The operation-April 20

On the morning of Wednesday April 20, Daniel underwent a Norwood Stage I palliation operation. To deal with the transposition of the great arteries and the underdeveloped right ventricle, the pulmonary artery and the aorta were connected to create a common vessel. (This is referred to as the division and anastomosis of the pulmonary artery to the ascending aorta.) The point where the left and right pulmonary arteries formerly connected to the trunk of the pulmonary artery was closed. A homograft was to be used to augment the ascending aorta. This operation also involved an atrial septectomy, division of the patent ductus arteriosus and the placement of a four-millimetre right-modified Blalock-Taussig shunt. The operating team is set out in the accompanying chart.

TABLE 6.9: Persons involved in the operation on Daniel Terziski, April 20, 1994
OR team member		Persons involved
Surgeon		J. Odim
Surgical assistants		B.J. Hancock, V. Hota (resident)
Anaesthetist		H. Reimer
Scrub nurses		S. Scott, C. McGilton
Circulating nurses		B. Zulak, W. Yakinchuk, C. Youngson
Perfusionists		T. Koga, M. Maas

The operation that Daniel was to undergo was a high-risk procedure. While the length of surgical time is always an important factor in pediatric cardiac surgery, it is of particular importance in a Norwood. Because Daniel had only a single working ventricle, that chamber was required to work twice as hard as normal. A lengthy operation could compromise this ventricle's function and increase Daniel's risk of serious complications. (Long bypass times could injure his lungs and could compromise his health, since during the post-operative period it might have become necessary to adjust his pulmonary blood flow. This is best done with healthy lungs.)

Daniel Terziski - pre-operative heart

Diagram 6.9 Daniel Terziski - post-operative heart Norwood Stage 1 1 - Modified right Blalock-Taussig shunt 2 - Atrial septectomy 3 - Homograft augmentation of ascending aorta and aortic arch 4 - Ligation and division of patent ductus arteriosius 5 - Closure of pulmonary artery 6 - Division and anastomosis of pulmonary artery to ascending aorta

Because of all the risks involved in a Norwood operation, it was important that the operating team be well prepared. In this case, Odim did not consult in advance with either Reimer or Kesselman, both of whom had experience with Norwoods. Nor did he speak with any of his previous teachers.

Deep hypothermia with circulatory arrest and cold-blood cardioplegia were used for myocardial protection.

TABLE 6.10: Length of phases of the operation on Daniel Terziski, April 20, 1994
Phase of the operation		Time taken
Induction		1 hour
Bypass		5 hours 59 minutes
Aortic cross-clamp		1 hour 42 minutes
Total surgical time		8 hours 40 minutes
Total operating-room time		10 hours 1 minute