAPVC.
- Classify DORV, diagnostic criteria and surgical management
- Interrupted aortic arch.
- Hypo plastic left heart syndrome.
- Post operative pulmonary hypertensive crisis an its management.
- Heart failure in first month of life.
- Ebstein anomaly.
- Persistent LSVC.
- Cor tritriatum.
- Pulmonary artery banding.
- Discuss surgical management of TAPVC in < 6months of age.
- Development of interatrial septum, Classify ASD,Describe surgical
management of Sinus Venosus type of ASD.
- Double Aortic arch.
- Maze procedure.
- Indications of ascending aorta replacement.
- Management of pulmonary hypertensive crisis.
- Indications & techniques of aortic valve repair.
- Etiology, diagnosis & management of endomyocardial fibrois.
- Surgical management of ectopia cordis.
- Indications & techniques of femoral bypass.
- REV procedure.
- DKS operation.
- Anastomotic devices in CABG.
- Geometric repair of LV aneurysm.
816
- Synthetic patches & graft used in cardiac surgery.
- Endartrectomy in coronary artery disease.
- TMR.
- HOCM.
- Surgically induced CHB.
- Management of carotid artery disease in patients with coronary artery
disease.
- Arterial switch operation.
- Surgical treatment in congestive heart failure.
- Vascular endothelial growth factor.
- Aneurysm of ductus arteriosus.
- Nonpulsatile axial pump.
- Recoarctation of aorta, definition and management.
- Congenital vascular ring.
- Infracardiac TAPVC.
- Cryopreservation.
- Phrenic nerve injury.
- Technique of closure of PDA during CPB.
- Conduit reconstruction of RVOT.
- Prevention and treatment of PR following TOF repair.
- Palliative shunts for TOF .
- Surgical anatomy of TOF.
- Discuss RVOT obstruction .
- Absent PV syndrome in infancy .
- Discuss diagnosis complications and management of post operative
bleeding following total correction of TOF.
- MAPCAS.
- TOF correction which small PA.
- Surgical management of RVOT obstruction .
- Anomalies of coronary arteries in management of TOF.
817
- Trans atrial repair of TOF.
- Outline Surgical treatment of single ventricle .
- Anomalous connection of left CA to PA (ALCAPA).
- Management of hypo plastic left heart syndrome .
- Evolution of fontan surgery .
- Discuss the modification of fontan operation and their application .
- Discuss surgical anatomy of tricuspid valve and management of tricuspid
atresia.
- Compare following Mustard, Senning, Arterial Switch .
- How will you prevent AV conduction injury during closure of VSD
associated with correction of TGA .
- Discuss variation in the pathological anatomy of TGA which make
diagnosis difficult / impossible .
- His bundle mapping.
- Atrial Isomerism.
- Azygos vein.
- Classification of aortopulmonary window.
- Coarctation of aorta.
- Absent pulmonary valve syndrome.
- Cervical aortic arch.
- Sites of aneurysm in coarctation fo aorta.
- Truncus atreriosus.
- Cor triatriatum.
- Supracardiac TAPVC & management.
- Taussig bing anomaly.
- Bronchopulmonary collaterals.
- Pulmonary vascular changes in left to right shunts.
- Pathological anatomy in tricuspid atresia.
- Anatomical variations of truncus arteriosus.
- Pathological anatomy of the transposition complexes of the heart.
818
- Endocardial cushion defects- developmental anatomy.
- Unroofed coronary sinus.
- Classification of left ventricular outflow tract obstruction.
- Atrial isomerism.
- Persistant left SVC.
- Right ductus arteriosus.
- Trabecular septomarginalis.
- Glenn shunt.
- Ross procedure.
- Ebstein anomaly.
- Bulbus cordis.
- Pumonary atresia with intact ventricular septum.
- Current role of pulmonary artery banding.
- Treatment of Interrupted aortic arch.
- Long term results after tetrology of fallot correction.
- Explain unifocalisation & its indications.
- Merits & demerits of right atrial approach in VSD.
- Treatment of hypertensive PDA.
- Management of LSVC during ASD closure.
- Classification of endocardial cushion defect.
- Grading of pulmonary vascular disease.
- Dextrocardia.
- ASD surgery using thoracotomy approach.
- Gastroepiploic artery as a conduit in CABG.
- Intracoronary irradiation .
- CABG on beating heart .
- Radial artery as conduit in CABG .
- Transmyocardial and percutaneous laser revascularization .
- Coronary-coronary bypass surgery .
- Management of single CAD .
819
- Coronary artery bypass conduits .
- Minimal invasive CABG.
- Long term results of myocardial revascularization.
- BIMA .
- Coronary collaterals .
- Post infarction VSD.
- Coronary end arterectomy .
- Angiographic anatomy of Coronary artery.
- Recent concept in surgery of CAD.
- Recent diagnostic aids in CAD.
- Total arterial revascularisation.
- Discuss management in of acute MI indicating pros and cons of each
therapeutic procedure .
- Redo CABG .
- Failed Coronary angioplasty .
- Controversies in the management of IHD.
- Graft anastomosis in calcific ascending aorta in CABG.
- Tandem CAD / Tandem Lesions.
- Discuss problem of Coronary artery spasm during CABG .
- All conduits in CABG.
- Anatomy of the coronary sinus with relevance to the retrograde coronary
perfusion.
- Surgical anatomy of the LAD coronary artery.
- Role of CT angio in evaluating coronary artery disease.
- Assessment of myocardial viability.
- Surgical ventricular restoration.
- Role of mitral apparatus in LV contraction various replacement
operations preserving mitral apparatus .
- Causes and mechanism of Thrombosis of prosthetic heart valves and
MV of a patient with thrombosed prosthetic valve .
820
- Complications of mitral valve surgery.
- Anatomy of MV apparatus and congenital malformation of MV .
- MV repair.
- Options available in prosthetic valve.
- Prosthetic valve endocardtis.
- Echo/Doppler assessment of mitral regurgitation.
- Rationale for MVR for IHSS.
- Changing the trends in management of MS.
- Durablity of prosthetic MV.
- Management of giant left atrium during mitral valve procedure.
- Choice of prosthetic MV.
- Discuss balloon valvulo plasty verses surgery.
- Acute rupture of chordae tendinae of MV .
- Restenosis of MV.
- MV replacement in Small LA.
- Discuss the result and indications of balloon valvotomy.
- MVR in giant LA.
- MVR with chordal preservation.
- Complications of MVR.
- Surgical anatomy of mitral valve apparatus.
- A patient develops massive bleeding following mitral valve replacement.
Possbilities & management.
- A 50 year old male develops lowcardiac output after 6-7 hours of
surgery.How will you assess & manage him?
- A patient with mechanical mitral vave comes with acute dyspnoea. What
are the possibilities & management?
- An ideal heart valve.
- Stuck valve.
- AV repair procedure.
- Role of homograft AV in cardiac surgery.
821
 - Discuss normal aortic root, what are the structures encountered during
aortic root enlargement.
- Valve of echo in preop evaluation of AV surgery.
- Homograft AV.
- Surgical management of subaortic stenosis at various levels below AV.
- Discuss methods of AV construction for mild moderate AR .
- Discuss the results of AVR with cryopreserved AV homografts.
- Discuss morphology of TV, etiopathology of TR and highlight basic
principles of surgical management .
- Classification of tricuspid stenosis.
- Current status and future prospective of cardiac transplantation.
- Immunosuppressants in cardiac surgery .
- Factors influencing increased survival rate following the cardiac
transplantation of man .
- Describe the method of detection and prevention of rejection of human
heart transplant .
- LVAD.
- Implantable cardioverter defibrillator.

Thoracic
- Achalasia cardia, Morphological and Physiological changes.
- Lung volume reduction surgery .
- Flail chest, patho physiology .
- Results of lung transplantation.
- Pneumocystic carinii.
- Alveolocapillary membrane.
- Blood supply of trachea.
- Lower esophageal sphincter.
- Diagnosis of broncho pleural fistula & management .
- Clinical indications & current status of lung transplantation .
822
- Use of VATS in thoracic surgery .
- Manometry of lower oesophagus.
- Pleural mesothelioma.
- Management of acquired benign obstruction of lower end of oesphagus .
- Classify carcinoma of lung discuss various treatment procedures of small
cell Carcinoma of the lung.
- Thymomas.
- Thoracoplasty.
- Liemyoma of esophagus.
- ARDS.
- Anatomy of bronchial tree and management of bronchiecteasis.
- Lobar emphysema .
- Discuss middle lobe syndrome.
- Discuss treatment of recurrent pneumothorax.
- Mediastinoscopy.
- Branchial artery embolisation.
- Vanishing lung.
- Jet ventilation.
- Rib notching.
- Foregut cyst.
- Benign tumours of oesophagus.
- Discuss treatment of post pneumonectomy empyema.
- Silhuoette sign.
- Traumatic diaphragmatic rupture.
- Indications of surgery in pulmonary tuberculosis.
- Neurogenic tumours of mediastinum.
- Extralobar sequestration.
- Pulmonary AV fistula.
- Carinal pneumonectomy.
- Bronchial artery embolisation.
823
- Management of multilocular empyema.
- Esophagomyotomy.
- Techniques of lung isolation.
- Esophageal bougienage.
- Malignant pleural mesothelioma .
- Post mediastinal mass lesion.
- Complications following lung resection and their management .
- Differences in lung function test in restrictive and obstructive airway
disease .
- Histological types of broncogenic carcinoma and staging .
- Diagnosis, prognosis, and management of superior sulcus tumors outline
its results .
- Early oesophageal carcinoma .
- Chylothorax .
- Dysphagia lusoria .
- Bronchogenic cyst.
- Diagnostic techniques in evaluation of oesophageal diseases .
- Classify diaphragmatic hernia and their surgical management .
- Occult lung cancer.
- Vigorous achalasia .
- Discuss the life cycle of Echinococcus Granulosus.
- FNAC in thoracic surgery .
- Cystic lesions of mediastinum .
- Adult respiratory distress syndrome.
- VATS.
- Thoracic manifestation of HIV-I infection.
- Fracture first rib .
- Diffuse spasm of oesophagus.
- Pulmonary contusion.
- Ruptured diaphragm .
824
- Oesophageal manometry in health and disease.
- Relevance of thymectomy in myasthenia gravis .
- Oesophagomyotomy .
- Management of tracheal tumors.
- Benign Oesophageal Strictures .
- Traumatic amputation of left lower lobe of lung.
- Hypotension after pnemonectomy.
- Factors preventing gastro-oesophageal reflux .
- Azygos lobe.
- Congenital traecheo-oesophageal fistula.
- Chronic empyema thoracis.
- Pre-cancerous lesions of oesophagus.
- Management of benign tumors of lung.
- Carcinoid tumour.
- Fungal ball in lung.
- Hernia of bochdalak.
- Empyema and pnemothorax in infancy and childhood.
- Congenital lobar emphysema.
- Oesophageal diverticulae.
- Short course of chemotherapy in pulmonary tuberculosis.
- Coin lesion.
- Swan-ganz catheter.
- Describe anatomy of lower end of oesophagus and management of reflux
oesophagitis.
- Surgical management of gastro-oesophageal reflux.
- Bronchial closure following pnemonectomy.
- Tracheal prosthesis.
- Cervical rib.
- Completion pnemonectomy.
- Management of tracheal stricture.
825
- Oesophageal perforation.
- Management of infected dead space in pleural cavity.
- Describe treatment of recurrent pneumothorax.
- Describe method of surgical treatment of budd-chiari syndrome.
- Describe briefly surgical treatment of pulmonary metastasis.
- Pulmonary sequestration.
- Development of diaphragm and surgical treatment of diaphragmatic
hernia.
- Mediastinal tumours in children.
- Measurement of residual lung volume and its importance.
- Rationale of various surgical procedures for relief of hiatus hernia.
- Pulmonary embolism.
- Recent concept in management of mediastinal infection.
- Pulmonary hamartoma.
- Pathophysiology of open pnemothorax.
- Lung volume reduction surgery.
- PEEP.
- Systemic venous oxygen saturation (SVO2).
- FEV1.
- Parameters used in discontinuing respiratory support of patient
following OHS .
- Complication following long term ventilation .
- IPPV.
- High frequency positive pressure ventilation .
- Intermittent mandatory ventilation.
- Congenital sternal anomalies.
- Peek expiratory flow rate.
- Dysphagia lusoria.
- Chylothorax.
- Use of laser in trachea-bronchial lesions.
826
 - Flail chest injury.
- Name the bronchopulmonary segments and describe the lymphatic
drainage of the lung.
- Mediastinal tumours.
- Pharyngeal diverticulum.
- Staging of bronchogenic carcinoma.
- SVC obstruction.
- Discuss mediastinal cyst.
- Malignant pleural mesothelioma.
- Pectus excavatum.
- Mediastinitis.
- Pathology of Bronchial adenoma.
- Right scalene node.
- Azygos lobe.
- Achalasia cardia.
- Treatment of MDR & XDR TB.
- Oesophageal manometry.
- Oesophageal perforation.
- Empyema necessitallis.
- Drug resistance acid fast bacilli.
- Double lumen endotracheal tubes.
- Anantomy of trachea & techniques of mobilisation.
- Zenkers diverticulum.
- Reccurent laryngeal nerve.
- Thoracic duct.
Vascular
- Diagnosis of Thoracic outlet syndrome.
- Middle aortic syndrome .
- Cervical rib and its management .
- Marfanoid aneurysm of ascending aorta .
827
- Classify aorta dissection and its management .
- Coronary subclavian steal syndrome.
- Endovascular stenting.
- PTFE grafts.
- Compatment syndrome.
- Paraplegia following surgery on descen.ding aorta
- Doppler ultra sound in diagnosis of DVT.
- Factors affecting in blood flow through a stenotic artery .
- List the inflammatory collagen disorder lesions of thoracic aorta and
outline the role of surgery .
- Compare various material available for arterial replacement .
- Discuss clinical features and management of chronic atherosclerotic
aorta iliac obstruction.
- Etio pathology of aorta arteritis .
- Surgical anatomy of aortic root, Pathology and management of annulo
aortic ectasia .
- Pathology of syphilitic aortitis verses athero sclerosis.
- Classification and etiopahology of dissecting aortic aneurysm .
- Pathological anatomy of dissecting aneurysm of the aorta.
- Deep vein thrombosis.
- Subclavian steal.
- Internal thoracic artery.
- Schatzis ring.
- Aschoff nodules.
- Metabolic alkalosis.
- Tracheal strictures.
- A victim of a road traffic accidents comes with massive air leak in the rt.
intrecostal drains. How will you proceed to manage him?
- A healthy 5 year old child is brought to the hospital with breathlessness
& mild stridor. What are the possibilities & line of management?
828
 - How will you manage the chylothorax following CABG?
- Investigation and management of pulmonary embolism.

