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Ann Thorac Surg 1995;60:55-59
© 1995 The Society of Thoracic Surgeons

Absorbable Polydioxanone Suture and Results in Total Anomalous Pulmonary Venous Connection

John A. Hawkins, MD, L. Luann Minich, MD, Lloyd Y. Tani, MD, Herbert D. Ruttenberg, MD, Jane E. Sturtevant, BSN, Edwin C. McGough, MD

Divisions of Cardiothoracic Surgery and Pediatric Cardiology, Departments of Surgery and Pediatrics, University of Utah and Primary Children's Medical Center, Salt Lake City, Utah


   Abstract
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 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background. Despite theoretical advantages of absorbable suture in the growing vascular anastomosis, there has not been a documented advantage over nonabsorbable suture in preventing late anastomotic stenosis in total anomalous pulmonary venous connection (TAPVC).

Methods. We reviewed our experience from 1982 to 1994 with 65 hospital survivors of total TAPVC repair to examine the influence of suture type on survival and incidence of late pulmonary venous obstruction. From 1982 until 1988, we used continuous nonabsorbable polypropylene suture for the pulmonary venous–left atrial anastomosis in supracardiac, infracardiac, and mixed types of TAPVC. In 1989, we adopted a running absorbable polydioxanone suture technique. Cardiac catheterization and echocardiography were used to evaluate late pulmonary venous obstruction.

Results. Late pulmonary venous obstruction occurred in 17% (4/23) of survivors after repair with polypropylene suture compared with 3.2% (1/32) after repair with poly-dioxanone suture (p < 0.05). There were no instances of late pulmonary venous obstruction in the intracardiac TAPVC group (0/10). All late pulmonary venous obstructions occurred within 16 months after operation. The actuarial 3-year and 5-year freedom from late pulmonary venous obstruction was 100% for intracardiac TAPVC, 96% for the polydioxanone group, and 81% for the polypropylene group. Five patients died late (5/65, 7.7%), 3 in the polypropylene suture group (3/23, 13%) and 2 in the polydioxanone group (2/32, 6%).

Conclusions. Continuous absorbable polydioxanone suture for the repair of TAPVC results in a low incidence of late pulmonary venous obstruction and death and appears to offer advantages over a continuous nonabsorbable suture. A continuous nonabsorbable suture may limit growth of a vascular anastomosis, particularly one involving a ``low-pressure'' anastomosis such as in the repair of TAPVC.


   Introduction
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 Introduction
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See also page 59.

The results of repair of total anomalous pulmonary venous connection (TAPVC) have improved substantially in recent years. Despite these improvements, there remains a small, but important group of patients in whom late pulmonary venous obstruction develops. Exact causes of late pulmonary venous obstruction are not always clear but in general include a fibrotic and stenotic process involving the anastomosis, long segments of pulmonary veins, or stenosis localized to the orifices of individual pulmonary veins. Suture technique has been thought to be important in the development of late pulmonary venous obstruction, and several authors [1, 2] have recommended an interrupted or absorbable suture technique for this low-pressure type of growing vascular anastomosis. Although the theoretical advantages of an absorbable suture line are clear for the growing vascular anastomosis [3–5], it is not known if they translate into a clinical advantage for the infant with TAPVC.

Since 1989, we have routinely used a continuous polydioxanone monofilament suture to create the common pulmonary vein–left atrial anastomosis in TAPVC. Here we report our long-term results and incidence of pulmonary venous obstruction with the use of absorbable suture in repair of TAPVC and compare them with those in an earlier group of patients in whom we used a continuous nonabsorbable polypropylene suture technique.


   Patients and Methods
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 Introduction
 Patients and Methods
Results
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Patient Population
All patients with TAPVC who underwent operative correction at Primary Children's Medical Center from 1982 through 1994 form the basis of this study. Those patients with a patent ductus arteriosus, a small ventricular septal defect, an atrial septal defect, or a patent foramen ovale were classified as having ``simple'' TAPVC. More complex forms of TAPVC with heterotaxy syndrome were also included in the study. The complete hospital and outpatient record of each patient was reviewed. In 1989 we adopted a continuous monofilament polydioxanone suture technique for the repair of all TAPVCs that involved a sutured anastomosis between the pulmonary veins and the left atrium. Prior to this (1982 through 1988), we routinely used a continuous nonabsorbable monofilament polypropylene suture for the anastomosis between the common pulmonary vein and the left atrium.

