WithAScalpel - Fumiya Yoneyama, MD, PhD

Aortic Root and Aorto–Mitral Continuity🤝 👉The aorto–mitral curtain is the fibrous continuity between the AoV and anterior mitral leaflet, spanning the interval between the left and right fibrous trigones. 👉It lies mainly beneath the left and non-coronary cusps, linking the aortic root to the mitral apparatus without intervening ventricular myocardium. #AmaraYadProject #cardiology #anatomy @shivkumarmd @JACCJournals

Balancing Pulmonary Flow & Volume Overload 👉Optimal circulation requires a balance between pulmonary blood flow and ventricular overload. 👉Excess pulmonary flow improves oxygenation but increases volume load and heart failure risk → PA banding may be needed. 👉Insufficient pulmonary flow reduces cardiac load but worsens cyanosis → SP shunt may be needed to restore PBF/oxygenation.

VSD Patch Closure with Outlet Extension — Surgeon’s View📷 👉The septal leaflet of the tricuspid valve may need to be detached or retracted to expose a perimembranous/muscular VSD with outlet extension. 👉Constant awareness of the AoV superiorly and the conduction axis postero-inferiorly.

Fetal Circulation: Placenta-Based Parallel Flow to Postnatal Serial Circulation 👉Fetal circulation uses the placenta and three key shunts — ductus venosus, foramen ovale, and ductus arteriosus — to bypass the liver, lungs, and normal serial flow. 👉Oxygenated blood is preferentially streamed through the umbilical vein–ductus venosus–PFO pathway toward the LA/LV and ascending aorta, supporting cerebral and coronary perfusion. 👉At birth, placental removal raises SVR, lung expansion lowers PVR, and rising oxygen tension promotes FO functional closure and ductus arteriosus constriction.

DORV: Clinical and Anatomical Classification 👉Anatomical classification: Subaortic, subpulmonary, doubly committed, or noncommitted VSD — based on the relationship between the VSD and the great arteries.

Glenn Circulation #7: High-Risk Indicators for Fontan Completion 👉High PVRi, elevated EDP, significant AV valve regurgitation, or ventricular dysfunction can compromise Fontan candidacy. 👉Prior PA/PV interventions or an intact atrial septum suggest anatomic risk and may require careful pre-Fontan assessment. 👉Syndromic, respiratory, and functional factors can increase perioperative risk and should be integrated into Fontan decision-making.

Practice, anytime and anywhere — for our patients A pen🖊 and string🧵can become a simple surgical simulator. The goal is controlled ligation: tie the knot securely without moving the pen. Small daily repetitions build reliable hands in the OR. @PipeCabreraV @rbarbosa91 @TomVargheseJr @SWexner @pferrada1 @pturnermd @AmCollSurgeons @CiruAndes2

Glenn Circulation #6: Pulsatile Glenn 👉Pulsatile Glenn preserves additional antegrade pulmonary blood flow, creating dual-source pulmonary perfusion: passive SVC flow plus pulsatile ventricular flow. 👉This may promote PA growth and improve systemic oxygenation by increasing effective pulmonary blood flow. 👉The trade-off is ventricular volume load and higher PA/SVC pressure, which can reduce Glenn efficiency.

Supravalvular AS: Anatomy, Physiology, and Surgical Strategy 👉Anatomy: fixed LVOT obstruction at the ST junction or proximal ascending Ao, often associated with Williams syndrome and branch pulmonary artery stenosis. 👉Physiology: LV pressure overload increases myocardial oxygen demand, while coronary ostial narrowing and impaired diastolic filling may limit supply. 👉Surgery: enlarge the STJ/root with patch aortoplasty while preserving the aortic valve, coronary origins, and associated arch/PA anatomy.

Glenn Circulation #5: Why Glenn Circulation Fails Over Time 👉As the child grows, more cardiac output is directed to the lower body, reducing SVC return and Glenn-derived pulmonary blood flow. 👉Elevated SVC pressure can promote VV collaterals, allowing venous blood to bypass the lungs and lower SpO₂. 👉Pulmonary AVMs and AP collaterals add intrapulmonary shunt, volume load, and inefficiency—progressively worsening Glenn performance.

Inguinal Ligament: The Gateway to the Femoral Vessels🛣️ 👉The inguinal ligament marks the transition from the external iliac vessels to the femoral vessels. 👉A clear mental map of this boundary helps define safe surgical exposure and vascular control. @PipeCabreraV @SWexner @pferrada1 @TomVargheseJr @pturnermd @AmCollSurgeons @BJSAcademy

Glenn Circulation #4: The Glenn Paradox 👉Lowering CO₂ reduces PVR, which appears favorable—but excessive hyperventilation can reduce cerebral blood flow. 👉Higher CO₂ increases cerebral perfusion, SVC return, and Glenn flow, which may improve pulmonary blood flow and SpO₂. 👉The “Glenn paradox”: too little CO₂ can decrease SVC-derived pulmonary blood flow and worsen desaturation despite lower PVR.

@loomba_rohit Thank you for sharing this beautiful specimen! 👉youtu.be/SH78nsHGj10?si…

Beautiful illustration! Apical displacement is accurate rather than inferior displacement! Best described as abnormal rotation of the valve about the aortic root! youtu.be/SH78nsHGj10?si…

Ebstein Anomaly: Atrialized RV and Tricuspid Malformation 👉Failed delamination of the tricuspid valve results in apical displacement of the septal and posterior leaflets, creating an atrialized proximal RV.