Miscellaneous
- Surgical management of AF.
- Cardiac contusion .
- Management of LV aneurysm .
- Surgical treatment of cardiac arrhythmias .
- Treatment of air embolism during OHS.
- Natriuretic peptids.
- Cardiac myxomas.
- Haemodynamic changes in constrictive pericarditis.
- Pectus excavatum .
- Management of sternal infection.
- Tricuspid valve endocarditis .
- Effect of nicotin on cardiovascular system.
- Rational of Lattisimus dorsi muscle in cardio myopathy .
- Use and complication of laser therapy in CV and thoracic surgery .
- Classify supraventricular tachy arrythmias and their surgical
management .
- Autotransfusion.
- Electrolyte monitoring in post of cardiac ICU.
- Unstable angina .
- Role of platelets in cardiac surgery.
- Surgery of EMF.
- WPW Syndrome.
- AIDS and cardiac surgery .
- Post operative compilations after pericardectomy for constrictive
pericarditis.
- Delayed sternal closure .
829
- Membrane oxygenator.
- Protamine reaction.
- Post surgical heart block .
- Minimally invasive surgery.
- Air embolism in cardiac surgery.
- ECMO.
- Treatment of Intraoperative problems in redo OHS.
- Factors affecting sternal healing .
- Discuss indications and results of dynamic cardio myoplasty .
- Discuss PA collaterals .
- Management of cardio myopathy .
- Blunt chest injury .
- Dual chambered pacemakers.
- Rota laser.
- Left atrial pressure.
- Membrane oxygenator.
- Atrial pacing.
- LVADS.
- Infected cardiac pacemakers.
- Salient design features & haemodynamics of any prosthetic heart
valve of your Choice.
- Cardiac Pacemakers.
- Modes of pacing.
- Pacemaker complications.
- Pulmonary artery balloon counter pulsation .
- Cardiac pacemakers and their use in the treatment of post operative
cardiac arrhythmias.
- Billable prosthetic valves .
- Advances in Cardiac pacing.
- Kaplan meier model.
830
- Triangle of Koch.
- Frank starling law.
- Ischemic preconditioning.
- Compare the haemodynamics of bileaflet valves and tilting disc aortic
valves.
- Compare and contrast early and late prosthetic valve endocarditis
discuss their treatment.
- Intro operative echo.
- DSA.
- Trans oesophgeal echo .
- 2D echo.
- Angiographic anatomy of coronary artery .
- Ultra sound of myocardium.
- Doppler principle.
- Echo in Valvular heart disease.
- CT scan in cardiac surgery.
- Use of MRI in cardiac surgery.
- Noninvasive modalities for Coronary anatomy.
- IABP.
- Retrograde cardioplegia.
- Physiological basis of warm heart surgery .
- Myocardial stunning.
- ECMO.
- Re-Perfusion injury .
- Various factors causing Myocardial injury during OHS and current
concepts of better Myocardial treatment.
- Principle of pediatric CPB.
- Retrograde cerebral perfusion .
- Fibrillatory arrest of heart .
- Cardioplegia .
831
- Physiological and bio chemical basis for Myocardial preservation.
- Hypothermia in OHS (over view).
- Pyrexia after CPB.
- Warm blood cardioplegia .
- Non pharmacological supports of operated heart.
- Prevention of paraplegia in aortic surgery .
- Strategies for Spinal cord protection.
- Infected cardiac pacemakers.
- Salient design features & haemodynamics of any prosthetic heart
valve of your Choice.
- Cardiac Pacemakers.
- Modes of pacing .
- Pacemaker complications.
- Pulmonary artery balloon counter pulsation .
- Cardiac pacemakers and their use in the treatment of post operative
cardiac arrhythmias.
- Billable prosthetic valves .
- Advances in Cardiac pacing.
- Compare the haemodynamics of bileaflet valves and tilting disc aortic
valves.
- Compare and contrast early and late prosthetic valve endocarditis
discuss their treatment.
- Bilateral submammry incision.
- Embryology of carotid arterial system of brain & discuss management of
ICA stenosis.
- Surgical anatomy of thymus & pathogenesis of myasthenia gravis.
- Subxiphoid incisions for cardiothoracic operations.
- Embryology & anatomy of Aortic arch.
- Anatomy of radial artery & the tests performed to evaluate the adequacy
of blood flow through the hand.
832
- Development of interatrial septum.
- Blood supply of sternum .
- Describe the anatomy of ventricular septum of man & what
developmental anomaly may require surgical intervention.
- Broncho pulmonary segments.
- RVOT.
- Schematic representation of coagulation cascade, evaluation &
management of bleeding disorders after Open heart surgery.
- Etio-pathology & management of Acute renal failure after open heart
surgery.
- Activated clotting time.
- Factors affecting blood loss during open heart surgery & detailed
methods of management to minimize the same.
- Describe the cardiovascular reserve sin health & post op cardiac surgery.
How can you manipulate them in post op period in order to achieve
successful result.
- What is Low cardiac output ,Investigations & management modalities of
Low cardiac output.
- Rheumatic carditis.
- Compare lung biopsy findings in MS,TOF,ASD.
- Lifecycle of echinococcus granulosus.
- Pathophysiology of MR.
- Methods of diagnosis & treatment modalities of infective endocarditis.
- Cyanotic coagulopathy.
- Noncardiac pulmonary odema of all OHS.
- Nosocomial infection in cardiac surgery.
- Physical principles of diffusion of gases.
- Additives in cardioplegia.
- Reperfusion syndrome/ Reperfusion injury after the CPB.
- Biopump.
833
 - Pulmonary embolism.
- Oxygen free radicals in cardiopulmonary bypass.
- Platelets & bleeding.
- Pulsatile perfusion.
- Use of filters in CPB.
- Dual chamber pacing.
- Atrial pacing.
- Elaborate on the additives used in cardioplegia.
- Overdrive pacing.
- Cardiac cycle.
- Cardiac metabolism.
- Diabetic foot.
- Saphenofemoral incompetence.
- Marker cardiac enzymes.
- Particulate emboli on CPB.
- Complement activation during open heart surgery.
- 1st heart sound.
- Diaphragmatic pacing.
- Paradoxical movement of chest.
- Diaphragmatic pacing.

Drugs
- Dobutamine.
- Oxygen free radical scavengers.
- Nitric oxide therapy.
- Pharmacological manipulations of pulmonary hypertensive crisis.
- Inotropic support after OHS.
- Vasodilator drugs in common use/ Vasodilators in cardiac surgery.
- Afterload reduction.

834
 - Anticoagulant therapy after prosthetic valve replacement in man &
women.
- Perioperative use of antibiotics in cardiac surgery.
- Beta blockers.
- Nitropruside.
- Isoprenaline.
- Digxoin.
- Compare vasopressor drugs in common use.
- Diltiazem.
- Anticoagulants in cardiac surgery.
- Dopamine.
- Milrinone.
- Amiodarone.
- Epsilon aminocaproic acid.
- Low molecular weight heparin.
- Protamine.

Recent advances
- Robotic cardiac surgery.
- New design of biological valves .
- Tissue valves in valve replacement .
- Principles involved in fabricating arterial substitutes .
- Tissue engineering in cardiac surgery.
- Role of Stem cell in Cardiac surgery.

History
- John Gibbon.
- Rene Favalaro.
- C Walton Lillehei.
- Alfred Blalock.
835
- Denton Cooley.
- Donald Ross.
- P K Sen.
- Alain carpentier.
- Alexis carrel.
- Micheal De Bakey.
- Alexis carrel .
- Norman Shumway.

836
 Theory answer writing samples

Arterial Switch Operation

Definition: -
It is a technique of the arterial switch operation involves transaction of the
great arteries, transfer of the coronary arterial origins & repositioning of great
vessels.

