Detailed Surgical Technique
After redo sternotomy, the aorta was cannulated centrally, and bicaval venous cannulation was achieved via femoral vein and left innominate vein. The anatomy was confirmed to be that of D-TGA with an anterior, rightward aorta originating from the RV. We selected a site on the diaphragmatic surface of the RV near the acute marginal border for inflow insertion, and transesophageal echocardiography (TEE) guidance revealed a heavily trabeculated RV. To ensure appropriate positioning of the inflow cannula towards the atrioventricular valve, we opted to arrest the heart. We then cored the ventricle to confirm two broad papillary muscles with attached chordae tendineae obscuring our view of the RV long axis. We placed a series of horizontal mattress stitches using pledgeted 4-0 Prolene suture through the papillary muscles and out through the inferior wall of the RV. This anchored the papillary muscle out of the cannula’s path (Figure 1). Additional intervening trabeculae without chordal attachments were sharply excised. The apical connector cap was secured to the RV wall with full thickness horizontal mattress sutures using 2-0 Ethibond. The cross-clamp was released after adequate de-airing. In our usual fashion, the VAD outflow graft was then draped around the right atrium and anastomosed to the ascending aorta with a partial side-biting clamp. TEE at the conclusion of the case confirmed the absence of tricuspid stenosis with notable moderate tricuspid regurgitation.