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Although complications of aortic valvuloplasty are rare order 100mg suhagra free shipping erectile dysfunction treatment penile implants, the anesthesiologist must be “prepared for the worst generic suhagra 100mg without prescription erectile dysfunction drugs natural,” which includes annular rupture and the creation of significant aortic regurgitation. Although annular rupture also is a potential complication of this procedure, the creation of pulmonary insufficiency is of less concern and better tolerated than aortic insufficiency. Angioplasty A number of transcatheter treatment options are available for management of pulmonary artery stenoses, including balloon angioplasty and endovascular stent implantation. Angioplasty has been shown to be highly effective in anatomically appropriate cases with a low complication rate. Hemodynamic and angiographic assessment of the lesion is obtained, followed by selection of an optimal balloon catheter, based on both the size of the stenosis and surrounding “normal” tissue. Using the same “over-the-wire technique,” a balloon is advanced and centered over the stenosis. A high index of suspicion for complications—including dissection or pulmonary artery tear, obstructive intimal flaps, thrombi, and reperfusion pulmonary edema—is justified, as management may require ventilatory manipulations and/or emergent cardiovascular resuscitation. Balloon angioplasty of coarctation of the aorta may be performed for treatment of native or recurrent coarctation. Angiography of the aorta is performed to delineate the coarctation and estimate the dimension of the coarctated segment and the adjacent aorta. As with other angioplasty techniques, the balloon size is based on the dimensions of the stenotic area and surrounding vessel. Pressure and angiographic data are obtained to determine adequacy of results and absence of complications. There is a 4–5% incidence of intimal tear and dissection that, in most cases, are nonprogressive. Endovascular Stent Placement Stent implantation in the pulmonary arteries or for aortic coarctation is used to maintain vessel diameter and decreased gradients in patients unresponsive to balloon dilation. Stents are mounted on balloon catheters, and the balloon/stent combination is advanced over a previously placed wire. A long sheath (originating in the groin or neck) is placed across the area of narrowing to prevent the stent from slipping off the balloon catheter as it makes its way through the heart or vessels. After the stent has been properly positioned, the long sheath is withdrawn to expose the balloon/stent combination. Most devices currently used include a left atrial disc with an occlusive membrane, a central spool or connecting pin, and a right atrial disc with an occlusive membrane. The membrane occludes flow through the defect, and within months, the device becomes incorporated into the septum due to endothelialization. A sizing balloon inflated across the defect permits estimation of the stretched diameter. The device attached to the delivery cable is loaded in the long sheath and advanced to the left atrium. The left atrial disc is opened, the device is withdrawn until the left atrial disc is in contact with the atrial septum; then the right atrial disc is opened, effectively “sandwiching” the atrial septum between the two discs. Hemodynamic compromise may be seen with tension on the wire if aortic or tricuspid insufficiency is induced. Great care must be taken to avoid entrapment in the mitral, aortic, and tricuspid valves during device deployment. Improvements in the devices developed more recently have significantly reduced the cath lab morbidity of this procedure. The embolization coils consist of a metal wire, either stainless steel or platinum, ± Dacron strands, and are available in multiple sizes, lengths, and shapes. The technique for coil closure of collaterals or other communications is straightforward. A catheter is placed in the vessel to be occluded, and a selective angiogram is done to delineate the anatomy and diameter of the vessel to be closed. Coils that are slightly larger than the diameter of the vessel are used because the vessel will distend when the coil is deployed. Using a long “pusher” wire, the coil is advanced through the catheter and deployed in the vessel. Coil dislodgement and embolization to a distal blood vessel are the most common complications. In general, the errant coil can be retrieved in the cath lab without much difficulty and a new coil of a larger size placed to occlude the vessel. It also may be performed in patients presenting with acute onset of cardiomyopathy for