Historical Aspects: -
1975 Jatene - 1st successful Arterial Switch operation.
1978 Aubbert - APwindow creation & baffle technique.
1972 - 1976 - DKS Technique of ASO in TGA with SAS.
Various modifications of arterial switch came thereafter.

Indications: -
Primary ASO
1. TGA, VSD.
2. Simple TGA.
3. DORV with subpulmonic VSD.
ASO , Repair of other anomalies ,Later on Fontan
1. DILV.
2. TGA, SAS, CoA, Severe Arch hypoplasia, OR Interruption with
Ductus dependent descending aortic flow in neonates.
Two stage ASO
1. Simple TGA late presentation.
2. RV dysfunction & TR after Mustard or Senning operation.
Double Switch
1. CCTGA, VSD.
837
 2. Unrestricted PBF with /without Ebsteins anomaly of morphologic RV &
TV.

Contraindications: -
1. Fixed LVOTO / significant PS.
2. TGA with IVS after > 2 - 3 week LV/RV ratio < 0.6.

Rationale for ASO: -

A. Why ASO?
Anatomically LV is > suitable than RV.

Criteria LV RV

Shape Ellipsoid Coma

Contraction pattern Concentric Bellow like

(Twist) (Peristalsis)

Inlet & outlet orifice Proximity > Separated

(Same line) (Perpendicular
to outflow)

Pump Pressure Pressure

Coronaries Two One

Developmental Stratum compactum Thinner

Of Myocardium thicker
838
Derived LV sinus (Primitive Vent) Bulbous cordis

Papillary muscle Two Small, Numerous

Atrio vent valve Mitral,> suitable Tricuspid, < suitable

Mortality
Atrial switch Simple TGA 0 -15 %.
TGA, VSD - 10 60 %.
Arterial switch - < mortality.

Dysrhythmias 13 -100 % with Atrial switch.

< Arterial switch.

Sudden Death - > with Atrial switch.

RV dysfunction CHF, TR, Hypoxia > with Atrial switch.
Systemic venous obstruction 0 -67 % Atrial switch.
Pulmonary venous obstruction 9 -11 % Atrial switch.

Miscellaneous
1. Intra atrial shunts.
2. Selective perfusion of rt. lung.
3. Atrial volume & function.
4. Persistent LVOTO.

Special Physiological & Anatomical considerations: -

839
 LV Status of LV
@ LV must pump against SVR.
@ Risk es with higher wall stress.
Wall Stress = Intracavitary pressure x Dimension / Wall thickness
@TGA, IVS, No PS
LV wall thickness Normal - es with in PVR.
2 -4 months - LV wall thickness adapted to pulmonary circulation,
No longer sustain systemic workload.
ASO performed in < 2 wks.
@ TGA, VSD
LV wall thickness remains normal during 1st yr of life & operation
can be postponed.
LVOTO Present in 10 %.
@ Sub pulmonic membrane, Anomalous mitral valve attachment to
septum, pulmonary valve abn, Prolapsing TV tissue, Dynamic septal
displacement.
@ Since LVOT will function as outlet for systemic ventricle These
abnormality have obvious importance.
MV Anomalies 10 %.
@ Cleft AML ,Parachute MV, AV canal defect, Abnormal attachment of
chordae to the septum leads to MS/MR Important when valve is
systemic AV valve.
Pulmonary root & semilunar Valve
After ASO becoming a systemic valve. 10 % cases have major
malalignment of sinuses, leads to PR.
Coronary Artery Anatomy -

840
 @ Lei dens Convention: In which sinus 1 is on the right of an imagined
observer standing in the non facing noncoronary sinus of Valsalva &
looking toward the pulmonary trunk. Proceeding in a counterclockwise
fashion, the next sinus is sinus 2.

@ 94% have Dual coronary system.

@ 6 % have Eccentric coronary ostia & intramural coronary artery.
@ High Risk coronaries
# LCA abnormalities LAD & LCx from rt. side.
# Single coronary artery.
# Intramural coronary artery.
Pre-operative Preparation: -
TGA, IVS
BAS to be performed

841

Good Palliation Not a good palliation

ASO within 2 wks. PGE 1 infusion

Ductus opens Ductus not
opened

ASO 1 2 days Emergency ASO.
Pts from other hospitals within 2 months primary ASO.
TGA ,VSD / DORV
Manage pt. with Decongestive therapy

Improves ICU dependent Ward dependent

ASO at 68 wks Emergency ASO Early ASO.
TGA ,VSD / DORV with CoA with well formed Arch -
CoA repair through Lt. thoracotomy 1st followed by ASO as described
earlier.
TGA with Multiple VSD
PA banding followed by ASO.
TGA with Arch hypoplasia / severe CoA / IAA with SAS.
@ Paralysis, IPPV.
@ PGE1 infusion.
@ Dopamine, Vasodilators.
@ Correction Acid Base & Electrolyte imbalance.

Improves Does not improve

ASO in 24 hrs Emergency ASO.

842
 @ ASO, VSD closure, CoA /IAA repair, RVOT resection single stage.
@ Arch hypoplasia for repair
Arch diameter - < wt in kg + 1 (3kg - < 4mm, 2.5kg - < 3.5mm).
Echo criteria for ASO: -
1. Normal LV size.
2. Adequate LV posterior wall thickness.
3. LV geometry & Septal wall thickness.
4. LV inflow & out flow normal (dynamic LVOTO is not a C/I).
5. LVSP 2/3 systemic.
Assessment LV for ASO: -
1. LV/RV volume ratio - > 0.6.
2. Interventricular septum convex in RV /straight.
3. LV pressure > 50 mmHg (2/3rd / 1/2 systemic).
4. LV mass index - > 50 gm / m2.

Operative Technique: -
Position
@ Supine with head extended.
Anesthesia
@ GA, morphine or phentanyl induction with non depolarizing muscle
relaxant.
@ Phenoxybenzamine 1 -2 mg / kg.
@ Albumin 5 % with NS.
Exposure
@ Median sternotomy, harvest pericardium.
@ Dissect Aorta, MPA, LPA, RPA, and Ductus.
Perfusion
@ Priming Fresh (<24 Hrs) heparinised Blood, adjusted with clear
volume expanders to achieve a mixture of the patients & prime Hb of 9
gm/dl.
843
 @ Prime volume 100 ml /kg, Fresh blood, 10 mmol / lit soda bicarb, 30
mg / lit Heparin, 20 mg / kg methyl prednisolone.
@ Cooling & warm with blood nasopharyngeal temp gradient not > 10
degree.
@ Bypass flow maintained at 15-0 -220 ml / kg/min.
@ Temperature TGA with IVS 20 -22 degree, TGA VSD CoA 15 18
degrees.
@ Perfusion pressure
25 35 mmHg for 2 -3 kg.
35 - 45 mmHg for 3 -5 kg.
45 55 mmHg for 5 10 kg.
@ Basic perfusion flow 150 ml / kg / min Hb of 9 gm /dl.
@ Most neonate & infants treated with 1-2 mg / kg of phenoxybenzamine
IV before / just as CPB is begun.
Cardioplegia -
@ 110 ml /min /m2 for 2 4minutes.
@ Repeat plegia 110 ml /min /m2 for 2mins.
@ Temp 5 6 degree.
@ Plegia pressure not > 30 mmHg.
Surgical technique
@ Cannulate High Aorta, Bicaval venous.
@ Dissect, ligate & divide ductus.
@ Cool, Distally clamp, Cardioplegia.
@ RA opened, VSD closure, LA vent through PFO.
@ PA transected few mm proximal to bifurcation.
@ Stay sutures taken.
@ Aorta transected in mid portion, 2-3 mm above the coronary ostia
edge.
@ Coronary buttons removed, sinus 1 first, D shaped with 0.5 -1 mm
cuff.
844
 @ Implanted into Proximal PA (Neo Aorta) without kink.
@ LeCompte maneuver to bring pulmonary bifurcation anterior to
aorta, (not required in Side side aorta & L- TGA).
@ Neo aorta constructed needs pericardial patch to augment distal aorta.
@ Proximal aorta gaps of coronary buttons closed with pericardial patch.
@ Neo PA constructed.
@ Associated CoA, IAA, Arch hypoplasia requires TCA.
@ Rewarm, CPB, Declamp, Off CPB.
@ Dopamine 5 - 10 micgm /kg /min.
@ Heart carefully observed for colour change & LA pressure monitored,
Ischemia of myocardium reflected by poor colour or rise in LA
pressure. Due to coronary kink & needs correction.
@ Bleeding Because multiple suture lines require careful hemostasis.
Chest closure : -
@ Pericardial & mediastinal tubes.
@ Silastic peritoneal dialysis catheter to be put.
Post op care : -
1. Ventilation Sedated & paralyzed until hemodynamically stable.
Initial Po2 will be low.
2. Phenoxybenzamine 0.3 -0.5 mg /kg cont.
3. Dopamine rarely reduced to 5 mics / kg /min.
Results: -
Survival
1. month 84 %
2. 1 One year 82 %.
Risk factors
1. Retropulomonary course LCA/ one of its branches.
2. Early date of operation.
3. Old age.
4. Longer circulatory arrest.
845
 Ventricular function No dysfunction.
Rhythm disturbance low.
RVOTO 5 10 % , Valve, Annulus, higher up.
Neo aortic valve incompetence 32 % mild,
Large pulmonary root before switch TBA, Large VSD, PA band
preswitch.
Atrial Switch Procedures

Introduction: -
It is physiological correction of TGA by transposition of the venous blood into
the ventricles.

Technique: -
1. Mustard procedure Use of large patch of pericardium.
2. Senning procedure Use of native atrial tissue.

