Ann Thorac Surg 2008;86:320-322. doi:10.1016/j.athoracsur.2008.01.093
© 2008 The Society of Thoracic Surgeons
How To Do It
Primary Repair of Infracardiac Total Anomalous Pulmonary Venous Connection Using a Modified Sutureless Technique
Efren Buitrago, MD,
Anthony L. Panos, MD,
Marco Ricci, MD*
Holtz Children's Hospital/Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida
Accepted for publication January 28, 2008.
* Address correspondence to Dr Ricci, Division of Cardiothoracic Surgery, University of Miami Holtz Center 3072 (R-114), 1611 NW 12th Ave, Miami, FL 33136 (Email: mricci{at}med.miami.edu).
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Abstract
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Primary repair of infracardiac total anomalous pulmonary venous connection is associated with a significant risk of recurrent pulmonary venous obstruction. Herein we describe a technique of primary repair in which a modified sutureless anastomosis is constructed by suturing the left atrium to the posterior mediastinal pleura that surrounds the pulmonary venous confluence.
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Introduction
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Primary repair of total anomalous pulmonary venous connection (TAPVC) of the infracardiac type is associated with a significant risk of recurrent pulmonary venous obstruction [1]. Size of the pulmonary venous confluence and individual pulmonary veins, anastomotic technique, and distortion of the pulmonary venous confluence by the left atrium have been implicated in the occurrence of recurrent pulmonary venous obstruction [2, 3]. Despite the advances made in recent years, prevention of this problem remains elusive. In this article, we describe a technique of primary repair of infracardiac TAPVC in which a modified sutureless anastomosis is constructed, suturing the left atrium to the posterior mediastinal pleura that surrounds the pulmonary venous confluence.
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Technique
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After the sternum and the pericardium were entered, the patient (a child) was heparinized and placed on cardiopulmonary bypass by cannulation of the ascending aorta and insertion of a single right atrial venous cannula. Systemic cooling to a rectal temperature of 18°C using a pH-stat strategy was performed while the aorta was cross-clamped and electromechanical arrest was accomplished by delivering cold blood cardioplegic solution to the aortic root. A generous incision was made in the right-sided mediastinal pleura, which was extended inferiorly toward the diaphragmatic surface (Fig 1A) to be able to rotate the heart toward the patient's right and position it under the right hemi sternum during the repair. Venting of the main pulmonary artery allowed effective decompression of the pulmonary vascular system in case of obstructed TAPVC. Furthermore, by using continuous low-flow hypothermic cardiopulmonary bypass as an alternative to circulatory arrest, pulmonary artery venting improved visualization of the surgical field once the pulmonary venous confluence was opened for the repair. After the target core temperature of 18°C was reached, the heart was reflected to the right and gently pushed under the right hemi-sternum, as shown in Fig 1B. This maneuver was facilitated by placing a heavy silk suture in the posterior diaphragmatic pleura, which was connected to an umbilical tape (Fig 1B). The umbilical tape was draped over the heart and was used to retract the heart under the right hemi-sternum (Fig 1B). Adequate exposure of the vertical pulmonary venous confluence located in the posterior mediastinum was provided. The posterior mediastinal pleura was incised over the pulmonary venous confluence (Figs 1B and 1C), minimizing lateral dissection if a modified sutureless repair was anticipated. Prior to opening the vertical vein, it was our preference to establish low-flow hypothermic cardiopulmonary bypass (systemic total body perfusion, 30 to 40 cc/kg at 18°C) and avoid complete circulatory arrest, if possible. The pulmonary venous confluence was longitudinally incised from the cephalad aspect down to the diaphragmatic end, as shown in Fig 1C. It was our preference to leave the vertical vein patent, as described by others [4]. A mirror incision was made on the left atrium (Fig 1B). The left atrium was subsequently connected to the pulmonary venous confluence by suturing the edges of the atrium to the posterior mediastinal pleura that surrounds the vertical vein (Figs 1C and 1D), thereby minimizing trauma to the venous wall and the risk of distortion once the heart was repositioned in the pericardial well. The anastomosis was constructed by using a 7-0 polypropylene suture. Fig 1E illustrates the completed connection between the left atrium and the pulmonary venous confluence. Figures 2 and 3
show the two-dimensional echocardiogram performed a few weeks after the repair.
