454. ACHD Surgery 101: Thinking Like a Surgeon with Elizabeth Stephens

CardioNerds (Drs. Rawan Amir, Tripti Gupta, and Alysha Joseph) discuss the fundamentals of adult congenital heart disease (ACHD) surgery with Dr. Elizabeth Stephens. Audio editing by CardioNerds academy intern, Grace Qiu.

Using a case of a young adult undergoing a Ross procedure, the episode walks through what happens in the operating room—from induction and intraoperative transesophageal echocardiography (TEE) to cardiopulmonary bypass (CPB), myocardial protection, and surgical repair. The discussion highlights key concepts including cardioplegia, cross-clamp and bypass times, hypothermic circulatory arrest, and the complexity of redo sternotomy. This episode provides learners with a practical framework to interpret operative reports, anticipate postoperative physiology, and better collaborate with surgical teams.

This episode was produced by the CardioNerds ACHD Council and planned by Dr. Rawan Amir.

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Pearls

“LV distension kills patients.”Preventing left ventricular distension with appropriate venting and awareness of aortic insufficiency is critical to intraoperative safety.

TEE can change the surgical plan in real time.Findings such as underestimated aortic regurgitation, mitral pathology, or a PFO may directly alter cannulation and cardioplegia strategy.

Cross-clamp time = myocardial ischemic time; bypass time = systemic stress.Both are key predictors of postoperative complications including renal injury, bleeding, and ventricular dysfunction.

Redo sternotomy risk is driven by anatomy, not just number.Aorta adherent to the sternum, conduit position, and chamber pressurization define risk more than the number of prior surgeries.

Think longitudinally—ACHD surgery is lifetime planning.Surgical materials and strategies must account for future interventions, especially in younger patients.

Notes:

Notes drafted by Dr. Alysha Joseph, aided by generative artificial intelligence.

What are the key steps in congenital cardiac surgery from incision to closure?

Preoperative planning is multidisciplinary, involving surgeon, anesthesia, cardiology, and ICU teams; high-risk inductions (e.g., critical AS, Williams syndrome) are identified early

TEE is performed immediately after induction to reassess anatomy and may reveal new findings (e.g., underestimated AI, mitral disease, PFO)

Median sternotomy is performed, followed by creation of a pericardial well to optimize exposure

Heparin is administered prior to cannulation; arterial and venous cannulas are placed for initiation of CPB

Cross-clamp is applied and cardioplegia delivered to arrest the heart, allowing a still and protected operative field

Surgical repair (e.g., Ross procedure) is performed, followed by de-airing, cross-clamp removal, and reperfusion

Patient is weaned from bypass with TEE reassessment, hemostasis achieved, and chest closed

What is cardioplegia and how is it delivered?

Cardioplegia is a potassium-rich solution that arrests myocardial activity and reduces metabolic demand

Most commonly used solution in the U.S. is Del Nido cardioplegia, originally developed for pediatric myocardium

Delivery strategies include:

Antegrade (via aortic root) – standard approach

Ostial (direct coronary delivery) – used when aortic root cannot be relied upon

Retrograde (via coronary sinus) – useful in severe AI or coronary disease

NOTE: Severe aortic regurgitation can impair antegrade delivery and requires alternative strategies and LV venting

What do cross-clamp time and bypass time represent clinically?

Cross-clamp time = duration of myocardial ischemia while the heart is arrested

Bypass time = total duration on CPB, reflecting systemic exposure to non-physiologic circulation

Prolonged cross-clamp time (>2–3 hours) increases risk of myocardial dysfunction, especially with poor baseline function

Longer bypass time is associated with increased risk of renal injury, coagulopathy