histopathological Dx of myocarditis. It is usual to obtain four to five specimens to improve the diagnostic gain, as the histopathological changes can be patchy. Complications of endomyocardial biopsy include cardiac perforation and tricuspid valve damage. A variety of other transcatheter therapeutic procedures may be performed in the cardiac cath suite. Rashkind balloon atrial septostomy, static balloon septoplasty, Brockenbrough transseptal needle puncture, and radiofrequency-assisted perforation of the pulmonary valve or the atrial septum are all less commonly used than the procedures described above, but routinely are undertaken in high-volume cath labs. These studies often are used to make a Dx of the mechanism of arrhythmia, assess the hemodynamic impact of the arrhythmia, assess efficacy of pharmacologic therapy, and map the location of abnormal conduction pathways or automatic foci. This procedure was first described in pediatric surgery in 1991, but has rapidly become a preferred therapeutic option for supraventricular tachycardia in this population. Pacemaker placement has become more common as data have accumulated regarding the risk of sudden death in patients with congenital complete heart block, as well as increased survival with postop heart block. These patients are often challenging for the anesthesiologist due to their abnormal cardiac anatomy and physiology. Many of them have undergone repeated catheterizations and have had multiple anesthetics. All patients require a thorough preanesthetic evaluation with emphasis on cardiorespiratory function and associated comorbidities (almost 30% of patients show associated anomalies or syndromes with Down syndrome being the most common). Particular attention should be paid to patients with single-ventricle physiology (Fontan circulation), who are dependent on their venous return for hemodynamic stability and oxygenation as well as prone to shunt thrombosis, specifically when dehydrated. In such patients early establishment of iv access to prevent dehydration is advisable. Spontaneously breathing patient is preferable so as to mimic normal baseline cardiac and respiratory physiologic state, and to perform subsequent hemodynamic calculations. General anesthesia may be a safer option for neonates and younger children because of patient anxiety, longer duration of procedure, and clinical state of the patient. Patients with moderate to severe pulmonary hypertension present extra challenges and care for these patients differs among institutions. Because physiological changes associated with intubation, and more likely extubation, might result in a pulmonary hypertensive crisis in these patients, sedation is favored by some anesthesiologists.
Plot on a made by the gynecologist via hysteroscopy order suhagra with american express erectile dysfunction treatment electrical, hystero- growth chart if delayed puberty is a consideration buy suhagra mastercard causes of erectile dysfunction in your 20s. Assess Sexual Maturity Key Questions Use the Tanner stages to assess and rate the stage of l Do you have cyclic abdominal bloating or cramping? The stage of breast and pubic hair development in the adolescent Presence of Premenstrual Symptoms or girl is related to her chronological age, age at men- Dysmenorrhea arche, and evidence of growth spurt. The breasts often Cyclic symptomatology of dysmenorrhea, in the ab- develop at different rates, so some asymmetry is com- sence of menses, can be caused by an incomplete out- mon. Plot these physiological events on the opening, imperforate hymen, intact uterus, or congeni- growth curve. If there is no indication of a uterus by examination or lower abdominal ultra- Screen for Eating Disorders sound, a karyotype is needed to determine the con- If you suspect anorexia nervosa or bulimia, administer genital disorder. A referral to an endocrinologist or a screening instrument to help determine the diagnosis. About half of any abdominal male gonads, which would be a risk of the females with eating disorders will have short for cancerous degeneration. Chapter 5 • Amenorrhea 55 Calculate the Body Mass Index production, there is no ovulation; anovulatory cycles Seventeen percent body fat is needed for most females are amenorrheic. Also look for Turner syndrome to be menarchal, and about 22% body fat is necessary stigmata—webbed neck and low-set ears (other signs for ovulation. Palpate the Thyroid Gland and Lymph Nodes Obesity causes amenorrhea secondary to ovarian Palpate the thyroid gland for diffuse enlargement, dysfunction. Assess for supraclavicular cell stroma convert androstenedione to estrogen (es- and infraclavicular lymphadenopathy or carcinogenic trone) as