WithAScalpel - Fumiya Yoneyama, MD, PhD

Cardiac Surgeon | Assistant Professor | @TexasChildrens | Visual insights in surgery, cardiology & intensive care | Views my own

[WithAScalpel - Fumiya Yoneyama, MD, PhD @WithAScalpel]

Classic Tetrad of TOF🍀

👉Malalignment VSD — the anatomical foundation, produced by anterior deviation of the infundibular septum.
👉Overriding aorta — the aortic root straddles the ventricular septal defect.
👉RVOT obstruction — subpulmonary narrowing defines the right ventricular outflow physiology.
👉RV hypertrophy — the consequence of chronic right ventricular pressure overload.

@alex1708ander @iamritu @CASivaram1 @OungSavly @loomba_rohit @SIwa23288585 @Prasannasimha

[Alexander Mladenow MD @alex1708ander]

Classic TOF undergoing very early surgical repair (< 3 months)

#echofirst @iamritu @CASivaram1 @OungSavly @loomba_rohit @WithAScalpel @SIwa23288585 @Prasannasimha

📌 RVOTO, bicuspid PV
📌 systemic RVSP
📌 right-sided Ao arch

10T-D micro multi-plane TEE probe @GEHealthCare

[WithAScalpel - Fumiya Yoneyama, MD, PhD @WithAScalpel]

Single Ventricle Palliation #2: Stage I Norwood Operation

👉The Norwood operation establishes unobstructed systemic outflow, secured pulmonary blood flow, and nonrestrictive atrial communication.
👉Pulmonary blood flow is provided through a controlled source, either an RV–PA conduit or a modified BTT shunt.
👉Because Qp remains a controlled “steal” from systemic ventricular output, careful Qp/Qs balance is essential to prevent systemic hypoperfusion and pulmonary overcirculation.

[WithAScalpel - Fumiya Yoneyama, MD, PhD @WithAScalpel]

Coronary Anatomy in d-TGA — Yacoub Classification📚

👉Type A: LCA from sinus 1 and RCA from sinus 2 — the usual and most common pattern.
👉Type B: Single coronary ostium, from either sinus 1 or sinus 2, with early branching between the great arteries.
👉Type C: Two separate but closely adjacent ostia, usually near the posterior commissure; often managed like a high-risk transfer pattern.
👉Type D: LAD from sinus 1 and RCA + LCx from sinus 2 — LCx courses posteriorly around the pulmonary root.
👉Type E: RCA + LAD from sinus 1 and LCx from sinus 2, often with side-by-side great arteries and complex looping.

[Alexander Mladenow MD @alex1708ander]

Usual coronary artery origins on TEE before and after ASO in d-TGA #echofirst #dTGA

Newborn, 3.5 kg

10T-D micro multi-plane TEE probe @GEHealthCare

[WithAScalpel - Fumiya Yoneyama, MD, PhD @WithAScalpel]

Single Ventricle Palliation #1: Pre–Stage I Physiology

👉Before Stage I, systemic output depends on ductal patency, atrial communication, and the balance between PVR and SVR.
👉A single systemic ventricle must support both circuits, with total cardiac output divided into Qp and Qs.
👉With complete intracardiac mixing, PA and Ao saturations are equal, and Qp/Qs reflects the PVR/SVR balance.

[WithAScalpel - Fumiya Yoneyama, MD, PhD @WithAScalpel]

Interrupted Aortic Arch — Surgical Pathways🗺️

👉One-stage repair: Perform Arch repair + VSD closure when anatomy is favorable; choose Yasui (DKS + LV-PA baffle + RV-PA conduit) for significant LVOT obstruction.
👉Staged repair: Use bilateral PAB + PDA stent or Arch repair + main PAB for stabilization, then proceed later to Arch repair + VSD closure or Yasui.
👉Biventricular repair: If the left heart is adequate, aim for Arch repair + VSD closure; use Yasui when direct LV outflow is not sufficient.
👉Single-ventricle pathway: If the left heart is too small, choose a Norwood-type strategy with DKS + Arch repair + RV-PA conduit/BT shunt, followed by Glenn and Fontan.

