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Ann Thorac Surg 1997;64:237
© 1997 The Society of Thoracic Surgeons

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Invited Commentary

Invited Commentary

Section of Pediatric Cardiac Surgery,Department of Cardiovascular-Thoracic Surgery,Rush-Presbyterian-St. Luke's Medical Center,1653 W Congress Pkwy,Chicago, IL 60612

See also page 235.

This patient described by Drs Palacios-Macedo and Fraser presented with a complex cardiac malformation including a persistent left superior vena cava (LSVC) with hemiazygous continuation of an interrupted inferior vena cava. The transfer of the LSVC in continuity with a long left atrial appendage as a tube to the right superior vena cava has not been reported previously. A postoperative echocardiogram at 8 months shows the anastomosis to be patent. The question posed to Drs Palacio-Macedo and Fraser is whether there was need for an extracardiac conduit or whether an intracardiac tunnel could be performed in this case. They suggested that the configuration of the pulmonary veins precluded the use of an intraatrial baffle. Shumacker and associates [1] in 1967 reported a similar technique using part of the left atrium as a flap. This tubular extension was implanted into the right atrium. Sherafat and colleagues [2] in 1970 and Kabbani and co-workers [3] in 1973 both reported that these grafts were thrombosed. They both cited the risk of thrombosis and compression between the aorta and the sternum in an extended extracardiac conduit. Gontijo and associates [4] reported the use of a polytetrafluoroethylene tubular graft that extended across to the right atrium in a 14-year-old patient. The use of nonviable material in an infant or growing child would not be advisable. Furthermore, one would seek to use a ringed conduit in the older patient to prevent compression.

An intracardiac repair would be my method of choice for rerouting the anomalous LSVC. This can be performed with the use of pericardium, Dacron, polytetrafluoroethylene, or the child's own tissue. Because pericardium can degenerate, become fibrotic, or calcify, I have used polytetrafluoroethylene since 1984. The intraatrial reroutings could be difficult if one used the methods described by Rastelli and associates [5] and Kirklin and Barratt-Boyes [6] in which the tunnel is created on the posterior wall of the left atrium or in which the pulmonary veins drain the tricuspid valve. Doctors Palacios-Macedo and Fraser stated that the intraatrial baffle could not be used because of the configuration of the pulmonary veins. Two previously reported methods may have been possible. Komai and colleagues [7] reported inverting the left appendage and swinging the edge of the appendage flap to the posterior wall of the left atrium around a cannula, forming a tunnel between the LSVC and the right atrium. The remaining atrial septal defect was closed with pericardium. Another intraatrial method described by Sand and associates [8] uses a Dacron patch to construct a baffle on the roof of the left atrium. The baffle begins at the base of the LSVC and left atrial appendage junction, extending across the right atrium superior and anterior to the pulmonary veins. An atrial septal defect is created if not present, and the atrial septum is reconstructed at the lip of the intraatrial tunnel. The major part of the tunnel is the child's own tissue. These methods would avoid the potential obstruction of the pulmonary veins and the mitral valve. They also avoid the area of the conduction system.

The extended extracardiac tube proposed by Palacios-Macedo and Fraser presents a novel and interesting approach to the rerouting of the LSVC to the right side. I am concerned about the potential for thrombosis or compression of this channel and await a longer follow-up report on this child.

References

1. Shumacker HB Jr, King H, Waldhausen JA. The persistent left superior vena cava: surgical implication, with special reference to caval drainage into the left atrium. Ann Surg 1967;165:979–805.
2. Sherafat M, Friedman S, Waldhausen JA. Persistent left superior vena cava draining into the left atrium with absent right superior vena cava. Ann Thorac Surg 1971;11:160–4.[Medline]
3. Kabbani SS, Feldman M, Angelini P, et al. Single (left) superior vena cava draining into the left atrium. Ann Thorac Surg 1973;16:518–24.[Medline]
4. Gontijo B, Fantini FA, de Paula e Silva JA, Barbosa JT, Vrandecic MO, Masci M da G. The use of PTFE graft to correct anomalous drainage of persistent left superior vena cava. J Cardiovasc Surg 1990;31:815–6.[Medline]
5. Rastelli GC, Ongley PA, Kirklin JW. Surgical correction of common atrium with anomalously connected persistent left superior vena cava: report of case. Mayo Clin Proc 1965;40:528.
6. Kirklin JW, Barratt-Boyes BG. Unroofed coronary sinus syndrome. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac surgery. New York: Wiley, 1985:533–40.
7. Komai H, Naito Y, Fujiwara K. Operative technique for persistent left superior vena cava draining into the left atrium. Ann Thorac Surg 1996;62:1188–90.[Abstract/Free Full Text]
8. Sand ME, MacGrath LB, Pacifico AD, Mandke V. Repair of left superior vena cava entering the left atrium. Ann Thorac Surg 1986;42:560–4.[Abstract]

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joseph J. Amato Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Amato, J. J. Search for Related Content PubMed Articles by Amato, J. J. Related Collections Related Article