2019, William Jewell College, Enzo's review: "Order cheap Super P-Force online no RX - Trusted online Super P-Force OTC".
Once the tip of the tube is in the pleural space discount 160mg super p-force fast delivery, the clamp is removed buy super p-force with a mastercard, and the chest tube is advanced and positioned apically for a pneumothorax and dependently for fluid removal order 160 mg super p-force with amex. The location of the tube should be confirmed by observing the flow of air (seen as condensation within the tube) or fluid from the tube. A simple suture to anchor the tube can be used, or a horizontal mattress suture can be used to allow the hole to be tied closed when the tube is removed. An occlusive petrolatum gauze dressing is applied, and the tube is connected to a drainage apparatus and securely taped to the dressing and to the patient. The end of the chest tube is grasped with a Kelly clamp and guided with a finger through the chest incision. In one series, insertion and management of pleural tubes in patients with blunt chest trauma carried a 9% incidence of complications. Major complications requiring surgical intervention, or administration of blood products or intravenous antibiotics occurred in only four (1. The use of small-caliber, less rigid, Silastic drains has been found to be as safe and efficacious as the more rigid, conventional chest tubes . Most institutions use a three-chambered system that contains a calibrated collection trap for fluid; an underwater seal unit to allow escape of air while maintaining negative pleural pressure; and a suction regulator. Suction is routinely established at 15 to 20 cm water, controlled by the height of the column in the suction regulator unit, and maintained as long as an air leak is present. The drainage system is examined daily to ensure that appropriate levels are maintained in the underwater seal and suction regulator chambers. Connections between the chest tube and the drainage system should be tightly fitted and securely taped. For continuous drainage, the chest tube and the drainage system tubing should remain free of kinks; should not be left in a dependent position; and should never be clamped. Routine milking and stripping of chest tubes is discouraged primarily in postoperative cardiac surgical patients. Dressing changes should be performed every 2 or 3 days and as needed, making sure that no dressing with high content of petroleum-based ointment is present, because this would macerate the skin around the chest tube insertion site. Adequate pain control is mandatory to encourage coughing and ambulation to facilitate lung reexpansion. If the patient develops clinical symptoms including shortness of breath, decreasing oxygen saturation, or subcutaneous emphysema, then radiographic evaluation is indicated . A tube should never be readvanced into the pleural space, and if a tube is to be replaced, it should always be at a different site. If an air leak persists, brief clamping of the chest tube can be performed to confirm that the leak is from the patient and not from the system. When the leak has ceased for more than 24 to 48 hours (or if no fluctuation is seen in the underwater seal chamber), the drainage system is placed on water seal by disconnecting the wall suction, followed by a chest film several hours later. If no pneumothorax is present and no air leak appears in the system with coughing; deep breathing; and reestablishment of suction, the tube can be removed. For fluid collections, the tube can be removed when drainage is less than 200 mL per 24 hours , unless sclerotherapy is planned. When the chest tube is removed, the lungs should be fully expanded, which minimizes the pleural space. This can only be achieved when the patient holds his/her breath while performing the Valsalva maneuver (i. Variation of success rates could be affected by a number of reasons including the underlying disease, the use of mechanical ventilation, or other factors . Also, there have been reports of successful management of small and large pneumothoraces with small size (8. Thirty-six (60%) patients were discharged after 4 hours, and 30 patients (50%) were managed as outpatients. Because evacuation of a pneumothorax and removal of pleural fluid are the main indications for chest tube insertion, ultrasonography has application for chest tube insertion and care. The linear high frequency probe lacks sufficient penetration to visualize deeper thoracic structures such as atelectatic lung underlying the pleural effusion, but is useful for identification of lung point while mapping out the extent of a pneumothorax. A free-flowing pleural effusion will assume a dependent position in the thorax owing to gravitational effect, so the operator examines for fluid over the lateral chest in the supine patient. The operator can readily locate a loculated effusion and insert a targeted chest tube for drainage of the pleural fluid . Chest Tube Insertion and Care Ultrasonography permits selection of a chest tube with the appropriate and safe angle and depth for insertion into a pleural effusion. The principles of site selection for chest tube insertion are the same as for thoracentesis (see Chapter 12 Thoracentesis). Site selection can be done rapidly in the emergency situation (thoracic trauma, tension pneumothorax on ventilatory support). Unintentional