A total of 77 patients underwent repair of TAPVC during this 13-year period, 65 patients with isolated forms of TAPVC and 12 patients with more complex associated anomalies. Age of the patients ranged from 1 day to 31 months (median age, 24 days). Forty patients were boys, and 37 were girls. Weight ranged from 1.9 to 12 kg (mean weight, 4.1 kg). Supracardiac forms of TAPVC were preponderant (39/77, 50.6%). Nineteen patients had an infracardiac connection (19/77, 24.7%), 10 had an anomalous connection to the coronary sinus (10/77, 13.0%) and 9 had a mixed-type connection (9/77, 11.7%). In the group with more complex TAPVC, there were 10 patients with various forms of heterotaxia-asplenia syndrome (5 with infracardiac TAPVC, 5 with supracardiac TAPVC), 1 patient with a large midmuscular ventricular septal defect, and 1 patient with critical pulmonary stenosis.

Preoperative stabilization was routine with correction of metabolic acidosis and intubation, when indicated. Preoperative cardiac catheterization was performed early in the experience. In recent years, echocardiographic examination has been routine, and catheterization is reserved for patients in whom the anatomy is not adequately explained by echocardiography. Emergent operation was undertaken after a short period of stabilization in all patients with evidence of pulmonary venous obstruction.

Operative Technique
Operative technique varied little over the 13-year experience. All patients underwent repair utilizing cardiopulmonary bypass with profound hypothermia to 18°C and circulatory arrest. Myocardial protection was achieved with multidose cold cardioplegia administration at 20-minute intervals.

A continuous running suture technique for supracardiac, infracardiac, and mixed types of TAPVC was used throughout the experience for the anastomosis between the pulmonary venous confluence and the left atrium. From 1982 through 1988, a continuous 6-0 monofilament polypropylene suture was used for this anastomosis and from 1989 to 1994, a continuous 6-0 monofilament polydioxanone suture.

Supracardiac TAPVC was repaired by the method described by Kirklin [6], that is, working from the right side with the right atrium and venae cavae retracted to the left. For infracardiac TAPVC, a vertical anastomosis was performed between the common pulmonary venous confluence and the left atrium by either the posterior approach of Williams and colleagues [7] or the method of Kirklin [6]. Intracardiac drainage to the coronary sinus was corrected by the method of Van Praagh and associates [8]. Mixed drainage was repaired by a variety of techniques, including direct anastomosis of a lobar branch to the left atrial appendage and repair of the remaining pulmonary veins by one of the techniques already mentioned. The atrial septal defect was closed by direct suture if closure did not encroach on the anastomosis. Pericardial patch closure of the atrial septal defect was performed if there was any question of narrowing of the anastomosis or size of the left atrium.

Recurrent stenosis or pulmonary venous obstruction was corrected by reoperation through a median sternotomy and excision of the stenotic anastomosis [2]. In cases of individual pulmonary vein stenosis, either the stenotic area was excised or the vein was reanastomosed to the left atrium using absorbable suture. Long-segment pulmonary vein stenosis was relieved by a pericardial or expanded polytetrafluoroethylene patch.

Patient Follow-up
Follow-up was obtained on all patients through clinic visits and direct patient contact during the months of October through December 1994. Routine chest roentgenography and echocardiography were used in the evaluation for late pulmonary venous obstruction. Routine postoperative cardiac catheterization was performed until approximately 1985 and has been performed selectively since then. Echocardiography has been done routinely in all patients throughout the study, and methods to evaluate pulmonary venous obstruction have been described in detail [9]. Late pulmonary venous obstruction suggested by clinical examination, echocardiograms, or chest roentgenograms was always evaluated by cardiac catheterization. Pulmonary venous obstruction was defined as a clinical picture combined with catheterization evidence of a pulmonary artery wedge pressure–left ventricular end-diastolic gradient greater than 5 mm Hg. Freedom from late pulmonary venous obstruction is reported by the actuarial method of Kaplan and Meier [10].