the body fat increases. Obesity also increases masses of the sternal notch and abdomen, which could sex hormone binding globulin, thereby increasing free arise from a tumor of germ cell, adrenal, or pituitary steroid levels. Perform Clinical Breast Examination Examine the Skin and Hair Physical examination verifes sexual maturation level. Observe for signs of thyroid dysfunction or adrenal The growth spurt occurs before breast development excess. Features of hypothyroidism include dry, (thelarche), which is followed by the appearance of coarse, faky skin; coarse hair that tends to break; and axillary hair. More than by fne, warm skin that is hyperpigmented at pressure 95% of adolescents are menarchal 1 year after they points. A congenital problem Perform a Head and Neck Examination might manifest as vaginal or uterine agenesis, and is During the head and neck examination note any visual identifed by the absence of a vagina, cervix, or uterus. Take menses behind an obstructed outfow tract needs im- that number (product) and divide by the patient’s height in mediate intervention to prevent infammatory changes inches. Needle aspiration is not recom- Example: Weight 5 75 pounds; height 5 4 feet 2 inches mended because it might potentiate infection. Vaginal walls that are pale and dry, have few rugae, 56 Chapter 5 • Amenorrhea and are friable are estrogen defcient. Pelvic Ultrasound and Vaginal Ultrasound Prolactin Levels Pelvic and vaginal ultrasound studies are used to deter- About one-third of women with no obvious cause of mine the presence of a uterus, the anatomical size and amenorrhea will have an elevated prolactin level. Ultrasound is used to measure reference range, less than 50 ng/mL, a progesterone ovarian size, to identify cysts, and to evaluate follicular challenge test is indicated. In primary amenorrhea, ultrasound is is high, greater than 50 ng/mL, or if the patient has helpful in assessing müllerian agenesis and gonadal galactorrhea, a cone-down view of the sella turcica is dysgenesis, because there could be internal organs and taken to rule out a pituitary adenoma. One-third of these patients than 200 ng/mL, is highly suggestive of a prolacti- also have urinary tract abnormalities; therefore an noma. A prolactin elevation less than 100 ng/mL, but abdominal ultrasound can be obtained at the same time higher than normal, is most frequently caused by pre- to evaluate that system. The hyperprolactinemia usually subsides a few weeks after stopping the offending Progesterone Challenge Test drug. Serum Follicle-Stimulating Hormone Levels The patient should respond to the medication within Ovarian failure, which causes a low estradiol secretion, 2 to 7 days. This demonstrates that there are Chapter 5 • Amenorrhea 57 suffcient endogenous estrogens to prepare the endo- cells, 40% intermediate cells, and 60% superfcial metrium and confrms that there is a functioning cells. Low estrogen effect is forms of progesterone can be used: micronized proges- demonstrated by the predominance of intermediate cells. A no menstrual fow, administer the regimen a second value greater than 3 ng/mL is found with ovulation. A positive test denotes that there is inadequate estrogen production either Pregnancy is the most common reason for amenor- from inadequate functional ovarian follicles, or from rhea in women of childbearing age. Chromosome Analysis (Karyotyping) Constitutional Problems Karyotyping is done to delineate probable chromo- somal abnormalities. It is used in the workup for Delayed Puberty ambiguous genitalia, primary amenorrhea, oligomen- A pituitary adenoma must be ruled out for all patients orrhea, delayed puberty, or abnormal development at with delayed puberty. Endometrial Biopsy Endometrial biopsy can be used to show the hormonal Anorexia Nervosa and Bulimia response of the uterine endometrium. Affected women have such a fear Basal Body Temperature Charting of being fat that they do not eat or they purge after A woman can take her awakening body temperature eating. Often these women are overachievers and have each day and chart it to determine if ovulation is oc- low self-esteem. If this increase in temperature occurs, ovulation has occurred and a Exercise-Induced Amenorrhea positive estrogen component is inferred. This amenorrhea is common in competitive athletes, but exercise can also cause skipped menses in the ca- Maturation Index sual trainer. Gymnasts, ballerinas, and long distance The maturation index indicates the degree of maturation runners are at high risk, especially if they started their of the vaginal epithelium and provides an objective as- training at a very early age. Body fat of 17% is needed sessment of