Mustard Procedure: -

1951 Mustard partitioned atriums with a large patch of pericardium,

redirecting caval venous blood to LV & pulmonary venous blood to RV.
Simple, safe & reproducible operation.
Indications
# TGA with intramural coronaries.
# TGA with IVS late presentation (>2 - 4 wks).
# TGA, VSD, PVOD.
# TGA, VSD, LVOTO.
# Atrio- ventricular discordance.
# Small LV.
Technique

846
 # Performed at any age but risk / complications > with operation. at, < 6
wks age.
# Balloon atrial septostomy at initial cardiac cath.
# Operation performed between 6 wks to 6- 12 month.
# Median sternotomy, Anterior surface of pericardium cleared.
# A large patch of pericardium excised for use as the atrial baffle.
# Pericardium roughly dumbbell shaped with two bulbous ends & a waist
that is 2.5 to 3.0 cms wide.
# For infant of 10 kg, the long side is 7 cm & the e short side 5cm long.
# The SVC end is 4 cm, & IVC end is 5 cm.
# For a child of 5 kg the margins are all 0.5 cm shorter.
# Both ends are rounded, particularly IVC to provide flexibility in
choosing the most appropriate suture line.
# Broms tech. Use of pericardial baffle shaped like a pair of trousers
where the two limbs are sized according to the diameter of SVC & IVC.
# Cannulation Aorta & Bicaval venous.
# Cool, Clamp & Cardioplegia.
# RA longitudinal incision.
# IAS Initial incision from centre on Fossa ovalis to center of SVC till it
reaches top of the atrial septum, care for preserving artery to SA node,
AS lateral to the incision excised.
# CS cut back into the LA.Raw edges of the incision sutured.
# The pericardial baffle is inserted into the common atrial chamber &
sutured in such away that SVC & IVC blood is diverted to the MV.
# Closure of the associated VSD / PS can be done.
# RA closure directly / If juxta position of LAA or mesocardia, RA will be
small Enlarge RA with pericardial patch.
Post operative course:
# Uncomplicated with inotropes except repair done in 1st 2month of life.
# Extubated with in 24 hrs.
847
 # Post op bleeding req. reoperation.
# Phrenic nerve paralysis req. prolongs ventilation.
Results: -
Early mortality 3.6 %, VSD/PS es risk.
Complications
1. Baffle leaks 23 %.
2. SVC obstruction 17 %, common because of residual ridge of septum
between SVC & tricuspid valve.
3. IVC obstruction 3 %.
4. Pulmonary venous obstruction 1.5 %, usually at the level of the original
atrial septum just anterior to the rt. Pulmonary vein orifices. Results
from a progressive adhesion of the baffle to the raw edge of the excised
septum. Suturing raw edge & keeping upper & lower baffle suture line
wide apart by the rt. Pulmonary veins & lateral wall of RA prevents this.
5. Stenosis of rt. & lt. pulmonary venous channels 1.2 % , > common
narrowing of lt. pulmonary venous channel in the posterior LA near the
orifices of the lt. pulmonary veins ,due to upper & lower baffle sutures
lines on LA too close.
6. Dysrhythmias 73 %, due to SA node dysfunc, because of injury to the
SA node artery. Preservation of a ridge of atrial septum between the SVC
& Tricuspid valve reduces this problem.
7. RV dysfunction & TR
Early 11%, due to RBBB, RVEDP, RVEF.
Care Meticulous perioperative myocardial care.
# Efficient CPB.
# Good myocardial protection.
# Short ischemic time.
# Effective myocardial hypothermia.
# Adequate post op CO.
# Avoid serious dyrhythmias.
848
 Late 76 % Class I, 24 % Class II.
Late mortality
Survival -
10 yr - 85 .8 %
15 yr - 81.5 %.
Senning Procedure: -

1959 Senning described an ingenious technique of complete intra atrial

redirection of the venous return by using native atrial tissue.
Advantage
1. Very small amount of material is required.
2. Growth potential.
Indications
@ TGA, IVS > 2 months old.
Too old for BAS.
@ TGA, IVS, LVOTO.
@ TGA, VSD, PVOD.
@ TGA, VSD, LVOTO.
@ DIV, PVOD.
@ AV dissociation with VA concordance.
@ C TGA.
Contraindications
@ Lt. juxta position of appendages.
@ LSVC not a C/I.
Technique
@ Median sternotomy, pericardial flap.
@ Cannulation Aorta & Bicaval venous.
@ CPB, Clamp, Cardioplegia.
@ Dissect Waterstons groove deeply without entering into LA.

849
@ RA Incision Anterior & parallel to the crista terminalis, anterior to SA
node, The distance between interatrial groove & rt. Atriotomy 2/3rd of the
circumference of SVC.
@ Atrial septal flap
Superiorly incision of limbic tissue, towards & within the SVC orifice,
Risk of entering in the roof of RA & damage to the SA node artery,
Ridge of limbic tissue left will cause SVC obstruction,
Fossa ovalis defect closed with patch.
Atrial flap sutured between lt. pulmonary veins & LAA,
Superiorly within the LA to the junction between the SVC & rt.
upper pulmonary veins,
Inferiorly to the junction between the IVC & rt. inferior pulmonary veins,
This makes the floor of the tunnel connect the caval orifices with the
mitral valve.
@ LA incision
Incise deeply in the interatrial groove,
Extend superiorly to the junction between SVC & rt. upper pulmonary
veins,
Inferiorly to the junction between IVC & rt. lower pulmonary veins,
Openings can be further enlarged by incising one / both rt. pulmonary
veins / tissue between them.
@ Posterior RA flap is sutured to the IAS directing caval blood to the MV.
@ Pulmonary venous pathway is created by suturing the anterior flap
of the RA wall to the rt. edge of the LA incision.
Care to be taken
# Avoid a purstring effect that would narrow the caval pathway.
# Damage to the sinus node.
# Restrict the pulmonary venous flow to the tricuspid valve.
@ Four pacing wires put.

850
 Results
1. Complications Early & late.
@ Venous hypertension
# SVC obstruction.
# Pulmonary venous pathway obstruction.
#Atrial dysfunction.
# Ventricular dysfunction.
# Arrhythmias.
# Pulmonary congestion.
@ Electrophysiological disturbances
# SR with junctional escape.
# JR.
# SVT.
@ RV dysfunction.
@ Tricuspid valve incompetence.
@ LVOTO.
2. Mortality - < 10 % (4.6 %).
Acturial survival -
84 % 5 yrs.
81 % 9 yrs.

Damus Kaye Stensel Procedure

Definition: -

It is an arterial switch operation without coronary translocation in patients

with SA obstruction without PS.

Historical aspect: -
851
Damus, Kaye, Stensel described in 1975.

Indications: -

1. DORV with subpulmonic VSD with SAS (Taussig Bing Anomaly).

2. TGA with Intramural / single coronary artery.
3. Stage I of Norwood procedure.
4. Univentricular hearts with SAS.

Operative Technique: -

Median sternotomy, Pericardium harvested.

Cannulation Aortic & Bicaval venous.
CPB, Cool, Clamp, Cardioplegia.
RA / RV approach.
VSD closed to direct LV blood to pulmonary valve.
MPA transected just proximal (5mm) to bifurcation.
Avoid the distortion of the ascending aorta & proximal MPA, by taking
marking sutures on the lt. medial & rt. medial aspect respectively.
Put incision on aorta just above the commissural post of AV.
Identify coronary artery & avoid distortion.
End to side anastomosis of proximal MPA & ascending aorta.
May need augmentation with pericardial / homograft / Gortex patch.
RV PA continuity achieved by homograft valved graft conduit.
Aortic valve still connected to RV, but aortic pressure remains higher
than RV pressure throughout cardiac cycle, so the AV remains closed.
AR poorly tolerated, in such case AV to be sutured.

852
Complications: -

1. AR Immediate / delayed.
2. PR.
3. Distortion of Great arteries.
4. Hemodynamic instability due to pulmonary circulation by systemic
pulmonary shunts.

Results: -

1. Early Mortality 20 -30 %.

2. Intermediate results - Good.

TGA, VSD, LVOTO Damus Kaye Stensel Operation

853
 FONTAN / BD GLENN / TCPC

Def: - It is a technique for diverting systemic (with / without coronary) venous

return to the pulmonary artery circulation (either directly or by way of the RV)
& leaving to the ventricle (s) only the systemic artery circulation.

Normal Anatomy Fontan Circulation

History & Surgical mile stones: -

1949 Rodbard & Wagner RV could be bypassed .

1951 Carlon proved in experimental laboratory, Systemic venous pressure
is adequate driving force for pulmonary blood flow .
1958 Glenn SVC RPA end end anastomosis .
1960 Haller Bidirectional Glenn Modified Glenn.
1971 (1968) Fontan & Baudet Fontan Operation, RA MPA (valved
/ non valved / direct) anastomosis.
854
1973 Kreutzer Atriopulmonary connection. (MPA with valve RAA).
1976 Maghdi Yacoub Fontan procedure for other univentricular hearts .
1988 DeLeval Lateral tunnel Fontan (TCPC).
1989 Hillel Laks & Billingslay Fenestrated Fontan .
1990 Nancy Bridges 1st transcatheter closure of Fenestration by clamshell
device.
1991 Douville HemiFontan operation.
1988 Humes & Marcelletti Extracardiac Fontan.
1997 Bailey Growing extracardiac Fontan.
Indications: -

A. Fontan operation
1. Tricuspid atresia.
2. Lt. Atrio-ventricular valve atresia.
3. Double inlet lt /rt. ventricle.
4. Pulmonary atresia, intact ventricular septum, Hypoplastic RV.
5. Hypoplastic LV/RV in biventricular heart with VSD with/without
straddling AV valve.

B. BD Glenn
1. Young age < 1-2 yrs.
2. Requires extensive PA reconstruction.
3. SAS with severe systemic ventricular hypertrophy.
4. Border line PVR /Systemic ventricular function.
5. Interrupted IVC & azygos continuation.

Glenn Shunt: -

It is a palliative shunt.
855
 3 Types
1. Classical Glenn shunt
@ Cut SVC & close cardiac end of SVC.
@ Cut RPA & close MPA side end.
@ Anastomose Distal end of RPA & Cranial end of SVC end end.

2. Modified Glenn shunt

@ Cut RPA & close the MPA side end.
@ Anastomose Distal end of RPA to side of SVC.

3. Bidirectional Glenn shunt

@ Cut SVC.
@ Anastomose upper end of SVC to the side of RPA.
@ Suture lower end of SVC.
@ SVC post. wall & RPA ant. Wall anstomose, Ligate RA end
of SVC Azzolina.

4. Bilateral bidirectional Glenn shunt when LSVC present.

@ Cut RSVC & anastomose upper end to the RPA, close lower end.
@ Cut LSVC & anastomose upper end to the LPA, close lower end.
@ Hepatic veins drain to LA.

Requisite for Glenn shunt

1. Lack of obstruction to pulmonary blood flow (normal PVR).
2. Good ventricular function.
3. Lack of associated cardiac defects, CoA/SAS/AV valve regurgitation.
Determinants of Glenn flow
1. Systemic ventricular end diastolic pressure.
2. Trans pulmonary gradient.
3. Atrio ventricular regurgitation.
856
 Ideal candidate
1. PA pressure 15mmHg.
2. PVR < 2 WU.
3. Adequate pulmonary artery size (50% of SVC diameter).
4. Good ventricular function.
5. Age (> 3 months; 9 months).
Benefits
1. Improves PBF Oxygenation.
2. No pulmonary artery hypertension.
3. Volume unloads the heart.
Disadvantage of classical Glenn
Commits the RPA (55% of pulmonary capillary bed) to SVC drainage
only (40% of systemic venous return).
Surgical Technique
@ With CPB.
@ With SVC RA shunt.
@ Without CPB & without shunt.
@ Advantage in case of Bilateral SVC only RA cannula required.
@ Non pulsatile MPA ligation, Humes et al.
MPA transaction, Girod et al.
@ Pulsatile No MPA interruption.
Additional BT shunt, Matsuda et al.
Complications
1. SVC syndrome.
2. Pleuro pericardial effusion.
3. Chylothorax.
4. LVEDP ( ventricular wall thickness diastolic compliance).
5. AV valve regurgitation.
6. SAS.
7. Increasing cyanosis (pulmonary thrombosis, Pop offs ).
857
 8. Pulmonary AV malformation.
9. Branch pulmonary artery stenosis.
Results
1. Operative Mortality 5 %.
2. Mean arterial saturation improved from 69% - 83%.
3. Acturial survival at 9 yrs 100%.
4. Hospitals stay 8 +/- 5 days.
5. 5 -7 yrs of palliation rapid deterioration & progressive cyanosis.