@OungSavly @AEPCcongenital @WGACHDChair @iamritu @CASivaram1 @loomba_rohit @alex1708ander @SIwa23288585 @swatigar @cardiopedhnn

[Oung Savly MD FACC FASE FESC FAAP FEACVI 🇰🇭 @OungSavly]

📌Outlet VSD with posterior malalignment of the outlet septum: subaortic narrowing 👉🏻CoA/IAA
📌Large PDA masks the classic abdominal aortic Doppler
@AEPCcongenital
@WGACHDChair @iamritu @CASivaram1 @loomba_rohit @alex1708ander @SIwa23288585 @WithAScalpel @swatigar @cardiopedhnn

[WithAScalpel - Fumiya Yoneyama, MD, PhD @WithAScalpel]

Cardiac Conduction Axis in Perimembranous VSD

👉In the normal heart, the RBB emerges on the RV septal surface posterior to the muscle of Lancisi.
👉With outlet extension, the RBB may run closer to the outlet margin, covered by the posterior limb of the trabecula septomarginalis, and emerge distal to the medial papillary muscle (MPM).
👉With inlet extension, the RBB shifts toward the inlet-side edge of the VSD, making the MPM an unreliable landmark.

[WithAScalpel - Fumiya Yoneyama, MD, PhD @WithAScalpel]

Single Ventricle Strategy — From Streaming to Fontan🗺️

👉In DILV/d-TGA/VSD ± subaortic stenosis ± coarctation, the physiology, anatomy, and surgical strategy can vary significantly!
👉Surgical strategy must secure systemic outflow: DKS, Norwood-type reconstruction, palliative ASO, arch repair, or SAS relief depending on anatomy.
👉The final goal is Fontan circulation, but success depends on a low-resistance pulmonary circuit and an unobstructed systemic ventricular outflow pathway.

[Irina Akhmedova @Irina67790690]

❗️Single inlet ventricle with left ventricular morphology.
〽️The right ventricle is severely hypoplastic.
〽️Transposition of the great arteries is present: the aorta arises from the hypoplastic right ventricle, 〽️while the pulmonary artery arises from the dominant left ventricle.
〽️Coarctation of the aorta is also identified.

Newborn baby

[WithAScalpel - Fumiya Yoneyama, MD, PhD @WithAScalpel]

Anomalous Aortic Origin of a Coronary Artery (AAOCA) #3: Surgical Procedure of Unroofing

👉Identify the intramural segment and incise the shared aortic–coronary wall longitudinally from the anomalous ostium toward the coronary exit point.
👉Traction stay sutures help expose the tunneled segment, allowing the common wall to be unroofed stepwise while staying within the coronary lumen.
👉If the intramural segment crosses a commissure, the commissure may need to be taken down and resuspended to preserve aortic valve competence.

[WithAScalpel - Fumiya Yoneyama, MD, PhD @WithAScalpel]

Tricuspid Valve — Surgeon’s View and Morphologic Variations📚🧐

👉The tricuspid valve is not simply “three leaflets”; clefts, accessory leaflets, and variable papillary muscles often define the repair strategy.
👉From the surgeon’s view, mapping the septal leaflet, coronary sinus, Tendon of Todaro, and AV node region is essential before placing stitches.

@alex1708ander @MarcoSa52466127 @ASE360

[Alexander Mladenow MD @alex1708ander]

Type IV tricuspid valve morphology on TEE - the rarest TV morphology type, reported in ~2% of cases #echofirst

[WithAScalpel - Fumiya Yoneyama, MD, PhD @WithAScalpel]

Anomalous Aortic Origin of a Coronary Artery (AAOCA) #2: Surgical Concept of Unroofing

👉Unroofing opens the shared aortic–coronary wall of an intramural segment, converting a tunneled coronary course into a wide, non-compressed neo-ostium.
👉It is best suited when the intramural course runs above the aortic valve; if the course is below the AoV, unroofing may be unsafe or inappropriate.
👉If dynamic compression persists in the Ao–PA corridor after unroofing, coronary reimplantation may be required to fully relieve ischemic risk.

