Ann Thorac Surg 1999;68:1869-1871
© 1999 The Society of Thoracic Surgeons
How to Do It
Left superior vena cava to the left atrium: do we have to change the traditional approach?
Shahar Zimand, MDa,
Patricia Benjamina,
Mira Frand, MDa,
David Mishaly, MDb,
Aram K. Smolinsky, MDb,
Julius Hegesh, MDa
a Cardiac Institute Department of Pediatric Cardiology, Sackler School of Medicine, Chaim Sheba Medical Center, Tel Hashomer, Israel
b Department of Cardiovascular Surgery, Sackler School of Medicine, Chaim Sheba Medical Center, Tel Hashomer, Israel
Address reprint requests to Dr Zimand, Department of Pediatric Cardiology, Sheba Medical Center, Tel Hashomer, 52621 Israel
e-mail: zimandsh{at}netvision.net.il
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Abstract
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Left superior vena cava (LSVC) to the left atrium is a rare congenital cardiac complex, which may appear as an isolated anomaly, or as part of more complex cardiac anomalies. Traditionally, an intraatrial baffle was the preferred surgical technique. Although this technique has proved reliable and successful, acute ligation and extracardiac repair are simpler and easier solutions, requiring less myocardial ischemic time. We present 3 patients who underwent simple ligation and discuss the literature for other extracardiac options of surgical repair. Our patients had short transient congestion in the left upper part of their body that resolved completely after a few weeks, without further complications. We believe that either acute ligation or extracardiac repair is a much simpler yet effective solution to divert the left caval flow to the lesser circulation.
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Introduction
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Intraatrial rerouting techniques have been the most common approaches to correcting left superior vena caval (LSVC) drainage to the left atrium in patients with no connecting vein. Although these techniques have proved reliable and successful, there are many cases in which extracardiac methods or simple ligation may be preferable. We report three cases that underwent acute ligation, and review the literature for other extracardiac approaches, to this unique systemic anomalous venous connection.
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Technique
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A 5-month-old baby was operated on for a common atrium and LSVC to the left atrium. A previous hemodynamic evaluation demonstrated a 3:1 left to right shunt at the atrial level, with normal right ventricular and pulmonary artery pressure and 85% saturation in the left ventricle. Venographic study of the systemic venous connection revealed a LSVC to the left atrium without a left innominate connection to the right superior vena cava (Fig 1). Due to the orifice location of the LSVC, it was judged to be impossible to divert the LSVC to the right atrium with an intraatrial baffle or to reimplant it into the right atrium. Before bypass, the LSVC was snared and the blood pressure in the occluded vein was measured to be 30 mm Hg. The atrial septum was repaired by a Dacron patch, the LSVC was divided from the left atrium, and ligated. During weaning from cardiopulmonary bypass, the baby maintained a satisfactory cardiac output and blood pressure without supportive agents. The baby’s postoperative recovery was uneventful, except for a bulging pulsatile fontanel and pitting edema in the left upper body, arm, and scalp. An ultrasonographic examination of the baby’s brain demonstrated mild to moderate enlargement of the cerebral ventricles. The venous congestion lasted for several weeks, and a full spontaneous regression was noticed at the age of 12 months, as confirmed by a second ultrasonographic examination of the brain. Clinically, no neurological deficit was noticed during 20 months of follow-up since the operation. The venous drainage from the baby’s head, neck, and congestion was a cause for concern.
We made a review of similar cases treated for the last 5 years with their postoperative course (Table 1). In both our experience and that of other similar cases reported in the literature [1–3], providing the left venous pressure did not exceed 30 to 35 mm Hg, no neurological complications had been reported irrespective of whether or not the left innominate vein was present.
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Results
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Surgical management and repair of LSVC to the left atrium is performed by one of four methods: (1) division and reimplantation of the LSVC to right atrium [2, 4]; (2) an intraatrial baffle to divert flow from the LSVC to the right atrium and to close the atrial septal defect [1, 2, 5, 6]; (3) simple ligation of the LSVC [1–7]; and (4) anastomosis of the LSVC to the left pulmonary artery [3, 7–9].
Reimplantation
Reimplantation of the LSVC to right atrium [2] or to the right superior vena cava (RSVC) [10] provides a good hemodynamic solution. Due to the orifice location of the LSVC from the lateral left superior corner of the left atrium, it is usually judged impossible to divert it to the right atrium or to the RSVC (Fig 1). Out of 28 patients reported by De Leval and associates [2], only 2 were found appropriate for this kind of repair. One of the patients had a juxtaposition of the atrial appendages, in which case, the right atrial appendage could serve as a conduit for the drainage of the LSVC. Van Son and associates [10] diverted the LSVC flow to the RSVC. According to our experience, this anastomosis may be difficult to perform, either anterior or posterior to the aorta. Consequently, it has the potential to obstruct both superior caval flows. Therefore, we believe it may be used only on specific occasions.
