Cardiac Surgeon | Assistant Professor | @TexasChildrens | Visual insights in surgery, cardiology & intensive care | Views my own
Joined July 2025
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Left-to-Right vs Right-to-Left Shunting
👉Left-to-right shunts increase pulmonary blood flow and produce pulmonary overcirculation with volume loading of the involved chambers.
👉Right-to-left shunts bypass effective pulmonary oxygenation, causing systemic desaturation and reduced systemic oxygen delivery.
👉Shunt direction and magnitude depend on anatomy, pressure gradients, ventricular compliance, PVR/SVR balance, and pulmonary blood flow.
Pulmonary Atresia with Intact Ventricular Septum (PA-IVS)—Pulmonary and Coronary Circulation🫀
👉Pulmonary blood flow is initially ductal-dependent, and RV decompression may establish antegrade RV–PA flow; however, in RV-dependent coronary circulation (RVDCC), decompression can precipitate myocardial ischemia.
3-day-old, SpO2 50% on room air with respiratory distress
@AEPCcongenital
@escardio @ASE360 @iamritu @alexsfelixecho @CASivaram1 @loomba_rohit @alex1708ander @CardioNeo @argulian @sujithsp @SIwa23288585 @swatigar @cardiopedhnn
Tricuspid Atresia: Anatomy, Great Artery Relationships, and Hemodynamics
👉Tricuspid atresia lacks an RA–RV connection, making interatrial communication essential for systemic venous return.
👉Type I (NGA): The LV supplies systemic flow; pulmonary blood flow depends on VSD size, PS/PA, and ductal patency.
👉Type II (TGA): The LV ejects into the PA; systemic output depends on the VSD/BVF and RV outflow tract patency.
Cardiac Conduction Axis—Surgical Anatomy📖
👉The AV node continues as the penetrating His bundle through the central fibrous body, coursing along the inferior margin of the interventricular membranous septum before branching into the LBB and RBB.
👉The RBB emerges on the RV septal surface posterior to the muscle of Lancisi, an important anatomical landmark for avoiding conduction injury during VSD closure.
A new dimension in cardiac imaging: Three-dimensional exploration of the atrioventricular conduction axis with hierarchical phase-contrast tomography
heartrhythmjournal.com/artic…
Mitral Valve Replacement — Series: #1–3
👉MVR is indicated when durable repair is unlikely, requiring careful assessment of valve pathology and periannular anatomy.
👉Surgical strategy emphasizes subvalvular preservation, secure prosthesis positioning, and individualized valve selection based on durability and anticoagulation requirements.
↓ Full series below
3/3 | #3 Valve Selection and Anticoagulation
👉Mechanical valves offer long-term durability but require lifelong warfarin, whereas bioprosthetic valves avoid routine lifelong anticoagulation at the cost of structural degeneration.
xitter.cf/WithAScalpel/status/21…
Mitral Valve Replacement #3: Valve Selection and Anticoagulation
👉Mechanical valves offer excellent durability but require lifelong warfarin anticoagulation, typically targeting an INR of 2.5–3.5.
👉Bioprosthetic valves generally avoid lifelong anticoagulation but carry a risk of structural degeneration and future reoperation.
2/3 | #2 Anatomy and Surgical Techniques
👉MVR requires precise knowledge of periannular structures, appropriate leaflet and subvalvular preservation, and secure prosthesis implantation.
xitter.cf/WithAScalpel/status/21…
Mitral Valve Replacement #2: Anatomy and Surgical Techniques
👉Key periannular structures include the circumflex artery, coronary sinus, AV node, aortic valve, and right/left fibrous trigones.
👉Leaflet resection or preservation depends on anatomy; preserving the subvalvular apparatus helps maintain LV geometry and function.
👉An appropriately sized prosthesis is secured intra- or supra-annularly, with mechanical valve orientation optimized for leaflet motion.
