Ann Thorac Surg 1995;59:1588-1589
© 1995 The Society of Thoracic Surgeons
How to Do it
Sinus Venosus Defect: Single-Patch Repair With Caval Enlargement
Vivek Pathi, FRCS,
Rafael Guererro, MD,
Kenneth J. D. MacArthur, FRCS,
Morgan P. G. Jamieson, FRCS,
James C. S. Pollock, FRCS
Department of Cardiac Surgery, Royal Hospital for Sick Children, Glasgow, Scotland
Accepted for publication February 10, 1995.
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Abstract
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We present a single pericardial patch repair of the sinus venosus defect with anomalously connected pulmonary veins, incorporating enlargement of the superior vena cava. In our small series to date this procedure has been carried out without morbidity or mortality. Noninvasive follow-up by echocardiography and electrocardiography, over the short term, has not detected any stenosis of the venous pathways or sinus node dysfunction.
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Introduction
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Sinus venosus defect with partial anomalous pulmonary venous drainage to the superior vena cava (SVC) or right atrium is an uncommon subset of the interatrial communications, accounting for 10% of these cases [1, 2]. The existence of many techniques for repair of this condition serves to highlight the problems encountered, particularly when the SVC is narrowed [3–6]. The most widely used technique is the simple patch repair as recommended by Kirklin and Barratt-Boyes with a separate patch to enlarge the SVC when warranted [7]. The proximity of the sinoatrial node to the repair and the need for a venous anastomosis gave rise to arrhythmias and obstruction, respectively, leading to modifications of the original methods [3].
We present a single patch repair of this anomaly using autologous pericardium, which is technically simple to perform and in our hands has to date been free of complications. This has been particularly useful where SVC narrowing has been present.
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Technique
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Under general anesthesia the chest is opened through a median sternotomy and the pericardium cleared of all tissue. A large patch is excised and placed between wet swabs. Two venous cannulas are placed via the right atrium (or high SVC), the ascending aorta is cannulated, and total cardiopulmonary bypass is instituted. The aorta is cross-clamped, cardioplegia is instilled, and the caval tapes are tightened. An atriotomy is performed and extended across the base of the SVC well posterior to the sinoatrial node (Fig 1
). This avoids the sinoatrial node, which is difficult to locate when the interatrial groove is indistinct. The pericardium is sutured around the atrial septal defect and the floor of the SVC, incorporating the orifices of the pulmonary veins (Fig 2). The upper margin of the fossa ovalis may be excised if the communication is restrictive. If no defect is present, one can be created by excising the septum at the fossa. Once the free edge of the atriotomy is reached, the second needle is used to anchor the patch to the inferior margin of the defect, leaving a patulous tunnel for pulmonary venous blood (Fig 3). A new suture then is used to complete the SVC pathway, enlarging it with the pericardium if required (Fig 4). The orifice of the neo-SVC therefore is not compromised.
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Fig 1. . The incision is made in the right atrium extending onto the base of the superior vena cava, well posterior to the sinoatrial node.
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Fig 2. . The pericardial patch is sutured around the interatrial defect, which may be enlarged to the fossa ovalis or created surgically. (For the sake of pictorial clarity, the fossa ovalis has been left intact.) The suture line is continued across the floor of the superior vena cava and completed by attachment to the free edge of the atriocaval incision.
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Fig 3. . Once the patch is completed and the pulmonary venous pathway is unobstructed, the patch is folded over and fashioned to fit the contours of the neo–systemic venous pathway.
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Fig 4. . The systemic venous pathway is completed by attaching the patch to the edges of the right atrium and superior vena cava, thus enlarging the cavoatrial junction.
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Comment
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Sinus venosus defect was one of the earliest anomalies corrected even before the advent clinical cardiopulmonary bypass [8]. The early techniques used an Ivalon patch to divert the pulmonary venous blood and pericardium to enlarge the systemic venous pathway externally [3–5]. The reported incidence of arrhythmias led to methods involving transection of the SVC, with anastomosis to the right atrial appendage [6]. This has the disadvantage of a venous anastomosis with the possibility of acute thrombosis or subsequent stenosis. We have used the single-patch technique in 15 patients between 1987 and 1993 with no mortality. Six of these required extension of the patch onto the SVC. All patients have had follow-up echocardiography (range, 0.5 to 7 years) with no incidence of narrowing of the venous pathways or of residual shunts. All have remained asymptomatic and none have experienced palpitations. Angiography was not thought to be indicated on clinical grounds. Interestingly, all patients have been in sinus rhythm with normal P wave vectors. In none of the operations was a nodal artery encountered, and it may be that in this particular condition the major blood supply to the sinoatrial node may pass anterior to the SVC. The length of follow-up to date makes it impossible to predict if late sinus node dysfunction will occur.
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Acknowledgments
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We are indebted to Mrs Jean MacDonald, Department of Medical Illustration at the Royal Infirmary, Glasgow, for her help and expertise.
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Footnotes
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Address reprint requests to Dr Pollock, Royal Hospital for Sick Children, Yorkhill, Glasgow, Scotland G3 8SJ.
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References
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- Swan HJC, Kirklin JH, Becu LM, Wood EH. Anomalous connection of the right pulmonary veins to superior vena cava with interatrial communications: hemodynamic data in eight cases. Circulation 1957;16:54–65.[Medline]
- Davia JE, Cheitlin MD, Bedynek JL. Sinus venosus atrial septal defect: analysis of 50 cases. Am Heart J 1973;85:177–85.[Medline]
- Kirklin JW, Ellis FH, Wood EH. Treatment of anomalous pulmonary venous connections in association with interatrial communications. Surgery 1956;39:389–98.
- Lewis FJ. High defects in the atrial septum. J Thorac Surg 1958;36:2–11.
- Schuster SR, Gross RE, Colodny AH. Surgical management of anomalous right pulmonary venous drainage to the superior vena cava associated with superior marginal defect of the atrial septum. Surgery 1962;51:805–8.
- Warden HE, Gustafson RA, Tarnay TJ, Neal WA. An alternative method for repair of partial anomalous pulmonary venous connection to the superior vena cava. Ann Thorac Surg 1984;38:601–5.[Abstract]
- Kirklin JW, Barratt-Boyes BG. Atrial septal defect and partial anomalous pulmonary venous connection. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac surgery. 2nd ed. Vol 1. New York: Churchill Livingstone, 1993;1:627–30.
- Lewis FJ, Taufic M, Vacro RL, Niazi S. The surgical anatomy of atrial septal defects: experiences with repair under direct vision. Ann Surg 1955;142:401–17.[Medline]
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Abstract
Introduction