Intraarterial baffle
The first repairs were reported by Rastelli and associates [1] at the Mayo Clinic in 1965. Many others [2, 6, 11, 12] found this repair to be the best option to reestablish venous drainage from the LSVC to the lesser circulation. Pericardial patch, artificial Dacron, and inverted left atrial appendage were all reported to be used for the creation of the new conduit, with good postoperative results [1, 2, 5, 6]. Early detachment and late deterioration of the baffle with venous obstruction have been reported [1, 2, 9]. Compromising pulmonary venous drainage to the mitral valve may complicate this technique at the outset, as judged by Foster and associates [8], or as a late complication, as described by Takach and associates [9]. The excessive flow along the posterior inferior left atrial wall in itself may markedly enlarge even a "normal" LSVC with a normal coronary sinus up to a point of partial obstruction of left ventricular inflow [11]. This kind of obstruction may be a result of intraatrial baffle, as presented by Takach and associates [9]. Due to the above early and late complications of this technique, we do not find intraatrial baffle to be justified for the diversion of LSVC flow into the lesser circulation.
Simple ligations
Out of 28 patients reported by De Leval and associates [2], 12 underwent a simple ligation of LSVC; the ligation was performed irrespective of the presence of the left innominate vein. As long as the RSVC was larger than the LSVC, a simple ligation was performed even without measuring the left venous pressure. In two other cases, both RSVC and LSVC were the same size, therefore, the venous pressure was measured and found to be 30 to 35 mm Hg. We followed De Leval and associates in our 3 patients, and performed a simple ligation, providing the left venous pressure did not exceed 30 mm Hg. One can see the advantages of performing a simple ligation. First, the operative technique is faster and easier; second, there is no need to create an intraatrial baffle with its short and long-term complications; and third, the obstruction of left venous return will create left-to-right venous collateral communications, as described clinically in De Leval’s patients and as seen in our patients.
A major disadvantage of simple ligation is the inadequate creation of left-to-right venous communications during the embryological life. Therefore, an acute obstruction of the LSVC will harm the venous return and will cause the venous pressure to rise to unacceptable levels [8]. As mentioned, only 12 out of 28 (43%) patients of De Leval and associates [2], met the criteria for simple ligation.
Anastomosis of the LSVC to the left pulmonary artery
This simple technical solution was first reported as a case report by Foster and associates [8] in 1978. Nineteen years later, Takach and associates reported a repair of obstructive intraatrial baffle by this technique [9]. Physiological factors limiting the application of this method are similar to those limiting the application of a bidirectional Glenn shunt: pulmonary vascular resistance must be low, and diameter of the pulmonary artery must be at least 50% of the SVC to avoid obstruction of flow [7, 13]. This technique has several advantages: it is an extracardiac method, and less invasive than an intracardiac repair, it does not require prosthetic material, and it may be used to repair other rare anomalies of excessive flow through a LSVC, enlarging the coronary sinus up to obstruction of the left atrial outlet [11]. By creating end-to-side anastomosis of the LSVC to the left pulmonary artery, an embryological step of left-to-right collateral communication in the venous system is maintained but in a less aggressive manner than by an acute ligation. Foster and associates [8] performed a repeat venogram of the left basilic vein and demonstrated extensive collateral development from the LSVC to RSVC through the Azygos and Hemiazygos systems. Clinically, 12 patients demonstrated by De Leval and associates [2], and 3 patients reported here, all had early postoperative clinical signs of venous congestion in the left upper part of their body, which lasted for a few weeks and resolved itself completely without any cerebral complications. According to De Leval and associates [2], less then 50% of patients are suitable for acute ligation; therefore, we believe that a good hemodynamic and operative solution for the majority of these patients (who do not meet the criteria for ligation) may be a simple left cavo pulmonary shunt.
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Comment
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LSVC to the left atrium is a congenital malformation of the sinus venous and caval system [14]. Intracardiac rerouting techniques have been the traditional and the most common approach to correcting this right-to-left shunt. Although this technique has proved reliable and successful, in most cases, extracardiac methods and acute ligation may be an easier, safer, and preferred solution to divert the left caval flow to the lesser circulation. We believe that our aim should be toward reducing myocardial ischemic time, and avoiding possible complications. Consequently, we plan to avoid wherever possible the use of intraatrial baffles.
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References
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Accepted for publication June 10, 1999.
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Abstract
Introduction
