“Lateral” Approach to Surgical Repair of Total Anomalous Pulmonary Venous Return

(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.

(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.

(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.

(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.

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.

(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.

Posterior view of anastomosis between venous confluence/vertical vein and LA. We favor a continuous, fine suture (7-0, 8-0 polypropylene).

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.

(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.