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Ann Thorac Surg 1997;63:1800-1802
© 1997 The Society of Thoracic Surgeons

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How To Do It

Correction of Left Superior Vena Cava Draining to the Left Atrium Using Extracardiac Techniques

Division of Cardiothoracic Surgery, University of California, San Francisco, San Francisco, California

Accepted for publication December 21, 1996.

	Abstract

Top Footnotes Abstract Introduction Techniques Technique 2 Technique 3 Comment References

 
Intraatrial rerouting techniques have been the most common approaches to correcting left superior vena caval drainage to the left atrium in patients without atrial isomerism and with no connecting vein. Although these techniques have proved reliable and successful, there are cases in which extracardiac methods for managing this form of anomalous systemic drainage may be preferable. In the present report, we describe three extracardiac approaches to the correction of left superior vena cava draining to the left atrium.

	Introduction

Top Footnotes Abstract Introduction Techniques Technique 2 Technique 3 Comment References

 
When unroofed (absent) coronary sinus occurs in the presence of a left superior vena cava draining exclusively to the left atrium, with no connecting vein, correction has most commonly been achieved either by rerouting left superior vena caval flow into the right atrium using intraatrial baffle or tunnel techniques, or by simple ligation [1, 2]. Although few venoatrial obstructive complications have been reported after repair by intraatrial rerouting [2], there are occasions on which atrial and pulmonary vein orifice anatomy may be more amenable to extracardiac methods of repair. In such situations, ligation of the left superior vena cava is potentially an option, although this may result in prohibitively elevated left superior caval and intracranial pressures [3, 4]. In this report, we describe three extracardiac techniques for correcting left superior vena caval drainage to the left atrium, drawing on our experience with 2 patients recently found to have this form of anomalous systemic venous drainage with no evidence of atrial isomerism.

	Techniques

Top Footnotes Abstract Introduction Techniques Technique 2 Technique 3 Comment References

 
Technique 1
In a 6-week-old patient with complete atrioventricular septal defect, common atrium, bilateral superior venae cavae, and unroofed coronary sinus with left superior vena cava drainage to the left atrium (Fig 1A), cardiopulmonary bypass was instituted by cannulating the ascending aorta, inferior vena cava, and left superior vena cava. The smaller right superior vena cava was temporarily occluded with a snare. After repair of the intracardiac defects, followed by closure of the right atriotomy and deairing of the heart, rewarming was commenced. During the warming phase, the left superior vena cava was transected at its entrance into the left atrium, then carried up over the ascending aorta and anastomosed end-to-end to an incision in the tip of the right atrial appendage (Fig 1B). The cardiac stump of the left superior vena cava was oversewn with running sutures.

View larger version (47K): [in this window] [in a new window]   Fig 1. . (A) Left superior vena cava (LSVC) draining to the left atrium (LA). (B) Technique 1, with anastomosis of the LSVC to the tip of the right atrial appendage, as described in the text. (C) Technique 2, in which the transected LSVC is brought under the aortic arch and over the central pulmonary artery and anastomosed end-to-side to the base of the right superior vena cava (RSVC), as described in the text. (D) Technique 3, a simple bidirectional left superior cavopulmonary anastomosis, as described in the text.

	Technique 2

Top Footnotes Abstract Introduction Techniques Technique 2 Technique 3 Comment References

	Technique 3

Top Footnotes Abstract Introduction Techniques Technique 2 Technique 3 Comment References

 
In older patients in whom pulmonary vascular resistance is not an issue, left superior vena caval drainage to the left atrium can be corrected by performing a bidirectional left superior cavopulmonary anastomosis [5], with end-to-side anastomosis of the proximal left superior vena cava to the superior aspect of the left pulmonary artery (Fig 1D).

	Comment

Top Footnotes Abstract Introduction Techniques Technique 2 Technique 3 Comment References

 
In patients without atrial isomerism, the most common approach to left superior vena caval drainage to the left atrium in the absence of a connecting vein has been intraatrial rerouting of blood from the left superior vena cava to the right atrium. This has been achieved by plicating the posterior wall of the left atrium, in effect "roofing" the "unroofed" coronary sinus, by using a patch to redirect left superior caval flow, or by using the inverted left atrial appendage as a baffle [1, 2, 4]. According to most reports, these techniques have proved reliable and successful, and they may be just as efficient as extracardiac techniques in many circumstances. However, they are bound to work most effectively when there is a clear path between the left superior vena caval orifice and the right atrium, which may not always be the case. The proximity of pulmonary veins to the orifice of the left superior vena cava often makes the placement of intraatrial baffles cumbersome. In such instances, extracardiac techniques for managing the anomalous systemic drainage may be preferable. Furthermore, even when the left superior vena cava connects to the left atrium at the base of the appendage, clearly superior to the entrance of the pulmonary veins, extracardiac remedies may be more straightforward technically and allow for a reduction in cardiopulmonary bypass time, as they can be performed during rewarming. In this report, we have described three extracardiac techniques for correction of left superior vena cava draining to the left atrium, which can increase the surgeon's versatility when approaching this lesion.