   Results
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 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
The operative mortality rate for the 65 patients with isolated TAPVC over the 13-year period was 12.3% (8/65) (70% confidence limits [CL], 8.3% to 17.9%), decreasing from 19.4% (6/31) (70% CL, 11.7% to 29.4%) during the 1982–1988 period to 5.9% (2/34) (70% CL, 2.0% to 13.2%) in the 1989–1994 period. Throughout the 13-year study, the mortality rate for the complex forms of TAPVC remained higher (33%, 4/12). Again, a reduction in the early mortality rate was seen, going from 43% (3/7) in 1982 through 1988 to 20% (1/5) in 1989 to 1994. The distribution of anatomic types of TAPVC and mortality is shown in Table 1Go. The more recent experience included 19 patients (19/39, 49%) with some degree of preoperative obstruction compared with 13 patients (13/38, 34%) in the earlier period. Median age at operation was 54 days in the 1982–1988 period compared with 15 days in the 1989–1994 period. The duration of circulatory arrest did not differ between the two time periods and averaged 38 ± 8 minutes (± the standard deviation) in the 1982–1988 period and 39 ± 7 minutes in the 1989–1994 period.


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  		Table 1. . Anatomic Types of Total Anomalous Pulmonary Venous Connection and Mortalitya
 
Pulmonary venous obstruction developed in 5 of the 65 operative survivors of both simple and complex TAPVC repair. Late pulmonary venous obstruction occurred in 4 (17%; 70% CL, 9% to 30%) of the 23 patients who survived with the polypropylene suture technique during the 1982–1988 period. In contrast, 1 (3%, 70% CL, 0% to 10%) of the 32 hospital survivors with a polydioxanone suture anastomosis had development of late pulmonary venous obstruction. Throughout the experience, no late pulmonary venous obstruction occurred in any of the 10 patients with intracardiac TAPVC to the coronary sinus. Actuarial freedom from late pulmonary venous obstruction for each group of hospital survivors is shown in Figure 1Go and was significantly less in the polydioxanone group (96% versus 81%) at 5 years (p < 0.05). The 4 patients with late obstruction in the polypropylene suture group (1982 through 1988) all had supracardiac TAPVC, and the 1 patient in the polydioxanone suture group had infracardiac TAPVC. There were no instances of late pulmonary venous obstruction in the patients with heterotaxy syndrome or complex forms of TAPVC. The pathologic characteristics of the pulmonary venous obstruction were variable, and a summary of intraoperative findings in these 5 patients is provided in Table 2Go. All 5 patients with late pulmonary venous obstruction underwent reoperation with no operative deaths and two late deaths.



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  		Fig 1. . Actuarial freedom from late pulmonary venous obstruction in survivors of total anomalous pulmonary venous connection (TAPVC) repair using a continuous polydioxanone suture technique (n = 32), a continuous polypropylene suture technique (n = 23), or no suture line (intracardiac TAPVC, n = 10).

 

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  		Table 2. . Characteristics of Patients With Late Pulmonary Venous Obstruction
 
Five (7.7%) of the 65 early survivors of repair of TAPVC died late, 3 in the polypropylene suture group (3/23, 13%) and 2 in the polydioxanone group (2/32, 6%). There were no late deaths in the group of patients with TAPVC to the coronary sinus. The late deaths of 2 patients in the 1982–1988 group were due to recurrent pulmonary venous obstruction after late reoperation (see Table 2Go). One other patient in the early group died of pneumonia and had no evidence of pulmonary venous obstruction at postmortem examination. The two late deaths in the 1989–1994 polydioxanone suture group occurred at 6 weeks and 3 months and were due to pulmonary lymphangiectasia and sepsis (in a patient with asplenia), respectively. Neither of the patients had clinical or catheterization evidence of pulmonary venous obstruction. Actuarial survival for the two periods and the experience with complex forms of TAPVC is demonstrated in Figure 2Go.



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  		Fig 2. . Actuarial survival of patients after repair of isolated total anomalous pulmonary venous connection (TAPVC) during the absorbable suture era (1989–1994, n = 34) and the nonabsorbable suture era (1982–1988, n = 31). Survival of patients with complex TAPVC is depicted for the entire study period (1982–1994, n = 12).