Hemifontan Operation: -

Douville et al 1991.
Anastomosis of both end of the divided SVC to both side of RPA with
placement of a prosthetic patch on the cardiac side of SVC.
Anastomosis of SVC- RA Jn. incision MPA/ RPA & patch in the RA to
exclude IVC / CS / Pulmonary venous blood flow.
One of the procedures while taking down of Fontan due to failure of
Fontan circuit / Part of preparation for staged Fontan.

Fontan Operation: -

Requirement
1. Central unbranched hilar portion of rt. & lt. pulmonary artery, be
enlarged if they are small.
2. CS should drain into the pulmonary venous atrium after Fontan &
not in systemic venous compartment,

Because prudent to protect main ventricular coronary venous
drainage against high pressure that are sometime present in the
systemic system after repair.
858
 IIbawi & coll. Have shown quite convincingly that CS pressure
> 15 mmHg reduces systemic ventricular output.
3. Measure PA, CVP, LAP.
4. Two atrial & ventricular pacing wires to be put.
5. Wide drainage of pericardium & both pleurae.

Ten Commandments, Choussat & Fontan 1971.

1. Age > 4yrs or < 15 yrs.
2. Sinus rhythm.
3. Normal systemic venous drainage.
4. Normal sized RA.
5. Mean PA pressure 15 mmHg.
6. PVR 4 U /m2.
7. Pulmonary artery aortic diameter ratio 0.75.
8. Ventricular EF 60%.
9. No AV valve dysfunction.
10. No impairing effects from previous shunts.
Circuit
Power Source
V

Pulmonary veins Systemic arteries

PVR SVR
Pulmo Fontan System
Arteries conduit veins

Ideal candidate ,Mayer et al. Criteria

859
1. Normal PA pressure (< 18 mmHg).
2. Normal PVR (< 4 U / m2).
3. Adequate pulmonary artery size.
4. Repairable localized PA stenosis.
5. Normal systemic ventricular function.
6. No / Mild AV valve regurgitation.
7. No LVOT obstruction.

Surgical Techniques : -

A. Atrio Pulmonary connection (APC).

# RAA PA anastomosis -
@ Non valved direct RAA PA connection.
@ MPA transected.
@ Trapdoor shaped atrial flap for posterior wall.
@ Pericardial / prosthetic patch anteriorly.
@ Primary closure of ASD.

# RA PA anastomosis
@ Roof of RA was incised.
@ MPA / RPA (to protect Art. to SA node).
@ Anastomosis done conventional / Diamond.

B. Lateral tunnel Fontan (TCPC).

@ De Leval et al, 1988.
@ Both RA & RV are unnecessary for Fontan circulation.
@ Tubular channel - # Less energy loss.
# Less Eddie current.
# Smoother flow.
@ + /- adjustable inter atrial communication.
860
@ MPA transected / ligated.
@ BD Glenn.
@ Caval Offset .
C. Fenestrated Fontan (f TCPC).
@ Laks et al, 1989.
@ Adjustable ASD / single or multiple fenestrations in the baffle.
@ R L shunt decrease RAP LV filling & CO.
@ Ideally takes care of transient ventricular dysfunction in early post op
phase.
@ Optimize CO.
@ Low Fontan pressure Lower incidence of pleuro-pericardial effusions.
@ Subsequent trans catheter closure.
@ Fenestrations
4 mm - < 12 kg.
5 mm - 12 -30 kg.
6 mm - > 30 kg.
@ Price paid
# Systemic desaturation.
# Risk of systemic embolisation.
# Need for additional procedure for closure of fenestration.

D. Unidirectional Fontan
@ Laks et al.
@ SVC flow Lt. lung (end end Glenn anastomosis).
@ IVC return to Rt. Lung (end end).
@ + /- adjustable ASD.
@ Improved pulmonary blood flow due to better streaming.
@ 60 % venous return larger Rt. Lung.
@ 40% of venous return smaller Lt. lung.
@ Improved V / Q matching.
861
@ SVC hypertension better tolerated.
@ So adjustable ASD for IVC return.
@ Disadvantage previous BD Glenn difficult candidate.

E. Extracardiac Fontan Operation

@ Marcelletti et al, 1988.
@ Use of Hemashield / Gortex tube graft from IVC RPA as a conduit.
@ Preservation of ventricular function by avoiding aortic cross clamp.
@ Preservation of ventricular & pulmonary vascular function by
minimizing CPB time & avoiding Hypothermia.
@ Preservation of SR by avoiding atrial incision & suture line in the
vicinity
of SA node.
@ Potential for optimal flow dynamics.
@ No separate patch material required for pulmonary artery
reconstruction.
@ SOS fenestration.

F. Growing Extracardiac Fontan

@ Use of rt.sided live pericardium with its blood supply intact for
making conduit from IVC RPA.
@ Bailey et al, 1997.
@ All benefits of extracardiac Fontan.
@ No need of homograft / prosthetic graft.
@ Autogenous tissue with growth potential.
@ Young age group can be benefited.
@ Nonthrombogenic parietal surface.
@ Viable & pliable.
@ Unique elasticity of the conduit may allow the respiratory bellows.
@ Fenestration in post op period easy in Cath lab.
862
 @ Concern - ? compression of rt. Pulmonary veins.

G. JLS Reeds modification of Fontan

@ LSVC CS in Tricuspid Atresia.
@ Upper end of RSVC RPA, Lower end of RSVC closed.
Upper end of LSVC LPA, Lower end of LSVC LPA.
IVC CS pericardial baffle, CS drains in systemic chamber.
OR
Ligate lower end of LSVC.
Anastomose both end s of RSVC RPA.
Baffle IVC SVC.
CS will drain in pulmonary venous chamber.

H. Mayers Modification of Fontan

Divide RPA & anastomose side of SVC.

Operative Steps: -

Under GA, Supine position.

Median Sternotomy, Opened pericardium to the rt.
Cannulation Aorta, High SVC, IVC.
On CPB, Dissect Ao, MPA & RPA, SVC high up to Azygos vein.
Azygos ligate doubly & divide.
Transect SVC.
Anastomose cranial & cardiac end of SVC to the RPA superior &
inferior surface respectively.
Cross clamp aorta & give cardioplegia, Arrest the heart.
RA opened obliquely slightly anteriorly.

863
 Gortex /Hemashield / RA wall used as a Tunnel from IVC SVC,
keeping the CS & ASD on the LA side.
Fenestration created in the patch ,
4 mm - < 12 kg.
5 mm - 12 30 kg.
6 mm - > 30 kg.
MPA transected & suture close both the ends / ligates the MPA.
Rewarm, Decalmp, Defibrillate.
RA closure.
Off CPB, Decannulate, Reverse Protamine.
Open both pleura widely / make window in the pericardium
connecting to the pleura.
Hemostais, close chest after putting pleural & pericardial tubes &
pacing wires.

Post operative Care: -

Parallel circuit circulation in series, Key factors for CO PBF
TPG.
Maintenance of preload (CVP) for adequate forward flow.
Keep PVR low Avoid pain.
Hypercapnia (pCo2 = 20 mmHg).
Respiratory alkalosis (pH 7.45 -7.5).
Hypoxia.
Pulmonary vasodilators (PGE1, NO).
No /less positive pressure ventilation (No PEEP).
Early Extubation.
Semi fowlers position.

Optimize systemic ventricular function,

864
 @ Systemic arterial dilator (SNP, Amrinone).
@ Inotropes.
@ Low hematocrit (30 35%).
AV sequential pacing.
IABP.
Closure of fenestration in appropriate phase.
Management of 3rd space loss with Albumin.
Keep drainage tubes patent.
Monitor CVP (SVC, IVC pressure), LA pressure x 24 hrs.
Remove catheter as soon as possible.
Anticoagulants 1st po day low dose 6- 12 wks.
Aspirin long term.
If pulmonary embolism STKinase.
F up 3-6 wks for fluid retention.

Complications: -
1. Pleuro pericardial effusions (30 5 %).
2. Ascites.
3. Protein loosing enteropathy.
4. Liver dysfunction.
5. Protein C deficiency.
6. Arrhythmias (SVT).
7. Systemic venous thrombosis.
8. Pulmonary venous thrombosis.
9. Thromboembolism - 2.6%.
10. Fontan Failure
@ Persistent low CO Low mixed venous saturation.

865
 Low urine output.
Poor peripheral perfusion.
Elevated LAP > 12 mmHg.
Continuing high Inotropic requirement.
After univentricular repair with need to maintain CVP higher than 18
mmHg & / or inordinately high fluid requirement to maintain systemic
arterial pressure.

Early Fontan takedown to BD Glenn.
Monitoring: -
RA pressure & significance

Normally maintained up to 16 mmHg.

If > that

See LA pressure
See LA pressure

LA > RA LA < RA

Echo for ventricular dysfunc. See PAPressure

Transplant only treatment Normal /Low PAP >

Obst of pathway PVD/
PAspasm/
Small PAs

866

Echo Hyperventilation.
Pco2 25-30
Take down Po2
SNP 0.5-1migm

PA /RAP

Reduced No

Spasm PVD /small PAs

Take down.
LAPressure LV dysfunction / Valve abnormality.
PAPressure Pulmonary vascular disease / Pulmonary spasm.
RAPressure Conduit block.

Closure of Fenestration: -

When RApressure 15 mmHg & SpO2 85 %.

Closure by Tightening Laks ligature or percutaneous balloon.

SpO2 - 100 %

RAP > 15mmHg RAP 15 mmHg
LAP, 7 -8 mmHg LAP to maintain CO.
CO es.

Reopen Close permanently.

867
Aim To avoid / stop pleural effusion formation.
Best results obtained by keeping aperture open for minimum 2months / open
permanently.

Results: -
Survival
Early Death 5-20%.
Time related survival -
Year %
5 70
10 65
15 50
Perfect Fontan operation 15 yrs 73% - Ideal palliative operation,
Not curative.

Modes of Death
Cardiac Failure 73%
Acute / Chronic
Pulmonary failure - 1%
Fluid retention - 10%
Neurologic dysfunc- 8%
Arrhythmias - 2%
Haemorrhage - 2%

Incremental Risk Factors

Acute ventricular decompression
Rx Staged Fontan / Fenestrated Fontan.
Late Pulmonary & ventricular deterioration

868
 @ Long standing non pulsatile pulmonary flow by systemic venous
pressure.
@ Abnormality of dominant ventricle.
Age at operation Young /Old.
Cardiac morphology Lt. AV valve atresia.
Small PAs Mc Goon ratio - 1.5
Z value - < - 3.5
Nakata Index - < 160 mm2 / m2.
PA Pressure MPA - >15 20 mmHg.
PVR - > 2 4 U / m2.
Advanced main chamber hypertrophy.
Atrial isomerism.
RA PA connection.

Functional Status
NYHA Cl I / II 94 %
90 % at 1 yr.
56 % at 10 yrs.

Haemodynamic Status
Resting / Exercise No difference.
Subnormal performance during exercise due to,
1. RAP Reflux.
2. Biphasic pulmonary flow.
3. Effect of Respiration.
4. Valved conduit from RV RV dilatation.

Cardiac Rhythm
SR Better performance.

869
 Atrial arrhythmias >.
CHB Rare.

Abnormality of Pulmonary circulation

upper lower lobe PBF.
Pulmonary arterio venous fistula.