insertion of the chest tube in a subdiaphragmatic position with injury to the liver or spleen, cardiac perforation, or lung insertion are all recognized complications of chest tube insertion that can be avoided by the simple expedient of using ultrasonography for all chest tube insertions, if the capability is available . Owing to the simplicity of the examination, ultrasonography is used to assess the amount of residual fluid. On occasion, a chest tube will not adequately drain the pleural effusion because of misplacement, tube blockage, or loculations. Ultrasonography can detect the adequacy of drainage; and, if the fluid is not being removed, guide decisions related to chest tube replacement or manipulation. Follow-up ultrasonography examinations take little time and are performed by the intensivist team at point of care as often as required in order to guide ongoing management of the chest tube. It is feasible to use ultrasonography as the main imaging modality for management of pleural fluid removal. Pneumothorax Scanning Technique A series of scan lines are performed over the chest in order to locate the pneumothorax and to establish a safe site for chest tube insertion that avoids injury to adjacent organs. In the supine patient, air in the pleural space will distribute anteriorly; so the examination for pneumothorax is concentrated over the anterior and lateral chest. Chest Tube Insertion and Care the presence of lung sliding, lung pulse, or B lines rules out pneumothorax at the site of the examination (See Chapter 11 Lung Ultrasonography). Multiple intercostal spaces can be examined in a short period time in order to exclude pneumothorax with a high level of certainty in the patient. Identification of a lung point verifies the presence of pneumothorax  and allows the operator to map out the lateral extent of the pneumothorax. Insertion where lung is still inflated against the chest wall may result in placement of the chest tube into the lung. The operator inserts the device into the area of the chest that lacks lung sliding and that is demarcated laterally by the lung point. Once the tube is inserted, adequacy of lung inflation is determined by the return of lung sliding, lung pulse, and/or B lines. The timing of chest tube removal following chest tube insertion for pneumothorax is guided with ultrasonography as follows [29–31]: 1.
Although this may have a slight effect on success gests that embryo transfer should be performed under rates quality 160mg super p-force, the other normal embryos are frozen and hence if ultrasound guidance as this allows more accurate a cycle is unsuccessful cheap 160 mg super p-force with visa, the patient can undergo repeated placement of the embryos in the uterine cavity and has single embryo transfers from frozen embryo replace been shown to significantly improve success rates  purchase super p-force paypal. After the outer sheath has been inserted in the correct location, an inner catheter containing the embryos is inserted into the outer sheath. When it is in the cor rect position a very small aliquot of fluid is used to emit the embryos from the end of the catheter. The inner catheter is then removed and handed back to the embryologist to confirm that no embryos have been retained in the inner catheter. If the catheter is clear, the outer sheath is gently withdrawn and the speculum removed. Although there is no chance that the embryos can ‘fall out’, many patients are not surprisingly very cau tious at this stage and quite often are allowed to rest in a supine position for up to 2 hours before being allowed to leave the hospital. It has been shown to be as efficacious as progesterone 712 Reproductive Problems but does require an injection and also increases the risk Table 52. The use of progesterone is more common and it can be given as tablets, injections, vaginal gel or vaginal pessa Age (years) 2012 2013 ries/rectal suppositories. The more intense regimens utilize injectable intra muscular progesterone with estradiol supplementa tion, normally in the form of tablets. It is not uncommon for the Age (years) 2012 2013 injectable progesterone to be changed to a vaginal preparation at around 8 weeks of gestation because of 18–34 30. Progesterone supplementation can also delay bleeding, even if the pregnancy test is negative. If the pregnancy test is nancy rates have fallen significantly while overall preg positive and in the normal range, then it is usual to offer nancy rates have shown a small increase (Table 52. In comparison, male age has very little repeated 48 hours later to assess the rise; it if it is subop impact. Over recent years there has been a proportionately greater increase in the number of treatments using frozen and thawed Results embryos compared with treatment cycles using fresh embryos. The oocyte is carefully positioned using a hold the results of the follow‐up studies are generally reassur ing pipette under gentle suction. Many centres will also recommend male karyotype ing pipette is slowly inserted to rupture the oolemma, and screening if sperm concentrations are below 5 million/ 3 the immobilized sperm injected into the oocyte with a very cm. The injecting pipette is then some microdeletion screening, although this is not rou carefully removed and the oocyte incubated under the tinely offered. These vary enormously depending