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.