Protein losing enteropathy 10 %

High RAP.
Site Jejunum / pleura / abdomen.
Other causes of protein losing enteropathy,
(CHF /Constrictive pericarditis / Atrial switch operation).
Rx Insertion of valve in IVC/RA/RV.

Thromboembolism 10 %.

Reoperation
Take down.
Pathway obstruction direct connection RA PA < chance.
Conduit valved / non valved > chance.
Other Reoperation 5 %.
Glenn shunt
Early mortality low.
> 6 month 5 %.
Interruption of RPA disadvantage.
85 % survival > 10 yrs.
Redistribution of pulmonary blood flow & Recurrent symptom
due to collaterals.

870
 Kawashima Operation

Introduction: -
It is an Intraventricular tunnel repair in DORV with subpulmonic VSD with
side by side relationship of great vessels, where intraventricular tunnel is lying
posterior to the pulmonary valve.

Historical Aspect: -
1971 Kawashima & coll described the technique of repair.

Indication: -
DORV, subpulmonic VSD, Side by side relation of great vessels Taussig Bing
Anomaly.

Pre-requisite: -
1. Great vessels should be side by side.
2. Enough distance between tricuspid & pulmonary valve.
3. No tricuspid valve chordae should be attached to malaligned septum.

Contraindications: -
1. Taussig Bing Anomaly with anteroposterior relation of great vessels.
2. Insufficient distance between TV & PV.

Procedure: -
Median sternotomy, Pericardiotomy.
Cannulation Aortic & Bicaval venous.
Cool, clamp, cardioplegia.
RA /RV approach.
RV opened transversely.
871
 Assess for distance between PV & TV, TV chordal attachment, VSD
position.
Enlarge VSD anteriorly.
Appropriate Dacron tube graft cut to make intraventricular tunnel from
LV Aorta, lying posterior to PV taking care of conduction tissue.
Rewarm, RV closure.
Off CPB, pacing wires, chest tubes.
TCPC of Kawashima
It is a Fontan operation in patient with persistent LSVC with Hemiazygos
continuation of IVC.
Usually associated with Atrial isomerism.
Persistent LSVC receives IVC blood through Hemiazygos vein.
Hepatic vein drains separately into RA / common atrium in midline /LA.
Modified TCPC is
1. LSVC disconnected from LA & LA end closed.
2. LSVC anastomosed end side / side side to LPA (if LSVC parallel to
LPA).
3. RSVC cut & both ends anastomosed to RPA.
4. Intratrial tunnel / baffle to drain hepatic venous blood to RPA.
5. If tunnel course is tortuous, Hepatic veins allowed to drain into
pulmonary venous chamber (Kawshimas modification), Resting arterial
saturation will be 87 92 % es with exercise.

872
 MIDCAB

Syn: - Minimally invasive direct coronary artery bypass.

Introduction: -
CABG performed via thoracotomy without the use of CPB, ed during early
months of 1996.

Advantage: -
1. Less invasive.
2. Cost effective.
3. Less morbidity.
4. Avoids morbidity of CPB.

873
Disadvantage: -
1. Technical advantage of anastomosis in motionless heart.

Historical Aspects: -
CABG without CPB 1960.
Largest series by Calfiore Italy.

Indications: - Especially for single vessel disease.

1. Single /Double /Triple vessel disease.
2. Primary / Reoperation.
3. Grafting of isolated lesion.
4. When there is C/I of CPB,
@ Diffuse cerebrovascular disease.
@ Multiple embolic events.
@ Extreme ascending aorta calcification.

Contraindications: - Relative,
1. Severe pulmonary disease.
2. Arrhythmias.
3. Multiple CAD, esp. LCx.
4. Poor ventricular function.
5. LAD disease,
@ Extreme calcification.
@ Intramyocardial LAD.
@ LAD Endarterectomy.
6. Non availability of arterial conduits.

Technique: -
874
 Anaesthesia
1. Single lung ventilation.
2. PA pressure monitoring catheter.
3. Rate lowering drugs B blocker / Magnesium.

Position
1. Rt. lateral Lt. anterolateral thoracotomy.
2. Lt. lateral - Rt. anterolateral thoracotomy
3. Supine Subxiphoid. Approach.

Incision
1. LAD 7 -10 cm incision in lt. 4th ICS from lt. border of sternum.
2. RCA rt. 4th ICS.
3. LCx Lt. lateral / posterior mini thoracotomy.
4. PDA & PLV -Sub xiphod mid way between xiphoid & umbilicus, midline
preffered over rt. subcostal for RGEA.

LIMA / RIMA /Gastroepiploic artery as an arterial conduits.

Stabilizing devices
@ CTS foot retractor, CTS Ultima.
@ Octopus II /III /IV.
Intracoronary shunts Flow through / Flow coil / Anastaflow. Or Use of
snares to occlude the Coronary artery.

Complications: -
1. Acute / late graft failure.
2. Post op. bleeding.
3. Chest wall defects.
4. Lung herniation.
5. > post op pain compared to sternotomy.
875
 6. Damage to coronary artery at the occluder site.

Results: -
1. Post op Hospital stay 53 + /- 28 hrs (2 days).
2. Transfusion 1.3 %.
3. Reoperation 6 % - Graft failure.
4. Early Mortality 0.5 -1 %.
5. Late Mortality 7 %.
6. Uncertainity of long-term results.
7. Late graft failure.
8. Use in multivessel diseases - Thoracab.
9. But in patients with risk of CPB / Median sternotomy MIDCAB is of
choice.

Rastelli Procedure

Introduction: -

Those forms of Transposition of great vessels associated with fixed

obstruction of the left ventricular (pulmonary) outflow tract is not candidates
for Arterial switch correction (Jatene Procedure). For these patients, the
Rastelli operation was introduced by G C Rastelli in 1969.

Indications: -

1. TGA, IVS, LVOTO.

2. TGA, VSD, LVOTO.

Contraindications: -

876
 1. Uncommitted VSD.
2. Straddling AV valve.
3. Hypoplastic ventricle.

Pre- operative Assessment: -

Echo, Cardiac Cath Angio required.

Objectives
1. Assessment of ventricular & valvular function.
2. The position & size of VSD & its spatial relationship to the subaortic
area.
3. The central & peripheral pulmonary arterial morphology.
4. The patency of surgical shunts.
5. The coronary arterial distribution.
6. The pressure & resistance of the pulmonary arterial circulation.
Intervention
1. Control of patent systemic pulmonary shunts.

Operative technique: -

Median sternotomy.
Cannulation Aortic & Bicaval venous.
Cool, Cross clamp aorta, Cardioplegia.
Enlargement of restrictive VSD (45 % cases) - Resection of the
infundibular septum so as to avoid damage to the conduction tissue.
Construction of intracardiac tunnel that results in closure of VSD in
such a way as to direct LV outflow through the VSD towards the Aortic
valve.

877
 Connection between the LV & PA is interrupted by division of MPA with
suture closure of the proximal end of or by patch closure of the
pulmonary valve.
Connecting the RV with the distal MPA/ pulmonary confluence with a
valved extracardiac conduit, such as a pulmonary / aortic cryopreserved
homograft.

Complications: -

Requires reoperation for,

Conduit obstruction.
Recurrent / residual VSD.
Residual LV- PA connection.
Sub aortic obstruction.

Results: -
Survival

1. Hospital Mortality-

Atypical defects 43 %.
- Multiple VSD 36 %.
- Straddling & abnormal choral insertion. 25 %.
Typical defects 15 %.
- Single perimembranous SA VSD.
- Without straddling of either AV valve.
2. Late survival

Acturial survival,
Years Overall Typical Atypical
878
 10 61 % 69 % 50 %
18 58 % 66 % 47 %
3. Risk Factors

# Younger age < 5 yrs.

# PRv Post op.

Mode / Cause of Death

Early Late
# Low CO. # Sudden Death.
# MI. # Pulmonary HTN.
# Pulmonary HTN. # LV Dysfunc.
# ARDS. # MR.
# Residual LV PA shunt. # Bacterial
Endocarditis.
# Rt. Heart failure. # SA obstruction.
# Residual LV RA communication. # MI.
# Temponade. # Noncardiac death.

Re-operation

1. Obstruction of Extracardiac conduit by Anterior compression by chest

wall.
31 % 5 yrs.
70 % 10 yrs.
84 % 18 yrs.
Post replacement survival,
62 % 10 yrs.
80 % 15 yrs.
2. Recurrent / residual VSD.
879
 3. Residual LV PA connection.
4. SA obstruction.
Arrhythmias Requires PPI.
Functional class 90 % - Class I II.
73% - Not on any cardiac drugs.
LV function LV function remained abnormal with persistent LV
dilatation & Hypertrophy.
RV function Abnormal RV function & Hypertrophy,
Because of proclivity of obstruction evidenced by the extracardiac
conduit.

Technical Modifications: -

LeCompte / REV operation

@ Make it applicable to small infants & children.
@ LeCompte & coll. Proposed this method.
@ Proposed avoiding the use of extracardiac conduit by anastomosing
the pulmonary artery to the Rt. Ventriculotomy.
@ Aorta & PA transected & proximal end of PA sutured.
@ Distal end of the PA with confluence brought anteriorly & aorta
sutured
( LeCompte Maneuver).
@ Infundibular resection done widely & the intracardiac tunnel
constructed establishing LV to Aorta continuity.
@ PA confluence anastomosed to the RV & augmented anteriorly
with autologous pericardial patch.
@ Need for reoperation due to conduit complication es.

Pugas Technique
@ Lack of VSD in TGA, IVS, LVOTO require Atrial switch operation.
880
@ To benefit this pt. it was proposed that creation of VSD on the
infundibular septum so that it can be corrected using Rastelli
approach.
@ Advantage
# Used for TGA, IVS with fixed valvar & subvalvar PS, not
amenable to Jatne procedure.
# LVOTO should have resulted in preservation of the LV muscle
mass & capacity of this ventricle to sustain systemic pressure.
# Anatomical (Arterial) correction to be done.
# VSD can be placed in the ideal position for better results.

TGA, VSD, LVOTO

881
 Intracardiac Tunnel - LV - Aorta RV PA Conduit

Rastelli Procedure

Tetralogy of Fallot with Pulmonary Atresia

Introduction: -
TOF - 3.9 % of CHD.
5 10 % PAtresia with VSD.
2/3rd associated with MAPCAS.
M > F, Severe cyanosis & hypoxia during neonatal period.
Life expectancy without surgery 50 % at 1 yr., 8 % at 10 yrs.

Definition: -
Tetralogy of Fallot with pulmonary atresia is a congenital cardiac malformation
characterized by under development of rt. ventricular infundibulum with
anterior & leftward displacement of infundibular (conal / outlet) septum & its

882
parietal extension with no luminal continuity between RV & pulmonary trunk
(or both rt. & lt. pulmonary arteries).
Or
Concordant atrioventricular & ventriculoarterial connection with VSD &
absence of continuity between RV & PA.

Under development of RV infundibulum.

Anterior & Lt. ward displacement of infundibular septum.
No luminal continuity between RV & PA or lt. & rt. PAs.
Usually congenital, may be acquired.

Historical Aspect: -
1973-74 Haworth & McCartney described this anomaly.

