Ann Thorac Surg 1998;66:1800-1802
© 1998 The Society of Thoracic Surgeons
Case Reports
Successful palliation of acute superior vena caval obstruction after the Senning operation
Afksendiyos Kalangos, MD, PhDa,
Maurice Beghetti, MDb,
Peter C. Rimensberger, MDc,
Ebrahim Khabiri, MDa,
Dominique Vala, MDa,
Bernard Faidutti, MDa
a Clinic for Cardiovascular Surgery, University Cantonal Hospital of Geneva, Geneva, Switzerland
b Clinic for Pediatric Cardiology, University Cantonal Hospital of Geneva, Geneva, Switzerland
c Intensive Care Unit, University Cantonal Hospital of Geneva, Geneva, Switzerland
Accepted for publication May 12, 1998.
Address reprint requests to Dr Kalangos, Clinic for Cardiovascular Surgery, University Cantonal Hospital of Geneva, 24, rue Micheli-du-Crest, 1211 Geneva 14, Switzerland
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Abstract
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Superior vena caval obstruction after an intraatrial baffle procedure can lead to acute cerebral complications and hence requires immediate management. We present a case of successful palliation of acute superior vena caval obstruction after a Senning procedure by establishing a venous shunt between the innominate vein and pulmonary artery. This technique resulted in immediate hemodynamic and functional improvement that subsequently allowed for the enlargement of the superior vena cava–right atrial junction with a pericardial patch.
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Introduction
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Systemic venous obstruction is a well-known complication of intraatrial baffle operations; postoperative cardiac catheterization has documented an incidence of 4% to 41% after the Mustard operation and less than 10% after the Senning operation [1]. Acute postoperative superior vena caval (SVC) obstruction, which may compromise cerebral perfusion, requires immediate management. We present a case of successful temporary palliation of acute SVC obstruction in an infant after a Senning procedure for transposition of the great arteries.
A male infant with dyspnea and cyanosis was diagnosed with D-transposition of the great arteries and a tiny muscular apical ventricular septal defect by cardiac catheterization, 6 weeks after birth. He underwent balloon atrial septostomy during the initial catheterization and was then referred to our institution for further evaluation and surgical treatment at the age of 7 months. Echocardiography confirmed the diagnosis, and surgical correction using the Senning procedure was decided upon. The infant was operated on with cardiopulmonary bypass (CPB) at deep hypothermia to 20°C with separate direct cannulation of the SVC and the inferior vena cava and intermittent periods of reduced flow. Myocardial protection was obtained with repeated crystalloid cardioplegia. The technique used was similar to that described by Quaegebeur and associates [2] except for the reconstruction of the interatrial septum (opened during balloon septostomy), which was performed by invagination of the left appendage in the left atrium. The left appendage was sutured above the left pulmonary veins and to the incised atrial septum, thus forming a trapezoidal flap based at the interatrial groove. The dorsal edge of the right atrial (RA) incision was then sutured to the atrial septal remnant between the tricuspid and mitral valve, so that the tissue of the Eustachian valve was incorporated inferiorly. Finally, the new left atrium was created by suturing the ventral part of the RA over both venae cavae, to the right of the interatrial groove incision performed in front of the right pulmonary veins. Interrupted 6-0 monofilament sutures were used at all sites to allow harmonious growth of both new atrial cavities. The child was weaned from bypass in sinus rhythm with moderate amounts of dobutamine and adrenaline. The aortic cross-clamp time was 85 minutes and the total CPB time was 105 minutes. However, despite diuretics and the semiupright position of the operating table, SVC mean pressure was 33 mm Hg and RA pressure was 12 mm Hg, resulting in a mean gradient of 21 mm Hg. There was no gradient between the inferior vena cava and RA mean pressures. We concluded that there was severe narrowing at the SVC–new RA junction.
Because no substantial change in gradient was observed during the 30 minutes after cessation of CPB, we decided to palliate this obstruction by performing a shunt between the innominate vein and the trunk of the pulmonary artery without the aid of CPB. We opted not to immediately repair the narrowed area because of the presence of myocardial edema, certainly caused by prolonged CPB. A segment of homologous saphenous vein graft 6 mm in diameter and 2 cm long (preserved in an antibiotic solution) was interposed in an end-to-side fashion between the inferior aspect of the innominate vein and the anterior aspect of the pulmonary artery trunk (Fig 1). Both anastomoses were performed with a running suture of 6-0 monofilament under lateral clamping without the aid of CPB.
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Fig 1. Operative view showing the venous homograft (arrow) interposed between the innominate vein and the trunk of the pulmonary artery (PA).
