Ann Thorac Surg 2008;85:1823-1824. doi:10.1016/j.athoracsur.2007.12.029
© 2008 The Society of Thoracic Surgeons
How To Do It
Alternative Repair for Challenging Variants of Partial Anomalous Pulmonary Veins
Ronald K. Woods, MD, PhD*,
Katherine L. Cleveland, MS, PAC
Mary Bridge/Swedish Pediatric Cardiothoracic Surgery Program, Mary Bridge Children's Health Center, Tacoma, Washington
Accepted for publication December 6, 2007.
* Address correspondence to Dr Woods, Mary Bridge Swedish Pediatric Cardiothoracic Surgery Program, Mary Bridge Children's Health Center, PO Box 5299, Tacoma, WA 98415 (Email: ronald.woods{at}multicare.org).
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Abstract
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We report a technique for repair of more challenging variants of partial anomalous pulmonary venous return to the superior vena cava.
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Introduction
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Principles of good surgical repair of sinus venosus atrial septal defect (ASD) with partial anomalous pulmonary venous return to the superior vena cava (SVC) include provision of durably unobstructed systemic and pulmonary venous pathways, closure of the ASD, and avoidance of arrhythmias. In the context of pulmonary veins connecting high on the cava, accomplishing these goals can be more difficult.
In 2004, we operated on a young child with very high pulmonary venous drainage. Intraoperatively, we found a very small appendage for which a Warden procedure would have required excessive tension [1]. Based in part on DeLeon and colleagues' [2] technique, we designed a composite atrial turndown reconstruction of the SVC with preservation of the atriocaval junction and obtained an excellent result. The procedural details are described herein. Surgical consent was uniform. Institutional Review Board exemption status was obtained on August 27, 2007.
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Technique
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After opening the pericardium left of midline, bicaval or tricaval bypass and blood-based cardioplegia are conducted in standard fashion. When present, the innominate vein is cannulated; otherwise, the superior venous cannula is placed well cephalad to the pulmonary veins. The right atrium is opened anteriorly from the tip of the appendage toward the atriocaval junction, limiting the incision to preserve the node and its blood supply. A longitudinal cavotomy exposing the pulmonary venous connections is kept well away from the atriocaval junction (Fig 1A). A patch (typically pericardium) is fashioned inside the cava from the most distal pulmonary venous ostium to the margin of the ASD using fine (6-0) polypropylene suture (Fig 1B). The heart is then de-aired and reperfused.
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Fig 1. Details of the repair viewed from the surgeon's perspective: (A) the atriotomy and cavotomy incisions are kept well away from the atriocaval junction, and the caval snare is secured just below the innominate vein; (B) placement of the intracaval pulmonary venous baffle into the atrium around the margin of the atrial septal defect; and (C) reconstruction of the systemic venous pathway using a portion of the atriotomy and the pericardial flap. The extent of the atriotomy sewn to the cava is variable, but should be tension free. The dashed line on the pericardial flap indicates the line of anastomosis to the cava and atrium, which is typically a rounded diamond configuration. Arrows indicate the systemic venous pathway.
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The systemic pathway is reconstructed using a combination of atrial appendage and autologous pedicled pericardium. The appendage atriotomy nearest the atriocaval junction is sewn with fine polypropylene to the corresponding margin of the cavotomy (Fig 1B). By limiting this approximation to about one-third of the cavotomy, tension is completely avoided. The atriocavotomy is then closed with the pericardial flap using a suitable calibration device to ensure unobstructed drainage (Fig 1C). For physically mature patients, more standard patch material may be used instead of pedicled pericardium.
Between February 2004 and June 2007, we used this technique in 4 patients. Indications in all patients were similar to the index case, with 1 patient also demonstrating bilateral SVC and a small right SVC (4 to 5 mm). Follow-up of 44, 26, 15, and 6 months, respectively, is complete to the present. All children are asymptomatic and free of clinically significant stenoses, which are defined as an echo-derived mean pressure exceeding 2 mm Hg in the pulmonary pathway and 6 mm Hg in the systemic pathway [3]. One child with a very small SVC experienced an early transient low atrial rhythm. All children are currently in sinus rhythm.
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Comment
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We acknowledge the meaningful contributions of many surgeons on this topic and regret constraints that preclude a thorough citation of their work. Specific examples of these techniques include Chartrand and colleagues' [4] repair using an incision across the atriocaval junction and appendage augmentation of the venotomy, the Warden repair [1], DeLeon and colleagues' [2] repair sparing the atriocaval junction and using a circumferential anastomosis of the appendage to an undivided cava, and Nakahira and colleagues' [5] repair in which a Warden-type repair is augmented with pedicled pericardium. Results reported using these and other techniques have generally been favorable; however, clinically significant stenoses of the venous pathways in 8% to 27% of cases and arrhythmias due to disturbance of the sinus node in 0% to 55% of cases have been reported [1–7]. Stewart and colleagues [7] provide a useful contemporary analysis of various techniques for repair and the occurrence of stenosis or node dysfunction.
Because no single technique is without drawbacks, nor is one technique ideally suited to the entirety of this condition's morphologic spectrum, our philosophy is to use the repair that we believe is most suitable for a given morphology. We do not regard the current technique as the optimal repair for all patients; however, it offers certain theoretic advantages: (1) of most importance, preservation of the atriocaval junction and the potential for sinus node integrity; (2) easy calibration of the size of the venous pathways; (3) growth potential of the systemic pathway; and (4) a tension-free atriocaval connection. At present, we use this technique for high pulmonary connection for which a standard Warden-type anastomosis would be small or under tension. Our experience is limited and early; however, we have been pleased with the results and therefore offer it as a consideration for other surgeons.
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Acknowledgments
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We wish to express our gratitude to Susan Russell Hall for creating the medical artwork for this manuscript.
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References
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- 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;38:601-605.[Abstract]
- DeLeon SY, Freeman JE, Ilbawi MN, et al. Surgical techniques in partial anomalous pulmonary veins to the superior vena cava Ann Thorac Surg 1993;55:1222-1226.[Abstract]
- Iyer AP, Somanrema K, Pathak S, Manjunath PY, Pradhan S, Krishnan S. Comparative study of single- and double-patch techniques for sinus venosus atrial septal defect with partial anomalous pulmonary venous connection J Thorac Cardiovasc Surg 2007;133:656-659.[Abstract/Free Full Text]
- Chartrand C, Payot M, Davignon A, Guerin R, Stanley P. A new surgical approach for correction of partial anomalous pulmonary venous drainage into the superior vena cava J Thorac Cardiovasc Surg 1976;71:29-34.[Abstract]
- Nakahira A, Toshikatsu Y, Kagisaki K, et al. Partial anomalous pulmonary venous connection to the superior vena cava Ann Thorac Surg 2006;82:978-982.[Abstract/Free Full Text]
- Gaynor JW, Burch M, Dollery C, Sullivan ID, Deanfield JE, Elliot MJ. Repair of anomalous pulmonary venous connection to the superior vena cava Ann Thorac Surg 1995;59:1471-1475.[Abstract/Free Full Text]
- Stewart RD, Frederique B, Kelle AM, Backer CL, Young L, Mavroudis C. Evolving surgical strategy for sinus venosus atrial septal defect: effect on sinus node function and late venous obstruction Ann Thorac Surg 2007;84:1651-1655.[Abstract/Free Full Text]
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Abstract
Introduction