on patient selection, If all the above results are normal, patients should be but success rates in appropriate circumstances can be counselled carefully that there is a slight increase in 30% live birth per transfer . Frozen embryo replacement cycle Gamete intrafallopian transfer the first pregnancy resulting from a frozen human Gamete intrafallopian transfer was first used around embryo was in 1985 and since then the use of frozen 1984 and here the eggs are collected laparoscopically, cycles has increased dramatically. Freezing surplus mor identified by the embryologist and then placed back in phologically normal embryos allows the use of those the fallopian tube, again laparoscopically, with a small embryos that otherwise may have been wasted. The use of day 1 freezing is normally confined to of assisted conception due to the scarcity of suitable lab elective freezing of all embryos when there is a high risk oratory facilities and embryological skills. Slow freezing protocols of embryos did not have to be cultured outside the body, few of the have now generally been replaced by ultra‐rapid vitrifi usual laboratory facilities were needed. The increased use of blastocyst culture very physiologically sound as both the egg and sperm are and the highly successful warming rates post vitrification in the appropriate place at the appropriate time. The are both leading to increased success rates with cryopre embryo travels physiologically down into the uterine served embryos. At to be a feasible option and the patient’s cycle is then least one fallopian tube should be healthy. Since conception Approximately 80% of frozen blastocysts survive the Assisted Reproduction 715 thaw process and, depending on the age of the patient, Procedure one, two or three embryos are replaced. After adequate suppression has the menstrual cycle is regular, the embryos can be been achieved, hormone supplementation in the form of replaced in a natural cycle (although this is unusual as oestrogen is used. This is generally an increasing regi recipients rarely have normal menstrual cycles). If the patient is preg nant this is continued up to approximately 12 weeks of Indications pregnancy. Therefore success rates with egg ● There is a significant increase in the use of thawed fro- donation are generally high. The main problem with oocyte donation is obtaining ● the concept of ‘freeze‐all’ embryos is currently being eggs. April 2005, anonymity for the donors has also been repealed and any resultant offspring can trace their genetic mother from the age of 18. The first successful Egg share programmes can be used where a person pregnancy from an egg donation cycle was in 1983. It combines the techniques of Surrogacy assisted conception with molecular genetics and cytogenetics to detect genetic disease in embryos at Surrogacy is used when a patient’s uterus is either absent the pre‐implantation stage. It allows couples who carry or unable to maintain a pregnancy, and a surrogate or host serious genetic disorders to have embryos free of these uterus is used to carry the pregnancy. Generally this pro diseases transferred into the uterus, allowing the cedure is used where a young patient has lost her uterus to woman the secure knowledge that she is starting off cancer or to uncontrollable bleeding, for example postpar the pregnancy with an unaffected embryo. Counselling is obligatory the Hammersmith Hospital in the early 1990s , and for both the patients and the surrogate. Generally, surro can now be applied to almost all hereditary conditions gates are women who have already had children them where the mutation is known. However, the child’s ● Single gene defects such as cystic fibrosis, thalassae legal mother is the woman who delivers the child and mia or sickle cell disease. The zona pellucida of the as an embryo due to the large size of the unfertilized eggs embryo is opened by using either acid‐tyrodes or special and the high water content. This caused problems dur lasers, and several trophoblast cells are removed for the ing the freezing process as ice crystals can form within specific test itself. The genetic material is amplified and a the egg, disrupting the delicate structures and resulting variety of different approaches are used to make the in its demise when thawed. Unaffected embryos are then trans As a result of these poor results such treatment was usu ferred to the uterus. Recently, an alternative approach to cryopreservation called vitrification has been attempted. This new technology may justify an expansion of uploidies in the egg (meiotic) or related to early cell the indications of egg storage from fertility preservation division in the embryo (post‐zygotic). Initial indications for the technique decreases in ovarian function and egg quality. The technique originally used Donor sperm used to be inseminated around the cervix multicolour fluorescence in situ hybridization and was using an unprepared specimen close to what was thought controversial not because of its attractive self‐evident to be the fertile time. Now a prepared sample of sperm is hypothesis but its lack of a robust evidence base. These techniques can be performed under either local anaesthetic or a light general anaesthetic.
