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The first task is to examine the heart to see if the preoperative diagnosis is correct. Dr. G uses delicate instruments to retract portions of the tricuspid valve and examine the extent of the defect of the ventricular septum, the wall between the two ventricles. She determines the exact size and shape of the VSD and trims the segment of pericardium she saved earlier in preservative. She cuts miniscule pieces of the pericardial tissue and sutures them along the walls of the VSD, creating anchor points for the actual covering. Each suturing is an intricate dance of fingers and forceps, needle and thread. Dr. G works with a small, hooked needle, grasping it with forceps, inserting the needle through the tissue, releasing and re-gripping with the forceps, pulling the hair-thin suture through, using a forceps in her other hand to re-grip the needle again and repeat. The pericardial tissue being sewn over the VSD has to be secure, and it has to stand up to the pressure of blood pumping through Claudia’s heart at the end of the operation. This isn’t like repairing knee ligaments, which can rest without use and heal slowly. Claudia’s heart is going to restart at the end of this operation, and whatever has been sewn into it has to hold, and work, the first time. The VSD repair involves cautious work around the tricuspid valve, and their proximity is a concern because the valve opens and closes along the ventricular septum with each beat. Dr. G and her team find that it’s preferable to actually divide the cords of the tricuspid valve to better expose the VSD. After the patch is fully secured, the tricuspid valve is repaired.
Things don’t go as smoothly during the attempt to repair the pulmonary valve. When Dr. G looks inside Claudia’s heart she discovers that the pulmonary valve is not nearly large enough, and it’s malformed. It only has two flaps where there should be three. She repairs it by what she later says is “just putting in a little transannular patch.”
Here’s what it’s like to “just” put a transannular patch on the pulmonary artery of a child as small as Claudia:
First, take a piece of well-cooked elbow macaroni. Tuck it away in a bowl of pasta that has a bit of residual marinara sauce still floating around in it. Take several different sized knitting needles. Slowly, without damaging the macaroni, insert one of the knitting needles into it to see if you can gauge the width of the macaroni on which you’re operating. Then using a delicate, incredibly sharp blade, cut a small hole in the piece of elbow macaroni, maybe a little larger than the height of one of the letters on the page in front of you. Now use pliers to pick up a small needle with thread as fine as human hair in it. Use another pliers to pick up a tiny piece of skin that looks like it was cut from an olive, so thin that light shines through it. Take the needle and sew the olive skin on to the hole you’ve cut in the piece of macaroni. When you’re finished sewing, hook up the piece of macaroni to a comparable size tube coming from the faucet on the kitchen sink, and see if you can run some water through the macaroni without the patch leaking.
That’s the food analogy. Those are the dimensions Dr. G worked with as she patched Claudia’s pulmonary artery. She made it a little wider to give it a chance to work more efficiently, to transport more blood with less blockage, requiring less work for the right ventricle so that the built-up heart muscle could return to a more normal size. It wasn’t the repair she’d planned to make, but it was the most suitable under the circumstances, and it gave Claudia her best chance.
Before restoring Claudia’s natural circulation, the team makes certain that no air is in the heart or the tubes from the pump, because it could be pumped up to the brain. Air in the brain is not a safe thing. When all the repairs are completed, Claudia is rewarmed and weaned from the bypass machine. She was on pump for 114 minutes and her aorta was clamped for 77 minutes, not an extraordinary length of time in either case.
Claudia’s heart starts up on its own, with a strong rhythm. With her heart beating again the beeps, and the peaks and valleys on her monitor return. All is well. An echo technician wheels a portable machine into the OR and puts a sensor down Claudia’s throat where it lodges behind her heart to perform a transesophageal echo —a more detailed view than the normal, external echo. Everything looks good. Chest drains are put in to handle post-operative drainage, and wires are placed for external pacemakers, should anything go wrong with Claudia’s heart rhythm during her recovery from surgery. Dr. G draws Claudia’s ribcage back together with stainless steel wires, perfectly fastened and tightly tucked down.
Claudia and the surgical team return to the CVICU, and Dr. G monitors her reentry to the unit, making sure the nurses understand Claudia’s condition and the proper procedures to be followed for the next 24 hours. From there, Dr. G enters a small room tucked away from the noise of the unit to meet with the family. Claudia’s mother, father, and aunt are waiting. Dr. G sees Mom wiping tears away.
“Are you crying? Oh, no, no need to be crying, everything is fine.” Her wide smile reassured Mom who put away her tissues.
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Many thanks to Mark Oristano and Pump Up Your Book! It was a pleasure providing a review.
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