vaginal hormone response as well as overall for menarche, whereas 22% body fat is necessary for hormonal environment. The index is read Congenital or Chronic Disorders from left to right and refers to the percentage of parabasal, intermediate, and superfcial squamous cells appearing on Turner Syndrome a smear, with the total of all three values equaling 100%. The typical features are short 58 Chapter 5 • Amenorrhea stature, webbed neck, shieldlike chest, and delayed or curettage. The average age of menopause in the a moon face, acne, hirsutism, kyphosis, purplish striae United States is 51 years. Clinical symptoms are hot fashes, night Thyroid Dysfunction sweats, insomnia, mood changes, and amenorrhea Amenorrhea from thyroid dysfunction subsides as for 12 months. If this occurs before age 40 years, it is soon as serum thyroid levels return to normal. Common causes of premature thyroidism frequently causes amenorrhea and is char- ovarian failure include genetic and enzyme disorders, acterized by fatigue, constipation, cold intolerance, immune disturbances, and chemotherapy. Offending drugs are primarily dopamine antagonist agents, estrogens, and Uterine and Outfow Tract Problems marijuana. Imperforate Hymen The woman with an imperforate hymen could present Chest Wall or Nipple Stimulation with a painful, bulging perineum. The higher the prolactin level, the Cervical Os Stenosis greater the likelihood that the patient will be amen- Stenosis of the cervical os can be the cause for either orrheic. Stenosis is often caused by therapeutic procedures of the cervix such Pituitary Adenoma as cryotherapy or cone biopsies.
This has been stud- • Celiac plexus blockade has been reported to be benefcial ied only for pancreatic cancer pain in adults purchase suhagra with a mastercard erectile dysfunction treatment in allopathy. A Cochrane in managing severe nausea and vomiting in patients with review  published its results in 2011 buy suhagra 100 mg without prescription erectile dysfunction treatment by exercise. Anatomy • The Cochrane review included six studies [26–31] pub- lished from 1993 to 2008. Sympathetic trunk Spinal Dorsal (posterior) root Thoracic part sensory of spinal cord (dorsal Intermediolateral root) cell column ganglion Ganglion of sympathetic trunk Spinal nerve to vessels and glands of skin Ventral (anterior) root Meningeal branch to spinal meninges and spinal perivascular Stretch plexuses (usually arises from (distention) White ramus communicans spinal nerve) Gray ramus communicans Abdominopelvic (greater, lesser, Ganglion of and least) thoracic sympathetic trunk splanchnic nerves Vagus Pain nerve (X) Celiac ganglion Enteric Ganglion of plexuses sympathetic trunk of gut Superior mesenteric ganglion Sympathetic Preganglionic Parasympathetic Preganglionic Afferent fibers fibers fibers Postganglionic Postganglionic Fig. By the same level of the L1 vertebral body and anterior to the crura of token, the medial pathway is impeded by the kidney on the diaphragm (Fig. The left celiac ganglion is saline may be utilized to penetrate the crura of the slightly lower than the right ganglion. Once • It is extremely important to correctly identify the bony contact is made, the depth of the needle is T12 spinous process by following the twelfth rib noted. The needle is then withdrawn and redirected medially and also by counting cephalad from the L5 at a steeper angle (60 degrees from midline) so the spinous process. The puncture point was defned as – The uppermost margin of the L2 vertebral body is the lateral margin of the L2 upper end plate under 20° identifed. Splanchnic Nerve Blocks • The splanchnic nerve block is similar to the above classic retrocrural technique. The needles, however, are aimed more cephalad to the anterolateral margin of the T12 ver- tebral body, being careful to hug the vertebral body. Although no longer com- surface farthest from the midline to project tangentially to B while mercially available, phenol has the beneft of minimal avoiding major abdominal organs; d (d’) the nearest skin surface to pain on injection. It may also be prepared as a 10%–12% project tangentially to B while avoiding interference with osteophytes solution with radiographic contrast medium, thereby or lateral bony structures of the L2 vertebral body; e (e’) the skin sur- face crossing the vertical line of the midportion of the pedicle; F mid- allowing monitoring of the neurolytic spread as it is line, Rt. Only one side is needed if the neurolytic chronic pancreatitis patients and was found to have solution spreads across the midline, particularly if the similar effcacy . Adamkiewicz (anterior spinal artery syndrome) caus- – These procedures are