An isolated In chest diseases discount super p-force online american express, such as pneumothorax purchase super p-force 160mg online, bronchiolitis and mass felt in an otherwise normal liver or an asymmetric emphysema and in chest deformities such as in rickets purchase super p-force 160mg amex, enlargement may suggest tumor or cyst. Although tip of the the liver is important in the assessment of hepatomegaly spleen is palpable in up to 5–10% of normal infants and especially to recognize “pushed down liver” which should children, it has to enlarge at least two to three times to be be differentiated from true hepatomegaly. Size, Margin, Contour and Consistency of Liver Is Hepatomegaly due to a Primary Liver Disorder or a Part the liver is to be palpated like any routine palpation of of a Generalized Disease? Common pediatric conditions such as protein energy Sometimes right subcostal palpation by cupping method malnutrition, anemia and tuberculosis can cause significant from above especially for shrunken firm to hard liver will be hepatomegaly. Primary liver the height of the liver in right midclavicular line (superior disorders usually present with signs of liver cell failure (e. Normal liver span at various ages is: • Less than 1 year: 4–5 cm Age of the Child • 1–5 year: 5–7 cm the age of onset is an important clue to the etiology • 5–12 years: 7–9 cm of pediatric liver disease (Table 9. Other Clues in History and General Physical Examination • Splenomegalyis commonly associated with hepatomegaly because of common pathogenetic mechanisms. Causes Helpful clues are: of predominant and massive splenomegaly are seen in • onset: Acute (viral hepatitis) or chronic (as in cirrhosis Table 9. Engorged neck veins Congestive heart failure, the scheme of investigations should be directed constrictive pericarditis judiciously at detecting the etiology and the mechanism of Rickets Wilson disease, tyrosinemia hepatomegaly as also the extent and severity of the disease. Cystic kidneys Congenital hepatic fibrosis Base line and special additional tests are given in Table Skin rashes Histiocytosis 9. Benign hepatomegaly associated with common febrile illnesses of children usually recedes Liver Spleen completely within a few weeks. Cases of acute viral hepatitis Glycogen storage disease (type 1) Gaucher disease also usually resolve within 6 weeks. On the other hand, Congenital hepatic fibrosis Hemolytic anemias Extrahepatic biliary atresia Extrahepatic portal hypertension Cyst (hydatid, abscess) Chronic myeloid leukemia Table 9. The same values are extrapolated for done in all suspected hepatobiliary diseases. The normal • In patients with choledocholithiasis with cholangitis the value is less than 1 mg/dL of which 20% is conjugated. The value may be raised four to enzymes are located in the cytoplasm of the hepatocytes tenfold or greater in obstructive jaundice. Ultrasonogram of abdomen Reversal of albumin: globulin ratio (A:G ratio) <1 (normal >1. The test involves the use of a specialized endoscope which has an ultrasonic transducer at the tip and helps in imaging the Bibliography organs from inside the bowel. Sleisenger and Fordtran’s offers the advantage of being able to biopsy any suspicious Gastrointestinal and Liver Disease, 9th edition. Philadelphia: lesion as well as drainage of pseudocyst of pancreas up to Saunders-Elsevier; 2010. Liver Disease in Children, Though there are many tests available for investigating Vol. New York: Cambridge University Press; and imaging the hepatobiliary tree, a judicious combination 2007. Principles of Clinical diagnosis in most cases, rather than doing all the tests at Gastroenterology, Vol 21, 5th edition. Recently non-immunologic genes have also been Viral hepatitis is a systemic viral infection marked by diffuse he- recognized to influence its clearance. It is distributed widely infection and the brunt of the attack is on the pregnant (18–80%) among the high risk multitransfused people, women with an associated high mortality. Immune-mediated extrahepatic manifestations such as maculopapular or urticarial rash, Transfusion Transmitted Virus and migratory arthritis, nephritis and papular acrodermatitis related Viral Hepatitis of childhood (Gianotti-Crosti syndrome) may be present. Complete blood counts, glucose, urea, children due to type C hepatitis is rare and is reported in creatinine, total protein, albumin are checked if the child is children receiving multiple blood transfusions. No treatment – – +/– IgG + Not detected normal Viral clearance 559 Investigations for etiology are not necessary unless prolonged cholestasis, ascites and coagulopathy may there are atypical manifestations or the child is hospitalized. Liver biopsy is not recommended in children with acute hepatitis but is essential in those with suspected Prevention acute on chronic liver disease or chronic hepatitis. General measures management Hepatitis A virus and Hepatitis E virus infection can be prevented by improving the environmental hygiene. A preparation of food are important steps in preventing the nutritious diet should be provided and undue physical spread of Hepatitis A and E viruses. Children with persistent vomiting, fever, fluid products is necessary prior to transfusion. Disposable retention, altered sensorium or gastrointestinal bleed require hospitalization. Patients with acute hepatitis C who have persistent with two doses of hepatitis A vaccine given 6 months apart viremia (i. The aim of treatment