Ann Thorac Surg 2005;80:1140-1142
© 2005 The Society of Thoracic Surgeons
How to do it
Modified Septosuperior Approach for the Repair of Supracardiac Total Anomalous Pulmonary Venous Return in Infants
Komarakshi R. Balakrishnan, MD
*
,
Usha Parvathy, MD
Department of Cardiothoracic Surgery, Sri Ramachandra Medical College University Hospital, Chennai, India
Accepted for publication March 25, 2004.
* Address reprint requests to Dr Balakrishnan, Department of Cardiothoracic Surgery, Sri Ramachandra Medical College University Hospital, Porur-Chennai 600116, India. (Email: krbalakrishnan{at}vsnl.com).
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Abstract
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An alternative technique for the repair of supracardiac total anomalous pulmonary venous return (TAPVR) is described. The pulmonary venous confluence (CPV) is identified below the right pulmonary artery between the aorta and superior vena cava. The atrial incisions are similar to a septosuperior approach of the mitral valve, modifying the incision on the roof of the left atrium to be parallel to the incision in the CPV. The common pulmonary vein is anastomosed to the roof of the left atrium. This approach offers optimal exposure for the repair without distorting the cardiac structures.
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Introduction
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Total anomalous pulmonary venous return (TAPVR) is one of the important cardiac lesions necessitating intracardiac repair in the neonatal period. Successful outcome depends on a wide anastomosis between the common pulmonary vein and left atrium (LA) without any anatomical distortion. This report describes our technique for correction of supracardiac TAPVR in 5 infants using the septosuperior approach.
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Technique
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After a median sternotomy, cardiopulmonary bypass is established with aortic and separate right-angled superior vena caval and inferior vena caval cannulation. The vertical vein is identified and looped. The pulmonary venous confluence (CPV) is identified above and behind the left atrium and below the right pulmonary artery. A fine silk tie is placed on the left atrial appendage and retracted to the left to act as a landmark. Using moderate hypothermia and cold cardioplegia, an oblique right atriotomy is made and extended into the roof of the left atrium and downward to the interatrial septum as described in the septosuperior approach of the mitral valve [1] (Fig 1). The lateral extent of the left atrial incision is toward the base of the appendage. The incision in the roof of the atrium is parallel to the proposed incision on the CPV. The aorta is gently retracted to the left. The CPV is opened transversely from the right pulmonary vein to the left pulmonary vein (Fig 2
[top]). The confluence is then anastomosed to the roof of the LA using 6-0 prolene sutures (Fig 2 [bottom], 3). The interatrial septum is either closed directly or with a patch. The right atrium is closed and the rest of the operation is completed in the usual manner. This approach was used in 5 infants. All of them survived the operation and were in sinus rhythm at the time of discharge. All were doing well at follow-up with widely patent anastomosis.
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Fig 1. (A) Oblique incision in the right atrium (RA) extended into the left atrium (LA). (B) Incision downward into the interatrial septum (IAS) and incision into the common pulmonary vein (CPV). (RPA = right pulmonary artery.)
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Fig 2. (A) Opening in the common pulmonary vein, left atrium, and interatrial septum. (B) The first layer of anastomosis between the common pulmonary vein and left atrium.
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Comment
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Several techniques have been described for the repair of supracardiac TAPVR. Each of them possesses a few drawbacks. The technique described by Williams [2] requires the heart to be lifted and retracted with its own attendant problems [3]. Also the initial sutures between the confluence and the LA have to be taken with the two structures far apart, which creates the potential for distortion of the spatial relationship and thus increases the chances of a kink. The technique used by Shuemacker [4] has the advantage of not requiring dislocation of the heart, but the atria need to be retracted leftward and the limits of the left atrium defined from the right is less. An additional disadvantage is the cumbersome nature of the final sutures. Other modifications include the superior approach described by Tucker [5] and the interaorticocaval approach described by Vouhe [6], where the posterior wall of the left atrium and the common pulmonary vein are exposed through the transverse sinus. This approach has limitations with regard to space and exposure in infants and neonates. The modified superior approach [7] overcomes these limitations, but is more complicated as it involves transection of the aorta.
Encouraged by our experience with the septosuperior approach for the mitral valve, we applied this method but with a slight modification regarding the incision on the left atrial roof. This helped achieve a wide anastomosis without any need for dislocation of the heart or risk of distortion. Only a slight retraction on the aorta is required to achieve optimal exposure for both the surgeon and the assistant. Additionally, separate caval cannulation ensures a bloodless field without the need for circulatory arrest. The SVC cannulation is easy because the superior vena cava is dilated in supracardiac TAPVR. An additional advantage is that, if required, associated intracardiac lesions can be managed using the same incision. This approach is ideal when the CPV is above and behind the LA—information easily ascertained by echocardiography. A possible criticism concerning this approach involves the risk of injury to the sinus node artery potentially causing atrial arrhythmias. All 5 infants in our series were in sinus rhythm after surgery.
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References
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- Smith CR. Septal-superior exposure of the mitral valve J Thorac Cardiovasc Surg 1992;103:623-628.[Abstract]
- Williams GR, Richardson WR, Campbell GS. Repair of total anomalous pulmonary venous drainage in infancy J Thorac Cardiovasc Surg 1964;47:199-205.
- Wilson WR, Ilbawi MN, DeLeon SY, et al. Technical modifications for improved results in total anomalous pulmonary venous drainage J Thorac Cardiovasc Surg 1992;103:861-871.[Abstract]
- Shuemacker Jr HB, King H. A modified procedure for complete repair of total anomalous pulmonary venous drainage Surg Gynecol Obstet 1961;112:763-765.
- Tucker BL, Lindesmith GG, 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]
- Vouhe P, Neveux JY, Bical O, Leca F. Surgical treatment of total abnormal pulmonary venous return. Value of the interaortico-caval approach Press Med 1984;13:2143-2145.
- Serraf A, Belli E, Roux D, Souza-Uva M, Lacour-Gayet F, 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]
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Abstract
Introduction
