Ann Thorac Surg 2006;82:196
© 2006 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Juan V. Comas, MD, PhD
Paediatric Heart Institute, Hospital Universitario "12 de Octubre", Carretera de Andalucía km 5,400, Edificio Materno-Infantil, Madrid, 28041 Spain
(Email: jvc{at}mi.madritel.es).
Nowadays in congenital cardiac surgery it is unusual to discover new pathologies. However, a sum of "minor" circumstances could create new entities that may need to be treated. In my opinion this is the case when a persistent left superior vena cava (LSVC) appears to be draining in a significantly dilated coronary sinus. This association has been proven to be partly responsible for significant left atrioventricular supravalvar obstruction. An 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.
Vargas and associates [1] present their experience in this unusual anatomic entity previously described by Cochrane and associates in 1994. The classical technique has been proposed to manage the problem by an intracardiac approach through transatrial septum with unroofing, segmental resection, and reconstruction of the dilated coronary sinus wall. The present report combines the previous experience with an extracardiac method that consists in the translocation of the LSVC to the right appendage.
It is clear that the final objective to repair this entity should be to eliminate the left atrial outlet obstruction and provide an adequate systemic venous drainage. To solve the first problem, an intracardiac approach is compulsory. It is impossible to be sure that a dilated coronary sinus with a proper flow will evolve to a normal situation or lead to a significant symptomatic improvement. A plasty with reduction and reconstruction of the dilated coronary sinus is the safe and necessary procedure.
Different options have been described to fix the second component. These range from the no touch technique to simple ligation of the LSVC (in presence of a left innominate vein connection with a larger right superior vena cava [RSVC] than the LSVC) or diverse reimplantations. Anastomosis of the LSVC to the RSVC, to the left pulmonary artery, or to the right atrium have been described and used. The right atrial appendage technique has been proven accessible and reproducible in different abnormal and complex situations. It is probably the adequate complement to an insufficient intracardiac approach.
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- Vargas FJ, Rozenbaum J, Lopez R, et al. Surgical approach to left ventricular inflow obstruction due to dilated coronary sinus Ann Thorac Surg 2006;82:191-196.[Abstract/Free Full Text]
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