potentially fraught with the risk ing spinal injury [50, 53]. Celiac plexus and splanchnic plexus peripheral nerve trained and experienced practitioners. Several approaches have been subsequently promoted, • Relative contraindications to these procedures include including retrocrural, transcrural, and transaortic via abdominal aortic aneurysm and respiratory insuffciency blind-landmark-derived techniques and fuoroscopic (i. There have also cian responsible for management of anticoagulants when been direct semi-open methods of video-assisted thora- stopping anticoagulant therapy, taking into consideration scopic radiofrequency ablation and open radiofrequency the risk-beneft ratio to abstaining from anticoagulants to ablation for chronic pain states. Initial diagnostic blockade with local anesthetics only is Side Effects and Complications advocated. Following successful diagnostic injections, neurolytic • Side effects after celiac plexus block occur secondary to modalities can be initiated to provide prolonged blockade of sympathetic fbers and the unopposed action effcacy. The use of cutaneous landmarks to perform these proce- abdominal cramping, and orthostatic hypotension and are dures is ill-advised in light of modern imaging generally transient. The performance of these techniques are fraught with lateral a needle placement at the thoracic levels and potential catastrophic complications, even in experi- subsequent pneumothorax or chylothorax [1–5, 36–46, enced hands. The complications associated with splanchnic nerve and pneumothorax in any patient noting dyspnea during celiac plexus blockade include pain at the injection site, post-procedure monitoring. To help avoid such com- bleeding, infection, trauma to adjacent tissue, and inad- plications, the smallest gauge needles possible should vertent injection into unintended tissue or structures. The most signifcant complications from blockade of the • Additionally, hematuria from damage kidneys or ureters splanchnic nerves and the celiac plexus can be mitigated and intravascular injection into the aorta or celiac vessels by use of modern imaging techniques by well-trained are possible complications. The evidence of effectiveness for relief of pain in the Pain structures innervated by the splanchnic nerves and celiac Pain at the site of the needle insertion plexus following their blockade has been demonstrated. Exacerbation of existing pain Pain in the mid- or low back Infection Acknowledgments This book chapter is modifed and updated from a Soft tissue abscess previous book chapter, “Celiac Plexus and Splanchnic Blockade” by Epidural abscess Allen W. Encephalitis Peritonitis Discitis Bleeding References Soft tissue hematoma Retroperitoneal hematoma 1. Celiac plexus block in the man- Epidural hematoma agement of chronic abdominal pain. Celiac plexus block and neurolysis for pan- Embolism or vascular thrombosis creatic cancer. Inadvertent intravascular neurolytic injection In: Manchikanti L, Singh V, editors. Interventional techniques Phenol may result in convulsions in chronic non-spinal pain. Anesthesiology-important advances in clinical medi- Soft tissue cine: celiac plexus alcohol block for upper abdominal cancer pain. Treatment of benign chronic abdomi- Spinal cord nal pain with neurolytic celiac plexus block. Nervi splanchnici durch Miscellaneous Leitungsanesthesia bei Magenoperationen und anderen Eingriffen Orthostatic hypertension/hypotension in der oberen Bauchule. Acute pancreatitis; an evaluation of the classifca- Pancreatitis tion, symptomatology, diagnosis and therapy. A technic for injection of the splanchnic nerves with Spinal cord compression alcohol. Management of upper Arachnoiditis abdominal cancer pain: treatment with celiac plexus block with Increased intrathecal pressure alcohol. Single-needle celiac randomized, prospective study for comparison of percutaneous plexus block: is needle tip position critical in patients with no bilateral paramedian vs. Autonomic innervation of viscera in relation to nerve Transdiscal blockade of the splanchnic nerves. Comparison between rolytic celiac plexus block: the transintervertebral disc approach. Philadelphia: Churchill- nicectomy in patients with unresectable pancreatic cancer. Celiac plexus block versus analgesics in pancreatic computed tomography guided cryoablation of the celiac plexus as cancer pain. Single-needle celiac patients with unresectable pancreatic cancer: a randomized con- plexus block. Endoscopic ultrasonography guided pain associated with pancreatic cancer: a meta-analysis. Percutaneous neurolytic celiac plexus gesia, celiac plexus block or thoracoscopic splanchnicectomy for block. Aortic dissection as a