 

   Comment
Top
 Footnotes
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Improving results in the repair of TAPVC have been widely reported and have led to increasing numbers of long-term survivors. The most common and difficult complication seen in these survivors is late pulmonary venous obstruction. This complication occurs in 5% to 15% of long-term survivors of TAPVC repair and usually develops within the first 6 to 12 months postoperatively [1, 2, 11]. Pathologically this obstruction appears to be either a fibrotic process occurring at the anastomosis [2] or at the pulmonary venous ostia or a diffuse process involving long segments of one or several lobar veins [11]. Although these complications have been well described, the exact causes of late obstruction are not totally understood, and methods to eliminate late obstruction are not known.

Suturing technique has been implicated by some groups as an important factor in the reduction of late pulmonary venous obstruction. Wilson and colleagues [1] reported a reduction in late pulmonary venous obstruction from 36% when continuous polypropylene suture was used to 9% when an interrupted suture technique was used. Similarly, Schäfers and associates [2] noted late pulmonary venous obstruction in 7% of patients when a continuous polypropylene suture technique was used and a subsequent reduction in late pulmonary venous obstruction to 0% with the use of a continuous polydioxanone suture and a relatively short follow-up. Wilson and colleagues [1] hypothesized that pulmonary venous obstruction after operation may be due to a so-called pursestring effect of the continuous suture line technique that is present from the beginning. On the other hand, Schäfers and associates [8] thought that a continuous nonabsorbable suture technique fixes the diameter of the anastomosis and the child's heart outgrows the surgically constructed communication over time.

It is possible that the anastomosis in the low-pressure atrial system may be even more vulnerable to a circumferential nonabsorbable suture line than one in a higher-pressure arterial system such as exists in coarctation of the aorta or after an arterial switch procedure. The low rate of late pulmonary venous obstruction in the absence of a circumferential nonabsorbable suture line is further supported by the absence of late pulmonary venous obstruction in our 10 patients with TAPVC to the coronary sinus where there is no suture line between the pulmonary venous confluence and the left atrium.

Polydioxanone and other monofilament absorbable sutures such as polyglactin offer a definite advantage in the growing anastomosis under experimental conditions [4, 5]. The use of polydioxanone suture for various pediatric cardiovascular procedures has been practiced for at least 10 years for a variety of anomalies including coarctation of the aorta, interrupted aortic arch, the Senning procedure, and TAPVC [3]. Despite the theoretical advantages of absorbable suture in the growing anastomosis, excellent growth of anastomoses has also been demonstrated with continuous nonabsorbable suture in repair of coarctation of the aorta [11], the arterial switch operation [12], and TAPVC [13, 14]. This emphasizes the difficulty in separating the contribution of anastomotic growth to late stenosis from other factors such as anastomotic tension, inflammatory fibrosis, and technical factors.

Certainly in TAPVC, the causes of late pulmonary venous obstruction can appear at several levels including the pulmonary venous ostia and long segments of lobar veins as well as the anastomosis. Although other authors [11] have been able to distinguish anastomotic stenosis from these other levels of obstruction, we found it quite difficult to separate anastomotic stenosis from individual pulmonary venous ostial stenosis because of the short distances involved and the characteristics of the fibrotic scar (see Table 2Go). Certainly, extension of the common pulmonary venous incision near or into individual pulmonary veins [15] may give the appearance of ostial fibrosis and scarring on reoperation, even if the real problem is at the anastomosis. Wilson and associates [1] postulated that postoperative pulmonary venous obstruction is a fibrotic process that affects the atrial wall and extends into the proximal end of the pulmonary veins and is likely due to a chronic low-grade degree of obstruction present early after operation.

It would be attractive to conclude from this study that a running absorbable suture leads to a lower operative mortality, a lower incidence of late pulmonary venous obstruction, and better survival. However, the very nature of a retrospective review with differing time periods makes these conclusions difficult to draw with any kind of certainty. Operative mortality was improved during the period of absorbable suture use (1989 to 1994), but experience and earlier operation were likely more important factors than suture type. It could be argued that because of the better results in recent years, improved technique and a ``learning curve'' may have a favorable impact on late pulmonary venous obstruction. However, the surgical techniques and operative times are nearly identical, and this study focuses on only hospital survivors and the incidence of late pulmonary venous obstruction. Late survival was also improved during the period of absorbable suture use and can be explained, at least in part, by a lower incidence of late pulmonary venous obstruction (see Fig 1Go). However, the number of late deaths in both groups are few, and the largest differences in actuarial survival (see Fig 2Go) occur in the early mortality rates.

