Surgical strategy to prevent cardiac injury during reoperation in infants

We employed SAC in 4 infants undergoing reoperative cardiac surgery (prior Norwood, n = 2; prior arterial switch operation with suprasystemic pulmonary artery pressures after a Le Compte maneuver, n = 1; prior Ebstein's anomaly, n = 1). In all cases the innominate artery was exposed at the level of the supra-sternal notch, and a 3.5 mm expanded polytetrafluoroethylene (ePTFE) graft was anastomosed to the innominate artery (n = 3), and a 10 French cannula inserted into the graft for whole-body perfusion. Right atrial cannulation was obtained by dividing the anterior aspect of the diaphragm at the level of the xiphisternum, gaining easy access to the right atrial-inferior vena cava junction, without separating the sternal edges.All four infants successfully underwent their operations using SAC. In one case (2nd stage palliation for hypoplastic left heart syndrome) a cardiac injury occurred upon sternal reentry, but utilizing SAC, this was repaired without consequence.Simplified aortic cannulation and direct right atrial cannulation may be obtained without dividing the sternum in complex reoperative infant surgeries, without making additional incisions. This may be life-saving in reoperative cardiac injuries in small infants.Simplified Aortic Cannulation (SAC), wherein the innominate artery is used as the arterial inflow site rather than the ascending aorta, has made a significant impact on the conduct of complex operations for congenital heart disease, such as the Sano-Norwood operation, and cardiac operations in very small neonates or those with diminutive ascending aortas. [1,2]In young infants requiring resternotomy, the femoral vessels are too small to initiate cardiopulmonary bypass, and the neck has usually been accessed for venous lines. Consequently, few alternatives exist for the congenital cardiac surgeon, in cases at high risk for re-entry cardiac injury, or, in the event of uncontrollable re-entry injury having occurred. Some advocate more proximal, but st