complica- neurolysis to prevent pain progression in patients with newly tion of celiac plexus block. They always have Chronic disorders of the musculoskeletal system affect taut bands that increase muscle tension and decrease range of approximately 10% of Americans and have become the main motion of the muscle. Myofascial elicited in response to movement of the involved muscle or pain syndrome which is caused by myofascial trigger points may occur spontaneously. Upon compression of this tender spot, the patient recognizes this pain; this is one of the criteria suggested by Trigger point injections were frst described by the Chinese Gerwin et al. Spot tenderness and a physician Ssu-Mo who practiced dry needling in seventh- taut muscular band have also been suggested as diagnostic century China . Having referred pain and being able to illicit a local later to Europe in the seventeenth century when it was intro- twitch response when compressing these areas are used as duced by Willem ten Rhijne .
The incision to the neo-ostium should be tions suhagra 100 mg with mastercard erectile dysfunction unani medicine, an ongoing multi-institutional study has been orga- extended gradually and stopped when the oriﬁce is identiﬁed nized to delineate the medical and surgical outcomes of these and will allow an appropriately sized dilator without difﬁ- patients over the long term purchase genuine suhagra online erectile dysfunction causes prostate. If the surgeon discovers that the incision has been extended outside of the heart, the intimal surfaces must be reattached using interrupted monoﬁlament suture before the 26. This is a critical repair because a poorly Sinus of Valsalva reconstructed oriﬁce will result in dissection, bleeding, and coronary occlusion. A later section reviews the repair of this Anomalous right coronary artery arising from the left aortic complication. Sometimes the common wall (tunica cardial infarction, syncope, and atrioventricular block are media) is so thick that leaving it in place could threaten the related to this anatomy, which is characterized by a slit-like newly formed oriﬁce by obstruction. It is also dent to consider removal of this part of the common wall associated with an intramural course of the artery within the using endarterectomy techniques. The unroofed segment wall of the aorta before it exits in the right coronary sinus en will result in an intimal gap between the coronary artery wall route to the epicardial surface. This requires tacking sutures, which are result of intermittent closure of the anomalous ostium within placed to reapproximate the intimal edges to avoid dissection the aortic wall during exercise or hypertensive crises. The rest of authors believe that the ischemic insult is due to the stenotic the unroofed segment will also require tacking sutures (not arterial course. A minority believe that the coronary artery is shown) to complete this part of the operation. As noted before, this series of interrupted sutures along A measured probe determines the oriﬁce diameter and, when the entire length of the unrooﬁng will prevent dissection, hem- advanced further into the tunnel, determines the point at which orrhage, and coronary artery occlusion. Any the proximal tunnel within the left coronary sinus and the untoward bleeding or ventricular dysfunction seen by complete unrooﬁng within the right coronary sinus. The intramural segment is unroofed in both sinuses of Valsalva, Rarely, the intramural oriﬁce can be hidden behind the and tacking sutures are placed (Fig. This the respective intimal ﬂaps of the coronary artery and the condition is discussed in a later section. Instead, the course of the shows the unrooﬁng procedure using sharp scalpel incision. The rest of the tack- pleted side-to-side anastomosis with continuation of the ing sutures remain to be placed to complete the procedure. Origin of the Coronary Artery Repair Deﬁning “unacceptable” is problematic and challenging, Complicated by Unwanted Transaortic however. If blood is actually seen swirling through the epi- or Transcoronary Incision cardial surface of the repair, the assessment is easy. Other assessments that can be obvious include kinking, stenosis, or The transaortic repair of an intramural coronary artery gener- suspected intimal integrity, which should stimulate a re- ally is a safe and reproducible operation, but occasionally the exploration of the anastomosis. This repair resulting in a disrupted or nearly disrupted coronary-aortic can be performed with the cross clamp in place and cardio- connection. This maneuver may settle the consequences and requires careful assessment during the problem, but internal and external sutures