1/3 | #1 Indications, Anatomy, and Prosthesis Selection
👉MVR is considered for irreparable mitral pathology, with prosthesis selection guided by valve anatomy, durability, and anticoagulation requirements.
xitter.cf/WithAScalpel/status/21…
Mitral Valve Replacement #1: Indications, Anatomy, and Prosthesis Selection
👉MVR is considered when durable repair is unlikely due to severe prolapse, leaflet restriction, rheumatic disease, or calcification.
👉Mechanical valves offer durability but require lifelong anticoagulation; bioprosthetic valves carry degeneration and reoperation risks.
Fumiya Yoneyama, MD, PhD | WithAScalpel retweeted
Ross Procedure and Left Ventricular Rehabilitation📚
👉The Ross procedure restores LV outflow using a pulmonary autograft, while endocardial fibroelastosis (EFE) resection may improve LV compliance and diastolic function.
👉In 36 infants undergoing Ross/Ross-Konno procedures, operative and late survival were both 94%, with a median LVEF of 56.5% at follow-up.
Jacob KA, et al. J Thorac Cardiovasc Surg. 2026;172:1074–1082.e2.
doi.org/10.1016/j.jtcvs.2026…
Open access in #JTCVS: Left ventricular rehabilitation after Ross operation for critical aortic stenosis with endocardial fibroelastosis. Read how surgeons saw excellent survival and substantial LV recovery: hubs.la/Q04zQtkp0
Mitral Valve Replacement #3: Valve Selection and Anticoagulation
👉Mechanical valves offer excellent durability but require lifelong warfarin anticoagulation, typically targeting an INR of 2.5–3.5.
👉Bioprosthetic valves generally avoid lifelong anticoagulation but carry a risk of structural degeneration and future reoperation.
Mitral Valve Replacement #2: Anatomy and Surgical Techniques
👉Key periannular structures include the circumflex artery, coronary sinus, AV node, aortic valve, and right/left fibrous trigones.
👉Leaflet resection or preservation depends on anatomy; preserving the subvalvular apparatus helps maintain LV geometry and function.
👉An appropriately sized prosthesis is secured intra- or supra-annularly, with mechanical valve orientation optimized for leaflet motion.
Arterial Cannulation—Insertion Depth and TEE Confirmation👀
👉Arterial cannula have depth markings that allow direct visual assessment of insertion depth in millimeters.
👉TEE confirmation helps verify cannula tip position and orientation, ensuring appropriate placement and avoiding obstruction or malposition.
This is where the CPB aortic cannula sits when the patient undergoes surgery through a right lateral thoracotomy. 👀 ME Ao asc LAX/SAX #intraopTEE #echofirst
With a conventional median sternotomy, the aortic cannula appears elsewhere on TEE - in the UE Ao Arch LAX view. 💡
Mitral Valve Replacement #1: Indications, Anatomy, and Prosthesis Selection
👉MVR is considered when durable repair is unlikely due to severe prolapse, leaflet restriction, rheumatic disease, or calcification.
👉Mechanical valves offer durability but require lifelong anticoagulation; bioprosthetic valves carry degeneration and reoperation risks.
Extracardiac Conduit Fontan
👉The IVC is transected at the cavoatrial junction and anastomosed to the pulmonary artery via an extracardiac PTFE conduit, establishing passive systemic venous return without atrial involvement.
👉A recent study highlighted by @AATSHQ found no significant difference in long-term freedom from Fontan failure between smaller (≤18 mm) and larger (≥20 mm) extracardiac conduits.
@konstantinov_ie @Dr_dUdekem
hubs.la/Q04zQsNG0
Surgeons in New Zealand and Australia found that despite recent suggestions, extracardiac conduit sizes do not appear to affect long-term clinical outcomes for patients who underwent the Fontan operation. Read in #JTCVS Open:
@konstantinov_ie @Dr_dUdekem hubs.la/Q04zQsNG0
