superior vena cava

So for some reason, some people just don't absorb the fluid from that space, and we need to take it out again.

And we can also put it into the superior vena cava, or the, the ...

It's called an atrial shunt, but typically it sits just in the, the SVC.

That was very commonly done a few decades ago, much less commonly done now.

It works really well, but it's a tricky thing to do, a difficult thing to fix when it doesn't work, and it's associated with problems like, uh, venous thrombosis of the jugular vein, or even shunt nephritis where you get this immune complex accumulation onto the shunt catheter in the circulatory system.

You can confirm the guide wire passing into the IVC or the aorta before you dilate.

The IVC from a modified mid-esophageal bicaval view, the thoracic aorta in the descending aortic views and from the right internal jugular you can watch the wire pass through the SVC into the right atrium on the bicaval view.

So you can firm the wire before you put a large bore cannula over it.

Which makes the dilatation a great deal safer.

Perfect.

Think about your blue blood returning through your IVC or SVC.

It's going into your right atrium.

And here it's going to have a choice whether you're a single ventricle that's RV is your pumping chamber to both systems, the pulmonary and systemic, or if it's your left side, that's the pumping chamber.

But then it continues to drop over the next couple of months, just at a slower rate.

And so by the time you hit your gland, your PVR has dropped to where it's going to essentially be.

And I don't know how much you want me to go into gland anatomy and physiology, but basically you are creating a connection between your SVC and your pulmonary artery.

And so that is how you're going to be supplying your pulmonary blood flow.

At the start, you see a, a re-entry, uh, as all pediatric surgeons are so good at doing.

You then see the, uh, SVC to pulmonary artery anastomosis dissected out.

Uh, Sami Said's really strict about how you have to dissect everything out off-pump without heparin, which looked very brave to me.

Uh, and then he dissected out the IVC, uh, and then he stuck a, a conduit on the inferior wall of the pulmonary artery while, uh, obviously blood was still going to the right lung off-pump, which was really impressive, but then came the most impressive bit.

And portal vein tends to be pulsatile at baseline, not like the actual crisp cardiac pulsatility, but more haziness because of arterial portal connections, uh, and you might not be able to use that.

Um, so you're relying more on intrarenal, um, venous flow and, and, and other things you have to look at like which are not in the liver such as IJV in ultrasound or SVC if you're able to access that from subxiphoid or femoral.

However, like these are all based on our experience rather than, uh, having, uh, formidable published data.

So in those cases, you're looking at, um, femoral vein, um, pulsatility?