can disrupt the unrooﬁng procedure. Another cross clamp and cardioplegic arrest unrooﬁng procedure performed with a scissors, although this must be performed and all reparative sutures removed. The part of the operation can also be performed sharply with a suture line must be débrided to remove the uneven edges scalpel. Invariably, the result cannot be repaired by even one extra millimeter can result in intimal coronary- direct anastomosis; a patch will be necessary to augment the aortic disruption, which may be transmural (a hole to the anastomotic suture line. Once this incision is performed, the surgeon the Aortic Commissure can now identify the intramural course of the right coronary artery and by a probe demonstrate its origin hidden behind As noted previously, rarely the oriﬁce of an intramural coro- the affected commissure. Clearly, a patch will be necessary nary artery may arise at the commissure between the right to create a neo-oriﬁce. This situation can cause signiﬁ- gous pulmonary patch is then used to augment the oriﬁce of cant consternation; the reason for the operation is seemingly the right coronary artery with anastomotic extension to the unidentiﬁed despite all efforts to identify the causative aortic wall, thereby forming the neo-oriﬁce (Fig. With some effort, the oriﬁce can be Tacking sutures are placed within the aorta at the unrooﬁng found, but the unsuspecting surgeon may conclude that there site and the right coronary artery neo-oriﬁce is constructed as is oriﬁce atresia. Inspection of the epicardial surface iden- affected commissure is not manipulated, so the possibility of tiﬁes the right coronary artery, which seems to arise from the resultant aortic regurgitation is remote. Actually, as the dotted/ oriﬁce is large and is not subject to the possible creation of a dashed line suggests, the epicardial right coronary artery is stenotic internal oriﬁce by a side-to-side anastomosis. On the the continuation of an intramural portion, which was not other hand, the autologous pulmonary patch and coronary identiﬁed. One resolution of this anatomic dilemma is to distortion create the possibility of epicardial bleeding as a apply accepted surgical solutions for coronary artery oriﬁce potential complication. This incision tools will verify adequate coronary ﬂow to avoid periopera- onto the surface of the right coronary artery is illustrated in tive complications. Also shown is the target area on the ascending aorta more superior Anomalous aortic origin of a coronary artery with a non- in the right coronary cusp, away from the potential constric- intramural malignant course between the aorta and pulmo- tor effects that occur between the aorta and pulmonary artery. First, it is very difﬁcult with modern diagnostic coronary artery to the epicardial surface. When operative indications are unfavorable reconstruction and distortion that can occur after present, intraoperative anatomic exposure can identify the repair, as shown in Figure 26. When an extramural course is identiﬁed, a epicardial dissection and coronary mobilization. Complications can be serious and require careful assessment of ventricular function and coronary ﬂow. As such, it is a general therapeutic modality to treat a variety of conditions that threaten life. One of the more com- mon indications is Kawasaki disease, in which patients may develop giant aneurysms and hemodynamically stenotic ves- sels. These patients are subject to coronary occlusion, ven- tricular dysfunction, and death. Infants presenting with left main coronary artery atresia are also candidates for coronary bypass. Injuries occur in the catheterization laboratory from unwanted coronary dissection due to catheter manipula- tion, coronary disruption due to overdilation of the aortic root, and coronary compression due to device placement. Coronary bypass should be in every congenital heart surgeon’s armamentarium for the unlikely Fig. In fact, long- term observation of the saphenous vein bypass graft has shown unfavorable tenting of the native coronary artery, resulting in poor perfusion. In general, there is no indication for the use of the saphenous vein as a bypass conduit in infants and young children. Coronary bypass therefore is not only possible, but has been shown to be effective and long-lasting. Traction sutures are placed at the pedicle to ensure proper orientation and gentle retraction. An incision is made posteriorly, to form an angled opening for the end-to-side anastomosis. Antegrade car- dioplegia is administered, and quiet, bloodless conditions are established. Antegrade cardioplegia is given to distend the coronary vessel, and a sharp blade is used for the coronary incision.