Resternotomy and Peripheral Cannulation

Resternotomy and reoperations to treat the sequelae and residua for congenital heart disease in the adult are associated with multiple challenges of intraoperative hemodynamic management, selective peripheral cannulation, safe reentry, and careful cardiac dissection. Resternotomy is a marker of operative mortality that increases with each successive mediastinal entry. Unwanted cavitary entry during sternal reentry can cause significant hemodynamic instability, especially in patients with prior Fontan operations. Any unexpected decrease in right atrial pressure owing to uncontrolled hemorrhage results in hypovolemic consequences that unfavorably impact the driving force (elevated central venous pressure) that controls the pulmonary circulation and cardiac output. These same sets of circumstances also negatively impact patients who are undergoing ventricular-to-pulmonary conduit replacement, reoperations for tetralogy of Fallot, and tricuspid valve repairs, among others. There are numerous methods of resternotomy. In this chapter, we offer some techniques that have been associated with excellent results and a minimal rate of unwanted cavitary reentry in our collective experience.