Previous investigators have reported techniques of anastomosing the left superior vena cava to the superior aspect of the right atrial appendage, either directly [6, 7] or using extensions of atrial tissue [7] or polytetrafluoroethylene tubing [8]. Technique 1 described herein is slightly different than those previously reported approaches, calling for an end-to-end anastomosis between the left superior vena cava and the tip of the right atrial appendage. This places less tension on the left superior vena cava and the anastomosis than would a connection to the superior aspect of the right atrial appendage. Moreover, it requires less length than an anastomosis to the superior aspect of the appendage. Another option, synthetic graft extension [7], does not allow for growth potential in young children.

The possibility of correcting left superior vena caval drainage to the left atrium using a bidirectional superior cavopulmonary shunt has been described previously [5]. Although aneurysm formation at the cavopulmonary anastomosis in this circumstance has been reported [9], bidirectional cavopulmonary anastomosis in the presence of pulsatile flow in the pulmonary artery system is well established in the literature and in our experience. Thus, aneurysm formation is not likely to be a persistent concern, as long as this approach is limited to patients with low pulmonary vascular resistance.

The most desirable approach of the three described in this report may be technique 2, in which the left superior vena cava is carried under the aortic arch and anastomosed to the medial aspect of the right superior vena cava (see Fig 1C). In most cases, with the left superior vena cava running through the mediastinum more posteriorly than its right-sided counterpart, bringing the left superior vena cava under the arch will be a more natural course than swinging it over the ascending aorta. Before proceeding with this approach, it is necessary to confirm that there is ample space between the central pulmonary artery and the aortic arch for positioning of the left superior vena cava, which there generally is, in our experience. It might be argued that this technique leaves the translocated left superior cava susceptible to arterial compression, but we do not believe that this will be a problem as long as the surgeon ensures that there is adequate space between the aorta and pulmonary artery and as long as proper anastomotic positioning is achieved. Moreover, the anatomic arrangement achieved with this technique is not markedly different from that found naturally in patients with a retroaortic innominate vein, which appears to be more common than previously thought [10].

Both of the patients described herein survived and were found on intraoperative and discharge echocardiography to have unobstructed left superior vena caval return to the right atrium. At follow-up of 7 and 8 months, there was no echocardiographic evidence of left superior vena caval or anastomotic obstruction in either patient.

	Footnotes

Top Footnotes Abstract Introduction Techniques Technique 2 Technique 3 Comment References

 
Address reprint requests to Dr Reddy, UCSF, 505 Parnassus Ave, M593, San Francisco, CA 94143-0118.

	References

Top Footnotes Abstract Introduction Techniques Technique 2 Technique 3 Comment References

 

1. Quaegebeur J, Kirklin JW, Pacifico AD, Bargeron LM. Surgical experience with unroofed coronary sinus. Ann Thorac Surg 1979;27:418–25.[Abstract]
2. Kirklin JW, Barratt-Boyes BG. Cardiac surgery. 2nd ed. New York: Churchill Livingstone, 1993:683-92.
3. De Leval MR, Ritter DG, McGoon DC, Danielson GK. Anomalous systemic venous connection: surgical considerations. Mayo Clin Proc 1975;50:599–610.[Medline]
4. Komai H, Naito Y, Fujiwara K. Operative technique for persistent left superior vena cava draining into the left atrium. Ann Thorac Surg 1996;62:1188–90.[Abstract/Free Full Text]
5. Foster ED, Baeza OR, Farina MF, Shaher RM. Atrial septal defect associated with drainage of the left superior vena cava to left atrium and absence of the coronary sinus. J Thorac Cardiovasc Surg 1978;76:718–20.[Abstract]
6. Taybi H, Kurlander GJ, Lurie PR, Campbell JA. Anomalous systemic venous connection to the left atrium or to a pulmonary vein. AJR 1965;94:62–77.
7. Shumacker HB, King H, Waldhausen JA. The persistent left superior vena cava. Surgical implications with special reference to caval drainage into the left atrium. Ann Surg 1967;165:797–805.[Medline]
8. Gontijo B, Fantini FA, Silva JAP, Barbosa JT, Vrandecic MO, Masci NGH. The use of PTFE graft to correct anomalous drainage of persistent left superior vena cava. J Cardiovasc Surg 1990;31:815–7.[Medline]
9. Teske DW, Davis JT, Allen HD. Cavopulmonary anastomotic aneurysm: a complication in pulsatile pulmonary arteries. Ann Thorac Surg 1994;57:1661–3.[Abstract]
10. Choi JY, Jung MJ, Kim YH, Noh CI, Yun YS. Anomalous subaortic position of the brachiocephalic vein (innominate vein): an echocardiographic study. Br Heart J 1990;64:385–7.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Doff B. McElhinney Frank L. Hanley Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Reddy, V. M. Articles by Hanley, F. L. Search for Related Content PubMed PubMed Citation Articles by Reddy, V. M. Articles by Hanley, F. L.