Ann Thorac Surg 2009;88:e27-e28. doi:10.1016/j.athoracsur.2009.06.077
© 2009 The Society of Thoracic Surgeons
How To Do It
Supracardiac Total Anomalous Pulmonary Venous Connection: The Transaortopulmonary Approach
Emmanuel Le Bret, MD, PhDa,*,
François Roubertie, MDa,
Emre Belli, MDa,
Bertrand Stos, MDa,
Anne Sigal-Cinqualbre, MDb,
Régine Roussin, MDa,
Alain Serraf, MD, PhDa
a Service des Cardiopathies Congénitales, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
b Département d'Imagerie Médicale, Scanner, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
Accepted for publication June 11, 2009.
* Address correspondence to Dr Le Bret, Service des Cardiopathies Congénitales, Centre Chirurgical Marie Lannelongue, 133 avenue de la Résistance, Le Plessis Robinson, 92350, France (Email: e.lebret{at}ccml.fr).
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Abstract
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We have been confronted with patients in whom classical techniques did not offer optimum exposure to correct supracardiac forms of total anomalous pulmonary venous connection, especially in neonates. Therefore, we present a surgical modification of the superior approach for enhanced exposure as a result of transection of the ascending aorta associated or not with the transection of the pulmonary trunk. The transaortopulmonary approach ensures a perfect exposition without any need to pull on the surrounding structures. Because of the better exposure, most patients do not require circulatory arrest.
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Introduction
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Since the first successful repair of total anomalous pulmonary venous connection (TAPVC), many surgical techniques have been reported. The classic technique for surgical repair of TAPVC was initially described by Kirklin [1]. Through a transatrial approach, the posterior wall of the left atrium is opened, the underlying common pulmonary vein is opened, and an anastomosis is performed. Although this approach is safe and reproducible, it requires several atrial incisions and is associated with a high incidence of postoperative supraventricular arrhythmias.
Tucker and colleagues [2] and Vouhé and colleagues [3] suggested the use of a superior approach between the superior vena cava and the ascending aorta. This approach offers good exposure through the transverse sinus to the roof of the left atrium as well as to the common pulmonary vein, but it can present spatial limitations, particularly in tiny neonates.
We have been confronted with patients in whom these techniques did not offer optimum exposure. Therefore, we developed since 1994 a surgical modification of the superior approach by transecting the ascending aorta [4]. More recently, we enhanced the exposure by adding pulmonary trunk division. We present details of this transaortopulmonary approach for the supracardiac form of TAPVC.
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Technique
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The operation is conducted under normothermic cardiopulmonary bypass with bicaval venous cannulation. Deep hypothermia with circulatory arrest is considered only when needed in some cases of obstructed TAPVC. Myocardial protection is ensured by blood cardioplegia delivered through the aortic root.
After institution of cardiopulmonary bypass and ligation of the ductus arteriosus, the ascending aorta is dissected free of the pulmonary trunk. The right pulmonary artery also is dissected and mobilized. The common pulmonary vein is identified below the right pulmonary artery and the ascending aorta and is dissected free of its pericardial attachments to the greatest extent possible. The aorta is cross-clamped, cardioplegia is delivered, and the aorta is divided 1 cm above the coronary ostia. The proximal stoma is held down gently by a stay suture, the right pulmonary artery is retracted upward, and the pulmonary trunk is retracted leftward (Fig 1).
At this stage, exposure of the roof of the left atrium as well as the common vein can be sufficient. If not, exposure can be optimized by section of the pulmonary trunk 1 cm above the pulmonary valve. The pulmonary root is then also held down gently by a stay suture. Division of both the aorta and the pulmonary trunk ensure a perfect exposure without any need to pull on surrounding structures (Fig 2).
The roof of the left atrium is opened widely. The common pulmonary vein is opened parallel to the left atrial incision, and the lungs are inflated gently to evacuate the remaining blood in the pulmonary vascular bed. No attempt is made to control the different pulmonary veins to avoid potential sites of late pulmonary vein stenosis.
The anastomosis is completed with 7-0 or 8-0 running suture. The pulmonary trunk and aorta are reconstructed by terminoterminal regular anastomosis. Air is removed from the heart, and the cross clamp is removed. After rewarming, if needed, the patient is smoothly weaned from cardiopulmonary bypass.
The vertical vein is always ligated, and no residual atrial septal defect is left in place. The sternum is left opened in case of obstructed TAPVC only if needed.
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Comment
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We have used this technique since 1994 in 79 patients with supracardiac TAPVC. The mean age for the entire series was 44 days, and the mean weight was 3.7 ± 0.9 kg. More than 70% were aged younger than 1 month. Obstruction of the pulmonary venous return was present in 36 patients (45%).
In 40 patients, section of the aorta alone allowed a good exposure. In the 39 others, both the aorta and the pulmonary trunk were divided. The mean duration of cardiopulmonary bypass was 84 ± 26 minutes and mean-cross clamping time was 43 ± 7 minutes, with no differences between those who had only section of the aorta and those who had both the aorta and the pulmonary trunk divided.
Circulatory arrest was used in 16 patients (20%); the mean duration of circulatory arrest for these patients was 16.6 ± 12.4 minutes. In 10 patients, an associated Warden [5] procedure was performed for the mixed form of TAPVC. Sternal closure was delayed in 25 patients (32%). Initial follow-up showed no gradient across the anastomosis.
Among the 79 patients operated on with this approach, 3 died, of which two had bilateral intrahilar multiple pulmonary vein stenoses, confirmed at postmortem examination. The last patient had to undergo a reoperation for a left upper vein stenosis and pulmonary hypertension. He had first a sutureless technique, then a left upper lobectomy, but he died of uncontrolled pulmonary hypertension. All the survivors have been followed up for a mean of 34.8 months. Pulmonary vein stenosis developed in 5 patients, and all 5 were reoperated on with the sutureless technique [6], with good results. At last follow-up, the patients are in New York Heart Association functional class I, without medication. Echocardiographic studies have revealed no gradient across the anastomosis.
In conclusion, the transaortopulmonary superior approach with division of the aorta eventually associated with division of the pulmonary trunk is a useful adjunct to the surgical techniques available for repair of supracardiac TAPVC. This approach provides a very good exposure, allowing a large anastomosis between the common pulmonary vein and the roof of the left atrium. There is no need to pull on surrounding structures, which reduces the risk of twisting the anastomosis. Owing to the better exposure, most patients do not required circulatory arrest.
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References
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- Kirklin JW. Surgical treatment of anomalous pulmonary venous connections Mayo Clin Proc 1953;28:476-479.
- Tucker BL, Lindesmith GC, Stiles QR, Meyer BW. The superior approach for correction of the supracardiac type of total anomalous pulmonary venous return Ann Thorac Surg 1976;22:374-377.[Abstract/Free Full Text]
- Vouhé P, Neveux JY, Bical O, Leca F. Surgical treatment of total abnormal pulmonary venous return. Value of the inter-aortico-caval approach. Press Med 1984;13:2143-2145.
- Serraf A, Belli E, Roux D, et al. Modified superior approach for repair of supracardiac and mixed total anomalous pulmonary venous drainage Ann Thorac Surg 1998;65:1391-1393.[Abstract/Free Full Text]
- 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/Free Full Text]
- Lacour-Gayet F, Zoghbi J, Serraf A, 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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Abstract
Introduction