Morphology: -
Major difference between TOF with PS & TOF with PA,
No blood passes from the RV to the lungs & consequently all pulmonary
blood flow arises from the ductus arteriosus, collateral vessels or fistula.
Pulmonary arterial anomalies are common.
Large aorto pulmonary collateral arteries are common.
1. RVOT
Atresia, congenital Infundibular / Annular.
# Infundibular 70 %.
@ Infundibular portion absent / conal septum fused with anterior
RV wall.
@ VSD large.
@ RV massively hypertrophied.
# Annulus level
@ Infundibulum patent.
@ Obstruction consist of thick fibrous membrane above
883
 the infundibulum.
2. Pulmonary Trunk
Present & reasonable size.
Hypoplastic.
Fibrous cord.
Completely absent 5%.

3. Branch PAs
# Confluence of rt. & lt. PAs
20 -30 % Nonconfluent PAs.
# Stenosis of origins of PAs
10 % RPA stenosis.
20 % LPA stenosis.
# Distribution of PAs (Arborization)
Confluent PAs 53 % complete distribution to all 20 pulmonary
segments.
3% - < 10 pulmonary segment distribution.
Nonconfluent PAs 80 % incomplete distribution of PAS.
>1/3rd has < 10 pulmonary segment distribution.
# Stenosis of PAs on the side of the ductus 65 %.
# Size of PAs Immediately prebranching portion of the RPA /LPA
is extremely small,
McGoon ratio 0.5.
Nakata index 20.
Z value - -10.
# Abnormality of Hilar branch pattern.

Acquired pulmonary atresia

@ Spontaneously after birth in TOF with PS.
@ Because of palliative operation.
884
 @ Acquired atresia is valvar / subvalvar / os infundibulum.
@ Morphologic characteristic > like TOF with PS.

Pulmonary blood supply:-

Derived from True pulmonary arteries & MAPCA.
True PAs
# Located in the anterior hilum.
# Adequate size / varying degree of hypoplasia.
# Confluent / non confluent.
MAPCAS
Robonovitchs Classification
Type I - Bronchial artery collaterals - Unprotected MAPCAS.
Anastomose with true PAs within the lung parenchyma.
Type II Descending aorta / Abdominal aorta Protected MAPCAS.
Enters hilum posteriorly to anastomose with the true PAs or
intra acinar vessels.
Type III From branches of aorta Protected MAPCAS.
Brachiocephalic, IMA, intercostals.
Smaller vessels that anastomose to the true central PAs or
spread out over the surface of the visceral pleura.
Essential collaterals Those that are the only blood supply to a portion
of
the lung or are so large that they are essential to the size of the
pulmonary vascular bed.
Redundant collaterals Those that are small & overlap with the true
pulmonary artery distribution.

Embryology: -
# Lungs develop from the foregut & their nutrient supply as that of the
oesophagous arises initially from the dorsal aortic plexus.
885
# About 27th day in the antenatal period, the arterial branches of paired 6th
aortic arch forms an anastomosis with the pulmonary vascular plexus.
# As a result the lung receives dual supply.
# With time, the branches from the 6th aortic arch enlarge & those from the
descending aorta become comparatively smaller. Persistence of the branches
from the aorta in postnatal life forms the MAPCAS
# They are variable in their origin, size, number, course & arborisation.

Clinically: -
A. Confluent & normally distributing rt. & lt. pulmonary arteries & PDA
50 % in this category.
PBF CHF.
B. Confluent rt. & lt. pulmonary arteries distributing to the majority, but
not all, of the pulmonary arterial segments.
25% are in this category.
PBF - Cyanosis.
50 % at 3yrs
90 % at 10 yrs die.
C. Confluent or nonconfuent LPA & RPA distributing to the minority of
Pulmonary arterial segments.
25 % cases.
PBF.
Only MAPCAS.

Surgical Treatment: -
Aim
Closure of VSD.
Establish continuity between RV & PA without excessive PBF, Pulmonary
congestion, LVVO.

886
Indication for operation
Surgical treatment can be individualized according to,
Arborization of pulmonary vasculature.
Amount of PBF.
Morphology & sizes of the native PAs & MAPCAS.
The age of the patient.
@ Protected PAs & MAPCAS
# PA size good RV - PA conduit.
# PA small Central shunt.
@ Hypoplastic / Absent PAs
# Unprotected MAPCAS - > 1yr? surgical options.
< 1 yr better option.
# Protected MAPCAS 3 options according to the size of the PAs.

Group A Complete repair with TAP.

Group B Complete repair with RV PA conduit.

Group C Unifocalisation +

PAs & MAPCAS Segments of the lung Surgical Rx

Size expected supplied

75% > 15 VSD closure

RV PA conduit.

50 74 % 10 -14 RV- PA conduit

Keep VSD open

< 50 % < 10 Central shunt.

887
Acquired pulmonary atresia - Complete repair with TAP (90 %).

Palliative operations: -
PBF - # Embolisation of MAPCAS.
# MAPCAS banding pledgetted mattress suture placed in the
aortic wall on the side of the collateral vessels.
PBF BT Shunt.

Unifocalization: -
Refers to those procedures that join the multifocal sources (True PAs & one / >
collaterals) into a single source.
Various procedures described
1. Either direct anastomosis of collaterals to the true PAs.
2. Placement of interposition graft (synthetic / autologous vein or
artery/xenograft / autologous pericardium) between collateral vessel &
pulmonary artery.
3. Staged / Single stage.
4. Thoracotomy / Median sternotomy / Clamshell (sub mammary)
approach.
5. Various material used ,
# Iyer & Roger Mee tech. PTFE / Gortex tube.
# Lacks tech. Autologous pericardial tube.
# Cherians tech. Homograft tube.
6. Unifocalization of all MAPCAS > 2mm size.
Ideal Unifocalization should,
1. Allow incorporation of all nonredundant collaterals & the true PA to each
lung without distortion.
2. Utilize conduit that will either grow or be large enough to supply
adequate blood flow in adulthood without replacement.
888
 3. Minimize the risk of thrombosis.
4. Be easily accessible from the mediastinum at the time of definitive repair.

Technique: -
Incisions
Thoracotomy for multistage unifocalization.
Median sternotomy
Clamshell approach
Previous surgery Hilar scar.
No need for extensive dissection.
Good exposure.

Single stage Unifocalization: -

Harvest the pericardium.
Dissection of native PAs & isolated up to their hilar regions.
Ascending aorta & SVC separated.
Dissection of MAPCAS
@ Dissecting along the aorta & the brachiocephalic arteries as per
angiography up to transverse sinus.
@ Descending aortic MAPCAS in posterior mediastinum after opening the
posterior pericardium.
@ In left arch the descending aortic MAPCAS approached by
dissecting between the area of left side of the ascending aorta & LA &
above or below the lt. main bronchus.
@ presence of LSVC & mediastinal lymph nodes made dissection more
difficult.
@ Care should be taken not to compress LCA.
@ In right arch the descending aortic MAPCAS were reached by
approaching between the ascending aorta, SVC & roof of the LA, usually
above or below the carina & rt. main bronchus.
889
 @ Avoid hemodynamic compromise.
@ Precautions were taken not to injure trachea, bronchi, esophagous &
phrenic, vagus & recurrent laryngeal nerves.
@ All MAPCAS were looped before going on CPB.
On CPB & beating heart, all MAPCAs were disconnected from their origin
& proximal end was closed. They were anstomosed end side or side
side to native PAs if present. Otherwise MAPCAs MAPCAS using 8-0
prolene suture.
Under cardioplegic arrest VSD closed with Dacron patch & RV PA
continuity established by cryopreserved aortic /pulmonary homograft
conduit.
Staged Unifocalisation: -
Pericardial / Gortex tube unifocalization.
Double lumen endotracheal tube, single lung ventilation.
Posterolateral thoracotomy.
Apex of the lung retracted inferiorly & posteriorly for true PA at the
anterior & superior aspect of hilum.
Retraction of lung anteriorly for AP collaterals.
Redundant collaterals ligated & divided.
Large patch of pericardium was harvested anterior / posterior to phrenic
nerve.
Patch draped with serous surface upwards over the posterior & superior
hilum with mid portion lying over the collaterals.
Site of incision marked, Coll. Individually clamped with shallow U
shaped clamp.
After incision on the pericardium & Coll anstomosis done with 6-0 / 7-0
prolene suture.
The remaining coll & true PA s anastomosed to the pericardial tube, Edge
of the pericardium folded & make a tube so it reaches anterior

890
 mediastinum, if it does not adult sized ( 16 / 18 / 20mm ) interposition
graft added to the pericardial tube.
Inflow to the tube provided either by a side to side anastomosis to the
ascending aorta /gortex graft from SCA tube.
Pericardial defect replaced with Gortex membrane.
Shunt size adjusted to achieve an arterial O2 sat 80 % at room air & 88-
90 % with Fio2 100 %.
Definitive Repair Criteria to be seen,
@ Mc Goon Ratio
LPA + RPA diameter at upper lobe branch level /Descending aorta at
diaphragm level.
>1 suitable for definitive repair.
@ Nakatas Index
Cross sectional area LPA + RPA / BSA
150 mm2/m2 suitable for definitive repair.
@ Post op pRV > 2/3 rd systemic High risk factor for definitive repair.
Conduit repair
@ After 4-5 yrs / adulthood.
@ Size Infant 14 18 mm.
>5 yrs 22 25 mm.
@ Tech
1. Orthotropic Same as native valve.
Adv. No compression by sternum.
Disadv. circular geometry lost.
2. Dacron hood Circular geometry maintained.
Compression by sternum.

VSD closure 6 18 months, if

L-R shunt, CHF, Improved resting O2 saturation.
Results: -
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 Survival
1. Early death 5 -20 %.
2. Time related survival - < TOF with PS.
3. Modes of Death Heart failure, Hypoxia, Haemorrhage,
Arrhythmias.
Incremental risk factor for Death
1. Size of central & proximal extra cardiac RPA & LPA.
2. Congenital nonconfluent RPA & LPA.
3. Number of MAPCAS - > risk.
4. Age Early repair, younger, old late repair.
5. Post op PRv /Lv - > 1 risk.
6. Duration of CPB - > risk.
7. Use of valved conduit - risk.
Heart block rare.
Functional status good.
Reoperation
1. Residual VSD 3 %.
2. AVR 1 %.
3. Valved conduit.
Freedom from conduit obstruction
Years % Now
99 -
5 95 95
10 59 90
15 11 -
20 - 60.
Mitral Valve Repair

