WithAScalpel - Fumiya Yoneyama, MD, PhD

Surgical Hand Coordination — Building Precision Through Daily Practice! 👍 👉Finger dexterity and bimanual coordination underpin controlled needle handling, tissue manipulation, and knot tying. 👉Short, focused daily drills refine movement economy, precision, and reproducibility for operative performance.

Glenn Circulation: From Flow Physiology to Fontan Risk Assessment 👉CO₂ affects Glenn flow twice: hypercapnia raises PVR but augments cerebral flow, SVC return, pulmonary flow, and SpO₂. 👉Over time, lower SVC contribution, venovenous collaterals, pulmonary AVMs, and APCs progressively reduce Glenn efficiency. 👉Pulsatile flow may support PA growth and oxygenation, but volume loading, high PVR/EDP, AVVR, or dysfunction signal Fontan risk.

Interatrial Septum—Right Atrial Anatomy and Conduction Landmarks📌💡 👉The interatrial septum is centered on the fossa ovalis, while the surrounding rims relate closely to the venae cavae, crista terminalis, and atrioventricular junction. 👉The Triangle of Koch—bounded by the tendon of Todaro, septal tricuspid annulus, and coronary sinus ostium—localizes the AV node near its apex.

Glenn Circulation: Physiology, Anastomosis, and Postoperative Oxygenation 👉The bidirectional Glenn diverts SVC flow directly to the pulmonary arteries, unloading the single ventricle. 👉A wide, tension-free SVC–RPA anastomosis and low PVR are essential for unobstructed passive pulmonary blood flow. 👉Post-Glenn SpO₂ depends on pulmonary venous and mixed venous saturation; optimize output, oxygen use, and hemoglobin.

Cardiac Conduction Axis—From the AV Node to the Bundle Branches⚡️💡 👉The AV node continues as the penetrating bundle through the central fibrous body and membranous septum before becoming the branching bundle. 👉The branching bundle gives rise to the LBB, while the RBB emerges onto the RV septal surface posterior to the muscle of Lancisi.

Complete AVSD Repair with Two-Patch Technique #7: ASD Patch Closure 👉The primum ASD patch completes atrial septation while protecting the displaced AV node during closure. 👉Begin along the left AV valve annulus/leaflet, then redirect the suture line onto the left atrial wall. 👉Complete closure by advancing from the left atrial wall to the ASD margin, maintaining a conduction-sparing course.

LVAD Evaluation Checkpoints🤖☑️ 👉A systematic assessment should include the device, inflow cannula, LV unloading, RV/PVR, aortic valve opening, aortic regurgitation, and mitral valve function. 👉Integrating pump flow with RAP, LAP, and inlet pressure helps distinguish volume imbalance, cannula obstruction, RV failure, and inadequate pump support.

@loomba_rohit @sickbayMIC @OungSavly @SIwa23288585 @Prasannasimha Valuable manuscript and worth reading!

Are postop hemodynamics associated with progression of left av #valve regurgitation after AVSD repair? cambridge.org/core/journals/… #chd #icu #criticalcare #pedsicu #medtwitter #foamed #surgery @WithAScalpel

Complete AVSD Repair with Two-Patch Technique #6: LAVV Cleft Closure 👉A marking stitch confirms cleft alignment, leaflet orientation, and the intended line of LAVV closure before suturing. 👉Close the cleft with multiple interrupted sutures directed toward the primary chordae, preserving smooth leaflet approximation. 👉Create a broad coaptation surface without eversion or stenosis, then confirm competence by saline testing and Hegar sizing.

Transposition of the Great Arteries—Mixing and Early Repair🫰🫀 👉In TGA, systemic and pulmonary circulations run in parallel, making effective intracardiac mixing essential for oxygen delivery. 👉BAS and PGE can stabilize preoperative physiology, while early ASO restores normal serial circulation.

Complete AVSD Repair with Two-Patch Technique #5: Patch–Leaflet–Patch Suture Sequence 👉The VSD patch is sized and positioned first to preserve common AV valve leaflet mobility and left AV valve geometry. 👉Interrupted sutures pass from the VSD patch through the common AV valve leaflet, establishing ventricular septation. 👉The same sutures pass through the ASD patch and are tied, creating a balanced patch–leaflet–patch sandwich.

Lower-Extremity Arterial Anatomy🌱🐾 👉The external iliac artery becomes the common femoral artery beneath the inguinal ligament, then divides into the profunda femoris and superficial femoral arteries. 👉The superficial femoral artery continues through the adductor canal and becomes the popliteal artery beyond the adductor hiatus—an important landmark for surgical exposure and bypass planning.

Complete AVSD Repair with Two-Patch Technique #4: VSD Patch Closure 👉The displaced conduction axis runs near the inferior VSD rim; place sutures slightly toward the right-sided margin. 👉Fashion the VSD patch slightly undersized—about 80% of the A–P span—to avoid chordal or annular tension. 👉Near the AV node, keep bites shallow and incorporate right AV valve tissue rather than the vulnerable septal margin.

Tricuspid Valve Anatomy—A Surgeon’s Map🗺️ 👉The anterior, posterior, and septal leaflets are oriented using the coronary sinus, tendon of Todaro, and caval orifices. 👉The septal annulus overlies the membranous septum and AV node region, requiring superficial sutures and respect for variable chordal anatomy.

Complete AVSD Repair with Two-Patch Technique #3: Conduction System for VSD Patch Closure 👉In complete AVSD, the AV node is displaced posteriorly and inferiorly, outside its usual position in Koch’s triangle. 👉The penetrating bundle arises from the nodal triangle and courses beneath the inferior bridging leaflet. 👉The non-branching bundle runs anteriorly just beneath the septal crest before dividing into right and left branches.