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Fig 1. (A) In preparation for infracardiac total anomalous pulmonary venous connection (TAPVC) repair, the right-sided mediastinal pleura is opened widely as shown by the dotted line to allow rotation of the heart to the right and exposure of the retro-cardiac pulmonary venous confluence. (B) The dotted lines indicate the incisions made on the left atrium and on the pulmonary venous confluence. The two arrows indicate the tension applied on the umbilical tapes connected to the posterior diaphragmatic pleura to retract the heart to the right and under the right hemi-sternum, thereby exposing the posterior pulmonary venous confluence. (C) The pulmonary venous confluence has been incised. The dotted line indicates the line of suturing of the left atrium to the posterior mediastinal pleura in relation to the confluence. (D) A sutureless anastomosis is constructed by suturing the left atrium to the posterior mediastinal pleura that surrounds the pulmonary venous confluence. (E) The sutureless repair has been completed.
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Fig 2. Two-dimensional echocardiogram showing the connection (arrow) between the left atrium and the pulmonary venous confluence. (LA = left atrium; LV = left ventricle.)
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Fig 3. Color Doppler image showing unobstructed pulmonary venous return to the left atrium. (LA = left atrium; LV = left ventricle.)
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Comment
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Sutureless repairs have been shown to be safe and effective in a variety of situations involving recurrent pulmonary venous obstruction after TAPVC repair, as originally shown by Najm and colleagues [5], and as confirmed by others [6]. Although several techniques have been described in which in-situ pericardium, isolated pericardium, or other patch materials are used [1, 3, 5, 6], the main principle of a sutureless repair is to avoid trauma to the pulmonary venous wall and endothelium, so as to reduce the risk of subsequent anastomotic stenosis. In this report, we describe a modified sutureless anastomosis in which the left atrium is sutured directly to the posterior mediastinal pleura that surrounds the pulmonary venous confluence rather than to the pulmonary venous confluence itself. Trauma to the endothelium of the pulmonary veins is limited, as the pulmonary venous wall is not directly incorporated into the anastomosis. Also, distortion of the confluence or individual pulmonary veins, or both, may occur with a conventional left atrium-to-confluence anastomosis when the heart is repositioned in the pericardium, with consequent pulmonary venous obstruction. Conversely, distortion of the pulmonary venous structures is prevented by the sutureless repair as the atrium is sutured to the less pliable posterior mediastinal pleura rather than to the thin pulmonary venous confluence. As we have used this technique in only 1 patient, we recognize that its application to a large number of patients with long-term follow-up are needed to draw definitive conclusions on its efficacy in preventing pulmonary venous obstruction. However, we believe that the principles of avoiding trauma to the pulmonary venous endothelium and minimizing distortion of the pulmonary venous confluence can play an important role in reducing the risk of recurrent obstruction. We also believe that the same surgical strategy could be applied to other types of primary repair of TAPVC (supracardiac) and certain cases of recurrent pulmonary venous obstruction.
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References
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- Ricci M, Elliott M, Cohen GA, et al. Management of pulmonary venous obstruction after correction of TAPVC: risk factors for adverse outcome Eur Journal of Cardio-Thoracic Surgery 2003;24:28-36.
- Hyde JAJ, Stumper O, Barth MJ, et al. Total anomalous pulmonary venous connection: outcome of surgical correction and management of recurrent venous obstruction Eur J Cardiothorac Surg 1999;15:735-741.[Abstract/Free Full Text]
- Devaney EJ, Chang AC, Ohye RG, Bove EL. Management of congenital and acquired pulmonary vein stenosis Ann Thorac Surg 2006;81:992-995.[Abstract/Free Full Text]
- Caspi J, Pettitt TW, Fontenot EE, et al. The beneficial hemodynamic effects of selective patent vertical vein following repair of obstructed total anomalous pulmonary venous drainage in infants Eur J Cardiothorac Surg 2001;20:830-834.[Abstract/Free Full Text]
- Najm HK, Caldarone CA, Smallhorn J, Coles JG. A sutureless technique for the relief of pulmonary vein stenosis with the use of in situ pericardium J Thorac Cardiovasc Surg 1998;115:468-470.[Free Full Text]
- Lacour-Gayet F, Zoghbi J, Serraf AE, et al. Surgical management of progressive pulmonary venous obstruction after repair of total anomalous pulmonary venous connection J Thorac Cardiovasc Surg 1999;117:679-687.[Abstract/Free Full Text]
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Modified primary sutureless repair of total anomalous pulmonary venous connection in heterotaxy.
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Abstract
Introduction