is to suppress of children vaccine failure has been well documented. Liver 560 Acute viral hepatitis is a self-limiting illness and the majority transplant is an excellent option in children with acute liver recover without any sequel. Fever, hyperbilirubinemia, failure who fulfill the criteria for liver transplantation. The ultimate result of ongoing liver injury tension, shrunken or enlarged firm left lobe of liver, firm and dysfunction appears to be chronic hepatitis or if left splenomegaly, ascites. Other features include skin months in adults) in view of the irreversible liver damage manifestations such as palmar erythema, leukonychia, that is likely to occur even before the onset of symptoms. In addition, chronic liver cell failure patients the laboratory tests should be chosen to arrive at an early may need periodically repeated prognostic laboratory tests diagnosis of the disease, assess the status of liver function, especially pre, per and post-liver transplantation stage detect complications, and determine the etiology and apart from donor screening tests. Biopsy • Elevated liver transaminases with conjugated hyper- helps in diagnosis, assessing disease activity, classification, bilirubinemia suggest active liver injury. Management Guidelines Management Goal of therapy is to identify the complications of hepatic encephalopathy and decompensated cirrhosis, and • Early detection and management of complications due prevent them by avoiding predisposing factors mentioned to decompensated cirrhosis. Specific Treatment • Treatment of portal hypertension, ascites and hepatic These include: encephalopathy are discussed separately. Sodium calories, fluid and electrolytes, vitamin especially fat restriction may be required despite hyponatremia soluble vitamins are routinely recommended with which may be dilutional. Please remember Hepatic encephalopathy that liver disease may influence drug choice and dose. The role of rifampicin in hepatic encephalopathy in Hepatic encephalopathy is characterized by: pediatric age group needs more study. Early detection of hepatic encephalopathy • Coagulation defects to be corrected with fresh frozen is possible by demonstrating constructional apraxia (inability plasma, clotting factors and vitamin K (single dose). It is suspected with a history and clinical features of underlying chronic liver disease. Nodular and shrunken ascites liver, abdominal veins and features of decompensation with extrahepatic manifestations of chronic liver disease will Refer to Chapter 9. If it is more than 12 mm, it is a useful predictor of impending • kayser-fleischer ring, sun flower cataract: Wilson variceal bleed. Abdominal ultrasound, esophago-gastro-duodenoscopy, • scratch marks and xanthomas: Chronic cholestasis.
Alternatively buy super p-force 160mg online, they may be candidates for a one and one-half ventricle repair combining a septation procedure with a bidirectional cavopulmonary anastomosis (see Chapter 31) order generic super p-force line. Obstruction can occur at a specific site or involve many segments of the right ventricular outflow tract cheap super p-force 160 mg with visa. Obstruction of the right ventricular outflow tract is commonly associated with other cardiac anomalies. An enlarged acute marginal branch of the right coronary artery often overlies the area of obstruction where an area of “dimpling” of the right ventricular free wall is also often present. Most often, a double-chambered right ventricle is associated with a perimembranous type of ventricular septal defect. After identifying the papillary muscles of the tricuspid valve, the remainder of the obstructing muscle is resected until the fibrous “os infundibulum” is visible. Misidentifying the Ventricular Septal Defect the circular opening visualized if a right ventriculotomy approach is used may, on first examination, appear to be the ventricular septal defect. Creating a Right Ventriculotomy In resecting the dense muscle bundles of double chamber right ventricle, it is important not to debride muscle through (and out) the right ventricular free wall. As a general rule, if a right angle clamp can be placed behind the muscle bundle and the bundle divided over the clamp, the surgeon will not “button hole” the right ventricle. These children usually present with mild to moderate cyanosis and may have intermittent hypoxic spells. Echocardiography can demonstrate the presence of additional ventricular septal defects, can usually delineate the initial course of the right and left coronary arteries, and can size the main and proximal right and left pulmonary arteries. Cardiac catheterization is reserved for those patients in whom the echocardiographic diagnosis is incomplete, when aortopulmonary collateral vessels are suspected, or for patients with previous palliative procedures. Staged Approach Several centers have reported satisfactory results with complete repair of tetralogy of Fallot in neonates. However, as the long-term results of repair of tetralogy of Fallot become available, the significant problem of right ventricular failure and its causes are being elucidated. It is now believed that pulmonary regurgitation plays a major role in the development of right ventricular dysfunction. For this reason, some surgeons advocate a staged approach in patients who require surgery before 4 to 6 months of