Volume 11, Issue 4 , Pages 275-285, Winter 2006
“Lateral” Approach to Surgical Repair of Total Anomalous Pulmonary Venous Return
Article Outline
For the majority of surgically correctable congenital heart lesions, several surgical methods have evolved that satisfactorily address the anatomic and physiologic issues. Most congenital heart surgeons agree that, whereas there may be individual preference for certain favored techniques, the well-prepared surgeon is familiar with alternative strategies which prove useful in differing anatomic/geometric circumstances. For the surgeon familiar with the wide spectrum of anatomic variability of total anomalous pulmonary venous return (TAPVR), this proposition is logical. In this article, the “lateral” surgical approach to repair of TAPVR is described in detail. This viewpoint relates to the author’s experience with surgical repair of TAPVR at Texas Children’s Hospital over the past 12 years involving 129 patients undergoing surgical correction. This method has been the favored technique at Texas Children’s Hospital during this period, although it must be emphasized that there have been anatomic variations encountered that have precluded the lateral approach. In these settings, alternative strategies, as described elsewhere in this issue of the Journal, have been successfully employed.
Patient presentation is quite variable in patients with TAPVR. The spectrum includes preterm, very small neonates with obstructed TAPVR (especially infracardiac) to older, essentially asymptomatic patients. For small babies, we have favored this approach and use median sternotomy and hypothermic cardiopulmonary bypass. We believe that TAPVR is one of the few congenital cardiac conditions for which periods of deep hypothermic circulatory arrest (DHCA) are an important necessity in achieving an optimum repair.
In patients presenting with profound compromise and desaturation, medical therapy is futile. Even the most critical patients require emergent operation. After establishing cardiopulmonary bypass (CPB) (single aortic and atrial cannulation), the ductus is ligated and the patient is gradually cooled to 18°C (nasopharyngeal) over a period of not less than 20 minutes. We favor pH-stat blood gas strategy and utilize the aid of transcranial Doppler and bicortical near-infrared spectroscopy to ensure adequacy of cerebral protection. Repair is facilitated by periods of DHCA interspersed with full CPB support for ideal visualization.
Operative Technique
Figure 1.
(A, B) TAPVR has a wide variety of anatomic presentations in my experience. In supracardiac TAPVR, the vertical vein may be long and ascend ventrally to the left pulmonary artery. These patients are rarely obstructed. The vertical vein may have a more diagonal course, to join the superior vena cava (SVC) or even the azygous vein (B). In some cases, the left superior pulmonary vein enters quite superiorly, immediately adjacent to the confluence with the left innominate vein. We find that, in many cases, the true venous confluence is quite short in transverse dimension. LLPV = left lower pulmonary vein; LUPV = left upper pulmonary vein; RLPV = right lower pulmonary vein; RUPV = right upper pulmonary vein.
Figure 2.
(A, B) The lateral approach to repair of TAPVR takes advantage of the natural association of the vertical vein and venous confluence with the left atrial appendage. In (A), the confluence and ascending vertical vein are seen in posterior relief and the relationship with the atrial appendage is seen. In (B), the atrial appendage is retracted inferiorly, demonstrating the relationship of these structures in anterior relief. (C, D) We believe TAPVR repair is facilitated by several principles. First, the anastomosis between left atrium (LA) and pulmonary confluence is optimized by utilizing the natural anatomic relationship/attitude. Second, we favor using every effort to completely avoid the individual pulmonary veins and their orifices. Third, the vertical vein is a natural conduit that should be used to augment the connection to achieve the widest possible, tension-free anastomosis. Finally, very small sutures are mandatory: we favor 7-0 or 8-0 Prolene. LAA = left atrial appendage.
Figure 3.
(A-C) In supracardiac TAPVR, the vertical vein may ascend between the left pulmonary artery (LPA) and left mainstem bronchus, a situation described as “PA vice,” which will always obstruct. In repairing this variant, we have often divided the ascending vein at its confluence with the innominate vein and then brought the vertical vein anterior to the LPA to facilitate a large anastomosis. (D) Lateral view of an unusual case of PA vice. Echo had predicted a vertical vein anterior to LPA. However, at surgery, the proximal bulbous vertical vein had folded over the LPA, giving the false appearance of an anterior course. This underscores the fact that echo diagnosis of lack of obstruction may be very misleading. LPA = left pulmonary artery; MPA = main pulmonary artery; PA = pulmonary artery.
Figure 4.
Surgical view and cannulation for repair of supracardiac TAPVR. Single aortic and right atrium cannulas in place with traction suture in LA appendage. Patent ductus arteriosus (PDA) ligated/divided. LPA = left pulmonary artery; MPA = main pulmonary artery.
Figure 5.
(A) The lateral approach requires reflection of the cardiac apex to the patient’s right. The LA appendage is retracted superiorly. Inset: Vertical vein divided and brought anterior to LPA. (B) With the heart reflected to the patient’s right, the venous confluence and vertical vein are incised. A corresponding incision is made in the base at the LA appendage (LAA). Inset: Great care is exercised to avoid the individual pulmonary veins. Ao = aorta; IVC = inferior vena cava; LPA = left pulmonary artery; MPA = main pulmonary artery.
Figure 6.
Posterior view of anastomosis between venous confluence/vertical vein and LA. We favor a continuous, fine suture (7-0, 8-0 polypropylene).
Figure 7.
The lateral approach is also suitable for most cases of infracardiac TAPVR. We favor division of the descending vein and utilization of the confluence and vertical vein in the anastomosis as shown. IVC = inferior vena cava; LAA = left atrial appendage.
Figure 8.
(A, B) We have encountered one case of separate descending veins independently draining the right and left lungs as demonstrated. The lateral approach was ideal for this problem—two separate anastomoses were constructed to the LA as demonstrated. Ao = aorta; IA = innominate artery; IVC = inferior vena cava; LA = left atrium; LCC = left common carotid artery; LLPV = left lower pulmonary vein; LSA = left subclavian artery; LUPV = left upper pulmonary vein; RLPV = right lower pulmonary vein; RPV = right pulmonary vein; RUPV = right upper pulmonary vein; SVC = superior vena cava.
Conclusions
Weaning from CPB in patients presenting critically ill with obstructed TAPVR may prove challenging. The left heart is often unprepared and easily overfilled. We prefer both left atrium (LA) and pulmonary artery (PA) monitoring in this setting. The surgeon must be prepared to wean from CPB with low systemic blood pressure to avoid over-distension of the left heart, which is an important stimulus for pulmonary hypertensive crisis. In rare cases, inhaled nitric oxide may be required.
The lateral approach to TAPVR repair utilizes a tissue–tissue connection between all available structures without tension on the individual pulmonary veins. We believe it offers an optimum opportunity for repair in most anatomic settings, and it is our favored method. Surgeons utilizing the transatrial approach preferentially should at least be familiar with the lateral approach for those instances in which the anatomy precludes other methods.
PII: S1522-2942(06)00091-2
doi:10.1053/j.optechstcvs.2006.09.003
© 2006 Elsevier Inc. All rights reserved.
Volume 11, Issue 4 , Pages 275-285, Winter 2006
