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454. ACHD Surgery 101: Thinking Like a Surgeon with Elizabeth Stephens cover art

454. ACHD Surgery 101: Thinking Like a Surgeon with Elizabeth Stephens

454. ACHD Surgery 101: Thinking Like a Surgeon with Elizabeth Stephens

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CardioNerds (Drs. Rawan Amir, Tripti Gupta, and Alysha Joseph) discuss the fundamentals of adult congenital heart disease (ACHD) surgery with Dr. Elizabeth Stephens. Audio editing by CardioNerds academy intern, Grace Qiu. Using a case of a young adult undergoing a Ross procedure, the episode walks through what happens in the operating room—from induction and intraoperative transesophageal echocardiography (TEE) to cardiopulmonary bypass (CPB), myocardial protection, and surgical repair. The discussion highlights key concepts including cardioplegia, cross-clamp and bypass times, hypothermic circulatory arrest, and the complexity of redo sternotomy. This episode provides learners with a practical framework to interpret operative reports, anticipate postoperative physiology, and better collaborate with surgical teams. This episode was produced by the CardioNerds ACHD Council and planned by Dr. Rawan Amir. CardioNerds Adult Congenital Heart Disease PageCardioNerds Episode Page Pearls “LV distension kills patients.”Preventing left ventricular distension with appropriate venting and awareness of aortic insufficiency is critical to intraoperative safety. TEE can change the surgical plan in real time.Findings such as underestimated aortic regurgitation, mitral pathology, or a PFO may directly alter cannulation and cardioplegia strategy. Cross-clamp time = myocardial ischemic time; bypass time = systemic stress.Both are key predictors of postoperative complications including renal injury, bleeding, and ventricular dysfunction. Redo sternotomy risk is driven by anatomy, not just number.Aorta adherent to the sternum, conduit position, and chamber pressurization define risk more than the number of prior surgeries. Think longitudinally—ACHD surgery is lifetime planning.Surgical materials and strategies must account for future interventions, especially in younger patients. Notes: Notes drafted by Dr. Alysha Joseph, aided by generative artificial intelligence. What are the key steps in congenital cardiac surgery from incision to closure? Preoperative planning is multidisciplinary, involving surgeon, anesthesia, cardiology, and ICU teams; high-risk inductions (e.g., critical AS, Williams syndrome) are identified earlyTEE is performed immediately after induction to reassess anatomy and may reveal new findings (e.g., underestimated AI, mitral disease, PFO)Median sternotomy is performed, followed by creation of a pericardial well to optimize exposureHeparin is administered prior to cannulation; arterial and venous cannulas are placed for initiation of CPBCross-clamp is applied and cardioplegia delivered to arrest the heart, allowing a still and protected operative fieldSurgical repair (e.g., Ross procedure) is performed, followed by de-airing, cross-clamp removal, and reperfusionPatient is weaned from bypass with TEE reassessment, hemostasis achieved, and chest closed What is cardioplegia and how is it delivered? Cardioplegia is a potassium-rich solution that arrests myocardial activity and reduces metabolic demandMost commonly used solution in the U.S. is Del Nido cardioplegia, originally developed for pediatric myocardiumDelivery strategies include: Antegrade (via aortic root) – standard approach Ostial (direct coronary delivery) – used when aortic root cannot be relied upon Retrograde (via coronary sinus) – useful in severe AI or coronary disease NOTE: Severe aortic regurgitation can impair antegrade delivery and requires alternative strategies and LV venting What do cross-clamp time and bypass time represent clinically? Cross-clamp time = duration of myocardial ischemia while the heart is arrestedBypass time = total duration on CPB, reflecting systemic exposure to non-physiologic circulationProlonged cross-clamp time (>2–3 hours) increases risk of myocardial dysfunction, especially with poor baseline functionLonger bypass time is associated with increased risk of renal injury, coagulopathy, and bleedingThese metrics often reflect both case complexity and intraoperative challenges What is hypothermic circulatory arrest (HCA) and when is it used? HCA involves complete cessation of blood flow to allow a bloodless surgical fieldTypically used in complex aortic arch repairsPatients are cooled to ~18°C to reduce metabolic demand and protect organsDuration is ideally limited to <30 minutes to minimize neurologic injuryAdjuncts include: Antegrade cerebral perfusion (ACP) – provides targeted brain perfusion Retrograde cerebral perfusion (RCP) – less effective for oxygen delivery What makes redo congenital cardiac surgery high risk? Re-entry risk depends on anatomical relationships: Aorta adherent to sternum (especially midline) poses high risk of catastrophic bleeding RVOT conduits or pressurized chambers near sternum increase injury risk Loss of peripheral vascular access from prior procedures limits bailout optionsAccumulated comorbidities (renal, hepatic dysfunction) increase ...
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