Andersons pediatric cardiology 359
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Abstract
Thischaptercoversavarietyoftopicsrelatedtotheconductofcongenital
heartsurgery,includingthecommonincisionsusedtoconductcongenital
heartsurgery;thematerialsusedforsurgicalreconstruction(including
patchmaterial,sutures,andselectionofartificialvalves);intraoperative
management,includinganesthesiaandcardiopulmonarybypass;strategies
forsupportforcomplexheartsurgeryinvolvingtheaorticarch(including
theuseofdeephypothermiccirculatoryarrestandantegradecerebral
perfusion);andthecurrentstateofmechanicalcirculatorysupport,
includingextracorporealmembraneoxygenation,cardiopulmonary
resuscitationontoextracorporealmembraneoxygenation,andtemporary
andpermanentsupportdevicesusedasbridgetotransplant.
Keywords
Congenitalheartsurgery;prostheticvalve;anesthesiaforcongenital
heartsurgery;cardiopulmonarybypass;deephypothermiccirculatory
arrest;antegradecerebralperfusion;neuroprotection;postoperative
management;ECMO;eCPR;ventricularassistdevices
SurgicalApproachestotheHeart
Avarietyofincisionsareusedincardiacsurgery.Themajorityofpediatric
cardiacsurgeriesareperformedthroughtwoincisions:themediansternotomy
andtheposterolateralthoracotomy.Otherincisionsareoccasionallyusedto
accommodateatypicalanatomyorallowforminimallyinvasiveapproaches.
Sternotomy
Themostcommonlyusedincisioncontinuestobethemediansternotomy(Fig.
16.1),inwhichthesternumisdividedalongitslengthfromtoptobottom.
Originallydescribedin1897,thisincisioncameintowidespreaduseafterthe
adventofcoronaryarterybypassgraftinginthe1960s.Theoverlyingskinand
subcutaneoustissuesaredividedwithacombinationoftheknifeand
electrocautery,andthesternumisdividedwithareciprocatingsaw(Fig.16.2).
Inneonatesandyounginfants,scissorscanbeusedtodividethebone.The
reciprocatingsawisusedwhenopeningthesternumforthefirsttime.Theblade
hasverticalmovementthroughashortdistance,andaprotectiveshoecoversthe
tipoftheblade.Theshoeglidesunderneaththesternum,andpreventsinjuryto
theunderlyingcardiacstructures.Atthecompletionoftheprocedure,the
sternumisclosedwithstainlesssteelwire,bands,orsometimes,insmall
children,heavysuturematerial.Theincisionprovidesexcellentexposure,andis
preferredformostintracardiacprocedures.Inadditiontoopeningthesternum
itself,theincisionisextendedforashortdistanceintotheupperabdomen,
separatingtherectusmuscleinthemidline.Becausethereisminimal
interruptionofmuscle,andbecausethesternumissolidlyreconstructedatthe
endoftheprocedure,theincisionislesspainfulthanothercommonlyused
incisions,suchasthethoracotomy.Thereisminimalrespiratorycompromise.
Earlyextubation,effectivecoughinganddeepbreathingareeasilyachievedwith
thisincision.Long-termfunctionalresultsareexcellent,andlungfunctionis
minimallyperturbed.Thisisincontrasttothesituationfoundafter
thoracotomies,whereadegreeofrestrictivelungphysiologyispredictable.1
FIG.16.1 Themediansternotomyincisionisthemostcommonlyused
incisionincongenitalheartsurgery.(A)Theskin,subcutaneoustissue,and
presternalfasciaaredividedwithacombinationoftheknifeand
electrocautery.Thesternumisdividedlongitudinallywithasaw.(B)The
incisionisextendedforashortdistanceintotheupperabdomen,dividing
therectusabdominismuscleinthemidline.
FIG.16.2 (A)Inprimarysternotomies,thesternumisusuallydividedwith
areciprocatingsaw.(B)Inredosternotomies,thesternumisdividedwith
anoscillatingsaw.Avarietyofsizesandshapesofbladescanbeadapted
forusewiththeoscillatingsaw.
Reoperationiscommonforsurvivorsofcongenitalheartsurgery.A