Anatomy of Mitral Valve: -

892
 Mitral Veil MV forms a continuous veil attach to the circumference
of mitral annulus.
Commissure identified by tips of the corresponding papillary muscle
& by the commissural chordae.
Mitral valve - The leaflets are covered with endocardium.They present
on atrial side a distinct ridge that follows the rim of the leaflets at a
certain distance from the free edge. the ridge defines the line of leaflet
closure & separates the leaflets into two zones.
# Rough zone Distal to ridge closure area represents the surface of
coaptation.
# Proximal zone Membranous & clear on transillumination.
AML Semicircular / Triangular.
Related to LCC & of NCC.
Aorto mitral continuity +.
2 zones Rough & clear.
PML Quadrangular.
Posterior to both commissures.
Wider attachment than AML.
Two indentations scalloped appearance.
3 zones Rough, clear, basal.
Annulus Zone of junction that serves as the attachment of the
muscular fibers of the atrium & the ventricle & on the attachment of
MV.
Annular tissue pliable, permitting sphincter contraction during lt.
atrial & LV systole.
Attached to two fibrous trigone.
In MR dilatation of the annulus occurs at the posterior level.
Mitral annulus in diameter during systole up to 26% due to
contraction of Basoconstrictor muscles.
Chordae
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 Commissural Arise as a main stem branches rapidly.
Insert into the free margin of the commissual region.
Two in number.
PML chordae have longer, thicker & widespread than
AML chordae.
AML chordae Attach in distal rough zone.
7 paramedial & Para commissural.
2 Main chorade from 2 papillary muscle attach
to ventricular surface
4 5 o clock on PMC side.
7 8 o clock on ALC side.
PML chordae 3 types
2 basal zones
10 rough zone.
2 Cleft chordae.
LV papillary muscles Two groups.
Anterolateral & Posteromedial.
Each one has one or two bellies.
PM papillary muscle has > 2 bellies.
Types
1. Completely tethered with fully adherent
to ventricular myocardium.
2. free & finger like 1/3rd / > portion in LV.
3. Intermediate type.
Arterial supply
Leaflets branch of Kugel artery, running at the base of the IAS,
br. of 1st segment of RCA /proximal LCx.
PM LAD/Diagonal/ OM AL.
LCx / RCA PM.
Physiology: -
894
 Closure of Normal Mitral valve
Process involves 3 phases
1. Leaflets meet edge to edge.
2. Leaflet bulge upwards, ballooning into the atrial cavity, contraction of
myocardial fibers.
3. Surface of coaptation between the two leaflets becomes more & more
extensive, so that during systole the leaflets are disposed against each
other in almost in vertical position.
Functional Approach
Aim Restoring the function rather than the anatomy of mitral valve
apparatus.

Carpentiers functional classification

Type I Normal leaflet motion
Annular dilatation.
Leaflet perforation.
Type II Leaflet prolapse
Chordal rupture.
Chordal elongation.
Papillary muscle rupture.
Papillary muscle elongation.
Type III Restricted leaflet motion
Restricted opening comm. fusion, leaflet & chordal fusion.
Restricted closure Excess tension on chordae during systole.

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MV Repair: -
Basis of functional repair
Goal defined as either limiting or increasing the leaflet motion in addition
to remodeling the annulus by a prosthetic ring to obtain an optimal
opening of the valve & a good surface of coaptation.
Indications
1. All cases of non calcified valve disease.
2. Rheumatic valve disease Repair possible 50 % adult & 90 % children.
3. Degenerative valve disease excellent indication.
Most durable.
Rate of reoperation 0.7 % / pt. /yr.
896
 Repair feasible in 95 %.
4. Subacute bacterial endocarditis after 15 days of antibiotics.
5. Congenital malformation Repair feasible in 80 %.
Whatever may be the cause of the disease,
# Operation should be carried out at early stage of disease.
# At the 1st onset of AF.
# Alteration of myocardial function.
Contraindications -
1. Valve calcifications.
2. Rheumatic etiology.
3. AML involvement.
* Advantage -
1. Preserves pts native valve.
2. No prosthesis no complications of prosthesis.
3. No complications of chronic anticoagulation (except pt. in AF).
4. Preservation of mitral apparatus & sub valve leads to better preservation
of post op LV function.
5. Preservation of mitral apparatus leads to maintenance of normal shape /
volume & function of LV.
* Disadvantage -
1. Surgical skill & expertise required.
2. Technically more demanding.
3. Require longer CPB, occ. may fail.
4. Valve calcification, Rheumatic involvement & anterior leaflet involvement
reduces likelihood of repair.
5. Uncalcified posterior leaflet disease is almost always reparable.
* Timing of surgery -
1. Symptomatic pt. with normal LV function (EF > 60 %, ESD < 45mm).
2. Asymp with LV dysfunction (EF 60 %, ESD 45mm).
3. Symp with LV dysfunction (EF 60 %, ESD 45mm).
897
4. EF > 30 %, Symp MR.
5. Asymp with normal LV function to preserve,
LV size, Function, Avoid sequence of chronic MR.
6. Asymp with normal LV function with recent onset of AF.
* Valve Analysis -
Atrium examined 1st for jet lesion (indicate porlapse of opposite leaflet).
Annulus for annular dilatation.
Leaflet tissue pliability / restricted motion / prolapse.
Precise prolapse can be checked by Reference point method.

* Technique of Repair -
A. Prosthetic Ring Annuloplasty
One of the major step of valve reconstruction & is mandatory in most
cases of MR.
Aim Reduce size of dilated annulus.
Restore the shape of orifice.
Dilatation of the annulus occurs at PML & commissures leading to gross
deformation of the annulus with anteroposterior diameter > transverse.
Measure surface area of AML with sized obturators.
Assessment of repair by saline injection into the LV.
The adequacy of repair assessed by considering function rather than
anatomic aspect of the result.
Adequate repair is if the line of leaflet closure is parallel to the mural
part of the ring, this indicate good apposition of the leaflets & a good
surface coaptation.
Various types of rings used,
1. Carpentier Edwards complete rigid ring
2. Cosgroves annuloplasty ring incomplete flexible.
3. Durans complete flexible annuloplasty ring.

898
4. Biflex complete flexible ring.
5. Posterior hard felt incomplete rigid ring (PHFA).

B. Repair of PML
PML prolapse due to ruptured chordae treated by Quadrangular resection
of the prolapsed portion & gap repaired by
# Annular placation.
# Sliding plasty of PML.

PML prolapse causing LVOTO Quadrangular resection of posterior

scallop is completed by two triangular resection at the base of PML
reduces height of PML, avoid systolic anterior motion of leaflet, prosthetic
ring annuloplasty to reinforce repair.

C. Repair of AML
Chordal Rupture
1. Leaflet fixation on secondary chordae

899
 Free edge of prolapsed leaflet sutured to adjacent secondary chordae close
to prolapse area.

2. Chordal transposition
Strong chordae of PML located opposite to prolapsed AML are detached
from PML & reattached to free edge of AML, gap in PML closed by
quadrangular or triangular resection.
Secondary chordae of AML can also be transposed.

3. Chordal replacement
Excessive scarring / degeneration of PML chordae PTFE neo chordae.
Chordal Elongation
Can be corrected by shortening plasty of the chordae.
Two techniques
1. Carpentiers technique At papillary muscle level,

900
 Invagination of the excess length of the chordae into a trench
created in the papillary muscle.
2. Sampath kumars technique At leaflet level,
Plicating elongated chordae at leaflet level.
Papillary muscle Elongation
1. Sliding plasty of PM
Portion of papillary muscle to which the prolapsed area is attached is
split longitudinally & resutured at a lower level.

2. Cunieform resection
A large papillary muscle with moderate prolapse (2- 6 mm) can be
shortened by a cuneiform resection of its tip. The height of the
resection equal to the degree of shortening. The horizontal trench
closed by separate suture.

3. Concertina technique

901
 A thinner papillary muscle with moderate elongation can be treated by
numerous superficial vertical sutures which can be shortened 3 -5
mm.

Papillary muscle Rupture

Requires papillary muscle reimplantation,
Indication
# When large ventricular wall segment is not infracted.
# When PM tip & trunk is only involved in infarction.
1. A ruptured papillary tip with chordae to PML-
The fibrous part of ruptured papillary tip can be attached to adjacent
noninfarcted PM.
Functional closure of leaflet assured before tying suture.
Site of attachment can be measured by chordal length using Carpentier
hook. Reinforced with ring annuloplasty.

2. When ruptured PM is not adjacent to other PM

902
 Disjoined tip can be attached to a noninfarcted part of the adjacent
ventricular wall. Tip must be implanted above the original site of rupture
to ensure enough chordal length to avoid restriction.
The suture passed through tip & ventricular wall through & through over
pledget.

D. Repair of Restricted leaflet motion

1. Results from comm. Fusion, chordal fusion, chordal shortening or
chordal hyprtrophy.
2. Resection of secondary chordae (attached to the ventricular surface of the
leaflet) improves movement of leaflet tissue.
3. Fused marginal chordae attached to free edge of leaflet are treated by
triangular resection
(Fenestration).
4. Calcification of mitral apparatus complicates valvuloplasty.
5. Time consuming.
Intra operative assessment of repair: -
Clinical
1. Saline injection.
2. Leaflet coaptation.
3. Jet of saline.
4. Line of closure is parallel to the mural part of the ring.

903
 TEE / Epicardial echo After Off CPB.
Residual MR immediately after CPB is due to,
1. Temporary Ventricular dysfunction.
2. Temporary ventricular dilatation.
3. Temporary systolic anterior motion of leaflets whenever ventricle is too
empty & hyperkinetic.

# Cardiac assistance.
# Proper adjustment of filling pressure.
# Cautious use of inotropes.

Restores ventricular function with no MR.

# A persistent 2 3 + MR.
# Persistent systolic anterior motion of the leaflet.
# Trans valvular gradient of > 40 mmHg .
with above precautions needs valve replacement (2 %).
Results: -
Survival
1. Mortality Early 0 %.
5 yr 74 -94 % survival.
15 yrs 72 %.
Modes of Death
1. Cardiac Failure.
2. Subsystem Failure.
3. Infection.
Risk factors
1. Older age.
2. Black.
3. Ischemic MR.
904
4. > LV enlargement.
5. Previous CABG.
6. High LVEDP / NYHA.
7. LV resection for Aneurysm.
Residual MR 13 -14 % (9 -20 %).
Freedom from
1. Thromboembolism - 93.9 %.
2. Endocarditis 96.6 %.
3. Anticoagulant Hemorrhage 95.6 %.
4. Reoperation 87.3 % (81 % at 7 yrs).
LVOTO 5- 10 % (Not seen in suture annuloplasty).
1. MVP.
2. Absent anterior motion with CE ring.
3. Myxomatous degeneration.
4. Redundant MV.
Functional Status Excellent.
NYHA I /II - 74 %.

905
 REFRENCES

Adult cardiac surgery R M Bojar

Congenital malformations of the heart Goor & Lillehei

Cardiac surgery John W. kirklin,Brian G. Barratt-Boyes

Glenns Thoracic & cardiovascular Surgery Arthur E. Baue, Graeme

Hammonds, Alexander Geha, Hillel Laks, Keith Naunheim, William W. L.
Glenn

Surgery of the Chest Sabiston & Spencer

Cardiac surgery in Adults Louis Henry Edmunds

The Chest X-Ray: A Survival Guide by Gerald de Lacey et al.

Introduction to chest radiology

Cardiac Valves: Assessment and Identification on RadDaily.com

A Diagnostic Approach to Mediastinal Abnormalities

by Camilla R. Whitten May 2007 RadioGraphics, 27,657-671.

Chest Radiology Plain Film Patterns and Differential Diagnoses

by James C. Reed

Thoracic Imaging: Pulmonary And Cardiovascular Radiology

by Richard Webb and Charles Higgins

Chest Radiology: Plain Film Patterns and Differential Diagnoses sixth

edition by James C. Reed
The Chest X-Ray: A Survival Guide by Gerald De Lacey, Simon Morley
and Laurence Berman

906