Takeuchi Procedure | ALCAPA | Superior Caval Cannulation, Cardiopulmonary Bypass, Exposure of ALCAPA

This patient's left coronary artery has an abnormal origin in the pulmonary trunk. The patient is undergoing a Takeuchi procedure as an alternative to excision and reimplantation.

The tissues of the right atrium have been found to be thin. As a precaution purse string sutures placed in the right atrium are buttressed with pericardial pledgets. The needle for the purse string suture is first passed through the edge of the pericardiotomy, then through the tissues of the right atrium, around the intended site of cannulation and then through the edge of the pericardiotomy at a different site. The process is repeated with the needle at the other end of the suture and when the pericardial pledgets have been harvested, the result is a double pledgeted purse string made with autologous pericardial pledgets.

The right atrium is incised within the purse string with a number 11 surgical knife. A superior caval cannula with a metal tip is inserted with its tip facing downwards, towards the patient's feet. The purse string is tightened, securing the cannulation site. The cannula is secured by tying it to the snugger. The cannula is deaired and connected to the upper limb of the Y-connector on the venous limb of the cardiopulmonary bypass circuit. Then the patient is placed on to cardiopulmonary bypass on partial flows.

A purse string suture is placed around the intended site of cannulation in the front of the inferior vena cava.The vein is then incised within the purse string and cannulated. The purse string is tightened and the cannula is unclamped. The patient is now on cardiopulmonary bypass on full flows. The cannula is secured by tying it to the snugger.

With the patient now on cardiopulmonary bypass on full flows, the heart and great vessels are now mostly emptied. This allows us to complete the task of freeing up the right pulmonary artery from the back of the ascending aorta. A purse string is placed in the front of the right superior pulmonary vein. A vent cannula will be placed in the vein through this purse string, into the left atrium. This will allow us to completely empty out the left side of the heart later.

With pump flows briefly reduced, an incision is made within the purse string, seen here in the bottom left hand corner of the picture. A vent cannula with a flexible stylet is introduced through the incision and its tip is gently guided through the mitral valve to sit in the left ventricle. The stylet is removed, the cannula deaired and connected to the vent section of the cardopulmonary bypass machine. The purse string is tightened and the cannula is gently tied to the snugger.

The interarterial plane can now be fully opened and the anomalous origin of the left coronary artery at the pulmonary trunk is sought. An accessory blood vessel crossing the interarterial plane between the aorta and the pulmonary trunk has been found. This vessel also has a branch directed downwards. Each limb of this T-shaped configuration is underrun with suture for security in case of bleeding.

The pulmonic bifurcation and the left pulmonary artery are freed up from the pericardial margins. The bottom part of the interarterial plane is opened further. The T-shaped accessory vessel, which was ligated earlier is now divided. This proximal part of the interarterial plane is opened fully to fully expose the aortic root, the pulmonic root and the left coronary artery origin.

The area in front of the right pulmonary artery is inspected to confirm clearance between it and the back of the ascending aorta. Then the pulmonic trunk, the pulmonary bifurcation and the left pulmonary artery are inspected to see that they are circumferentially free.

At this point the superior caval cannula had been found to be entraining air. A supplementary purse string suture was placed outside the existing one and tightened, eliminating the air entrainment.