[WithAScalpel - Fumiya Yoneyama, MD, PhD @WithAScalpel]

SVAS Repair — Restoring the Sinotubular Junction🍾

👉Enlarge the STJ/root into a symmetric, physiologic geometry while protecting the AoV and coronary origins.
👉McGoon (1-sinus), Doty (2), Brom (3): sinus and ascending aortic reconstruction.
👉Beyond the STJ: coronary ostia, arch anatomy, and branch PAs may define the true surgical plan.

@OungSavly @alex1708ander

[Oung Savly MD FACC FASE FESC FAAP FEACVI 🇰🇭 @OungSavly]

📌Supravalvular aortic stenosis (SVAS) / Williams syndrome in TEE @alex1708ander

[WithAScalpel - Fumiya Yoneyama, MD, PhD @WithAScalpel]

Anomalous Aortic Origin of a Coronary Artery #1: Intramural vs Interarterial Course

👉Intramural course means the coronary artery runs within the aortic wall; when it is above the aortic valve, unroofing can create a new coronary orifice.
👉Interarterial course means the coronary artery passes between the aorta and pulmonary artery, where external compression may cause ischemia.
👉If an interarterial course remains after unroofing, coronary compression can persist — in that setting, coronary reimplantation may be required.

[WithAScalpel - Fumiya Yoneyama, MD, PhD @WithAScalpel]

Multi-Directional Needle Control — Eiji-happō in Calligraphy🖋️

👉X-shaped or figure-of-8 sutures require the needle to move precisely across multiple directions and planes.
👉Like Eiji-happō in calligraphy, surgical precision begins with mastering direction, rhythm, and balance.

@PipeCabreraV @SWexner @pferrada1 @AmCollSurgeons @BJSAcademy @CiruAndes2 @TomVargheseJr

[Dr Luis Felipe Cabrera Vargas MD FACS @PipeCabreraV]

The X or 8 suture technique! Step by step! @SWexner @pferrada1 @AmCollSurgeons @BJSAcademy @CiruAndes2 @TomVargheseJr

[WithAScalpel - Fumiya Yoneyama, MD, PhD @WithAScalpel]

Lymphatic Circulation — Anatomy, Flow, and Failure

👉Most interstitial fluid returns via the venous system, while the remaining 10–15% is cleared by the lymphatics through the thoracic duct into the left venous angle.
👉Lymph flow is driven by intrinsic lymphatic contractions, one-way valves, skeletal muscle pump, arterial pulsations, and negative intrathoracic pressure, and works best when downstream venous pressure is low.
👉In Fontan circulation, chronically elevated CVP and loss of favorable diastolic drainage impair lymphatic return, leading to protein-losing enteropathy, plastic bronchitis, and chylothorax.

[WithAScalpel - Fumiya Yoneyama, MD, PhD @WithAScalpel]

DCJA VSD — Aortic Cusp Support Matters🫸

👉In doubly committed juxtaarterial VSD, the absent infundibular septum places the aortic and pulmonary valves in fibrous continuity.
👉Loss of subarterial support can allow RCC prolapse into the defect, especially under the LV-to-RV systolic jet.
👉VSD closure is not only septal repair — it also protects aortic valve geometry and prevents progressive AR.

@RitikaTuliMD
#MedEd #VSD #CardioMed #CongenitalHeartDisease https://t.co/dVfGMBmSi3

[Ritika Tuli @RitikaTuliMD]

#CardioNugget™

In outlet/supracristal VSDs, the right coronary cusp can lose its supporting septal “shelf” and get pulled/prolapse into the VSD by the Venturi effect from the high-velocity LV→RV jet.

Over time:
RCC prolapse → poor cusp coaptation → progressive aortic regurgitation.

Board pearl:
VSD + new AR = think RCC prolapse, especially outlet/supracristal VSD.

#CardioNugget #MedEd #VSD #CardioMed #CongenitalHeartDisease

Image from: https://t.co/faTphG0eHx