title: Surgical strategy to prevent cardiac injury during reoperation in infants.
abstract: BACKGROUND
  Simplified Aortic Cannulation (SAC), wherein the innominate artery is used as the arterial inflow site rather than the ascending aorta, has proved to be a useful technique for arterial cannulation especially for small neonates undergoing complex cardiac operations. Since few technical options are available for re-entry cardiac injuries in small infants, we postulate that this technique may be equally helpful in those situations.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA. ckc@uab.edu
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Knott-Craig
authors.forename: Steven P
authors.initials: SP
authors.lastname: Goldberg
authors.forename: James K
authors.initials: JK
authors.lastname: Kirklin
mesh_terms: D001013:Aorta, Thoracic; D006348:Cardiac Surgical Procedures / Q000592:standards*; D002404:Catheterization / Q000379:methods / Q000592:standards; D006335:Heart Injuries / Q000517:prevention & control*; D006801:Humans; D007223:Infant; D007431:Intraoperative Complications / Q000517:prevention & control*; D017410:Practice Guidelines as Topic; D012086:Reoperation / Q000592:standards