Although this is neither a prospective nor a randomized study, it does demonstrate that a continuous polydioxanone suture for repair of TAPVC is associated with a low incidence of late pulmonary venous obstruction and good intermediate-term survival. Reoperation for late pulmonary venous obstruction can be performed with low operative mortality but less predictable long-term results. A more complete understanding of the mechanisms of late pulmonary venous obstruction will be necessary to determine the exact role of anastomotic growth in the reduction of long-term morbidity and mortality.


   Footnotes
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Abstract
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Presented at the Thirty-first Annual Meeting of The Society of Thoracic Surgeons, Palm Springs, CA, Jan 30–Feb 1, 1995.

Address reprint requests to Dr Hawkins, Division of Cardiothoracic Surgery, University of Utah Medical Center, 50 N Medical Dr, Salt Lake City, UT 84132.


   References
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 Footnotes
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Wilson WR, Ilbawi MN, DeLeon SY, et al. Technical modifications for improved results in total anomalous pulmonary venous drainage. J Thorac Cardiovasc Surg 1992;103:861–71.[Abstract]
  2. Schäfers, H-J, Luhmer I, Oelert H. Pulmonary venous obstruction following repair of total anomalous pulmonary venous drainage. Ann Thorac Surg 1987;43:432–4.[Abstract]
  3. Myers JL, Campbell DB, Waldhausen JA. The use of absorbable monofilament polydioxanone suture in pediatric cardiovascular operations. J Thorac Cardiovasc Surg 1986;92:771–5.[Abstract]
  4. Chiu IS, Hung CR, Chao SF, Huang SH, How SW. Growth of the aortic anastomosis in pigs: comparison of continuous absorbable suture with nonabsorbable suture. J Thorac Cardiovasc Surg 1988;95:112–8.[Abstract]
  5. Arenas JD, Myers JL, Gleason MM, Vennos A, Baylen BG, Waldhausen JA. End-to-end repair of aortic coarctation using absorbable polydioxanone suture. Ann Thorac Surg 1991;51:413–7.[Abstract]
  6. Kirklin JW. Surgical treatment of total anomalous pulmonary venous connection in infancy. In: Barratt-Boyes BG, Neutze JA, Harris EA, eds. Heart disease in infancy: diagnosis and surgical treatment. Edinburgh: Churchill Livingstone, 1973:89–100.
  7. Williams GR, Richardson WR, Campbell GS. Repair of total anomalous pulmonary venous drainage in infancy. J Thorac Cardiovasc Surg 1972;64:132–5.[Medline]
  8. Van Praagh R, Harken AH, Delisle G, Ando M, Gross RE. Total anomalous pulmonary venous drainage to the coronary sinus. A revised procedure for its correction. J Thorac Cardiovasc Surg 1972;64:132–5.
  9. Minich LL, Tani LY, Hawkins JA, McGough EC, Shaddy RE. Abnormal Doppler pulmonary venous flow patterns in children after repaired total anomalous pulmonary venous connection. Am J Cardiol 1995;75:606–10.[Medline]
  10. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457–81.
  11. Lacour-Gayet, F, Bruniaux J, Serraf A, et al. Hypoplastic transverse arch and coarctation in neonates. J Thorac Cardiovasc Surg 1990;100:808–16.[Abstract]
  12. Arensman FW, H-Sievers H, Lange P, et al. Assessment of coronary and aortic anastomoses after anatomic correction of transposition of the great arteries. J Thorac Cardiovasc Surg 1985;90:597–604.[Abstract]
  13. Sano S, Brawn WJ, Mee RBB. Total anomalous pulmonary venous drainage. J Thorac Cardiovasc Surg 1989;97:886–92.[Abstract]
  14. Cobanoglu A, Menashe VD. Total anomalous pulmonary venous connection in neonates and young infants: repair in the current era. Ann Thorac Surg 1993;55:43–9.[Abstract]
  15. Stark J. Anomalies of pulmonary venous return. World J Surg 1985;9:532–42.[Medline]

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