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After removal of the vascular clamp applied on the shunt, the SVC mean pressure decreased to 14 mm Hg, pulmonary artery mean pressure increased from 7 to 12 mm Hg, and left atrial mean pressure increased from 7 to 11 mm Hg. Pressure lines, pacing wires, and chest tubes were inserted, the chest was left open, and the child was transferred to the intensive care unit. Substantial clinical improvement was noted within 24 hours, with a gradual decrease in the swelling of the face, neck, and upper torso and regression of cyanosis of the lips. Transesophageal echocardiographic and pulsed Doppler studies showed an obstruction within the systemic venous pathway, no stenosis in the pulmonary venous atrium, and a moderately decreased biventricular function. The shunt could not be visualized at echocardiography. A single contrast injection via the SVC catheter allowed us to detect patency of the shunt and confirmed SVC obstruction (Fig 2). Repeat echocardiographic controls showed progressive recovery of biventricular function with only small amounts of dobutamine. This allowed for surgical revision of the systemic venous pathway on the third postoperative day.
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Fig 2. A single contrast injection by the superior vena cava shows obstruction at the junction between the superior vena cava and the new right atrium (black arrows) and patency of the shunt between the innominate vein and the pulmonary artery (white arrow).
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Reoperation disclosed severe narrowing of the systemic venous pathway just below the SVC–RA junction. The superior aspect of the systemic venous pathway was then enlarged with an autologous pericardial patch measuring 25 x 12 mm sewn with a running suture of 6-0 monofilament. After weaning from bypass without difficulty, intraoperative measurements of SVC–RA (18 mm Hg–16 mm Hg) gradients revealed values no greater than 2 mm Hg with the shunt clamped. The shunt was then ligated at both anastomotic sites and cut.
Postoperatively, clinical and echocardiographic evaluation indicated resolution of the obstruction. The child was extubated on the fifth postoperative day and discharged home on day 16. He remains asymptomatic and without clinical and echocardiographic evidence of caval or pulmonary venous obstruction after 1 year of follow-up.
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Comment
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In contrast to chronic postsurgical SVC obstruction, which is usually surmounted by adequate collateral circulation to the inferior vena cava, the acute form can lead to progressive upper compartment venous congestion, which may compromise cerebral perfusion. The mechanisms of acute postoperative vena caval or pathway obstruction after the Senning procedure have frequently been attributed to technical errors, such as tautness of the suture lines, distortion of the venae cavae by the new pulmonary venous atrium reconstructed over them, and sometimes mistakes in determining the dimensions of the baffles, the size of which depend on the dimensions of both atria. Postoperative tissue edema can also contribute to the aggravation of these lesions.
The case described here was the only apparent SVC obstruction encountered in a series of 60 Senning procedures performed in our institution. Because the Senning procedure uses viable atrial tissue, we prefer to perform the entire reconstruction with interrupted sutures to better ensure the expected future tissue growth. However, this technical concept requires longer aortic cross-clamp times than running sutures and can compromise the pediatric heart, which is more vulnerable to the effects of ischemia and reperfusion [3]. This is why in our case, surgical repair of SVC obstruction was not immediately considered. The use of a cavo-bipulmonary anastomosis at the time of the Mustard operation to alleviate acute SVC obstruction had already been reported [1]. However, this anastomosis requires additional aortic cross-clamping and CPB times and exposes patients to long-term complications of such a shunt. Use of balloon angioplasty in chronic SVC obstruction after atrial inversion operations has gratifying results: 81% of these stenoses are successfully treated with no evidence of gradient recurrence in survivors [4]. On the other hand, despite a single successfully treated case in the literature, concern still exists about the possible dilatation of a fresh suture line in the setting of acute postoperative SVC obstruction [5]. Successful management of an acute SVC obstruction by shunting the upper venous circulation into the pulmonary artery with a venous homograft demonstrates that this can be attempted as an alternative to immediate repair, cavo-bipulmonary anastomosis, or balloon dilation angioplasty.
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References
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- Marx G.R., Hougen T.J., Norwood W.I., Fyler D.C., Castañeda A.R., Nadas A.S. Transposition of the great arteries with intact ventricular septum: results of Mustard and Senning operation in 123 consecutive patients. J Am Coll Cardiol 1983;1:476-483.[Medline]
- Quaegebeur J.M., Rohmer J., Brom A.G. Revival of the Senning operation in the treatment of transposition of the great arteries. Thorax 1977;32:517-524.[Abstract/Free Full Text]
- Taggart D.P., Hadjinikolas L., Hooper J., et al. Effects of age and ischemic times on biochemical evidence of myocardial injury after pediatric cardiac operations. J Thorac Cardiovasc Surg 1997;113:728-735.[Abstract/Free Full Text]
- Mullins C.E., Latson L.A., Neches W.H., Colvin E.V., Kan J. Balloon dilation of miscellaneous lesions: results of valvuloplasty and angioplasty of congenital anomalies registry. Am J Cardiol 1990;65:802-803.[Medline]
- Benson L.N., Yeatman L., Laks H. Balloon dilatation for superior vena caval obstruction after the Senning procedure. Cathet Cardiol Diagn 1985;11:63-68.
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A venous shunt between the innominate vein and pulmonary trunk
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1299 - 1300.
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Abstract
Introduction