age. Patients who become symptomatic early in life or are ductal dependent tend to have small pulmonic valves and usually require a transannular patch. By performing an initial shunt procedure (see Chapter 18) and delaying definitive repair, the hope is that the native valve and/or annulus can be preserved. In addition, 3% to 5% of patients with tetralogy of Fallot have an anomalous left anterior descending coronary P. The course of the left anterior descending coronary artery across the right ventricular outflow tract may preclude an appropriate transannular incision. However, many will require a right ventricular to pulmonary artery conduit as part of their repair, and this is best delayed as long as is possible and practical clinically. A generous patch of autologous pericardium is harvested, attached with metal clips to a piece of plastic, placed in 0. Such treatment fixes the pericardium and thereby lessens the chances of aneurysmal dilation of the patch. If the patient has undergone a previous systemic to pulmonary shunt, it is dissected circumferentially to allow for closure with a metal clip at the initiation of cardiopulmonary bypass (see Chapter 18). In the absence of a shunt, minimal manipulation should be performed before cannulation to prevent hypoxic spells. Besides confirming the anatomy with transesophageal echocardiography, an external examination of the heart is conducted. The surgeon looks for an anomalous coronary artery crossing the right ventricular outflow area, evaluates the size of the main and branch pulmonary arteries, and notes the distance between the aortic valve and the left anterior descending artery, which indicates the width of the right ventricular outflow tract. A hypoplastic right ventricular outflow tract may favor the need for a right ventriculotomy or the probability of a transannular patch. Systemic cooling to 28°C to 34°C is achieved, the aorta is clamped, and cold blood cardioplegic solution is infused into the aortic root (see Chapter 3). In patients with discrete infundibular muscular obstruction and an adequate pulmonary annulus, the repair can be done through a transatrial approach. Transatrial Technique After achieving cardioplegic arrest, the tapes around the vena cavae are snugged down, and an oblique right atriotomy is made. The septal leaflet of the tricuspid valve is retracted to allow exposure of the ventricular septal defect and the right ventricular outflow tract. When adequate resection of hypertrophied muscle has been completed, it should be possible to visualize the pulmonic valve. Buttonholing of Anterior Right Ventricle Care must be exercised when resecting muscle from the right ventricular outflow tract not to perforate the anterior wall. Resection near Ventricular Septal Defect It is important to limit the resection of muscle along the anterior margin of the ventricular septal defect as this may compromise suturing of the patch to this edge. This can be secured in place with a continuous suture or multiple interrupted horizontal mattress 5-0 braided sutures with felt pledgets (see Chapter 21). Transventricular Technique Some surgeons prefer a right ventriculotomy approach for patients with tetralogy of Fallot. The advantages include the ability to resect all obstructing muscle bundles under direct vision and to enlarge an underdeveloped infundibulum with a patch. The potential disadvantages include scarring of the right ventricle, which may give rise to ventricular dysfunction and dysrrhythmias. Even when a transventricular approach is used, every attempt is made to preserve the pulmonic valve leaflets and to avoid a transannular patch. The hypertrophied infundibular muscle bundles are incised and selectively excised as needed to open up the outflow tract. Limiting Right Ventriculotomy To better preserve long-term right ventricular function, the length of the ventriculotomy should be limited to that needed to open the hypoplastic portion of the infundibulum. Detachment of the anterior leaflet of the tricuspid valve may be useful to expose the outlet portion of the defect (see Chapter 21). Extensive Resection of Muscle Bands When a right ventriculotomy is performed, muscle resection can be more limited because the patch itself will open up the outflow tract. Aggressive muscle resection leads to more endocardial scarring that may contribute to right ventricular dysfunction. Injury to the Aortic Valve the aortic valve leaflets are immediately below the superior margin of the defect and can be punctured during suturing if deep needle bites are taken in this area. Pulmonary valvotomy, if necessary, is carried out by bringing the pulmonary valve leaflets downward into the ventriculotomy. Transpulmonary Approach to Pulmonic Valve and Annulus Whether a transatrial or transventricular approach is used, evaluation of the pulmonic valve may be difficult working from below. After inspecting the valve and completing a valvotomy, if required, a Hegar dilator of the appropriate size is passed into the right ventricle (see Appendix section). If the annulus cannot be opened adequately with passage of sequentially larger dilators, the incision on the pulmonary artery is extended across the annulus only as far as necessary. This incision should be made through the anterior commissure of the pulmonic valve to reduce the amount of pulmonary insufficiency.