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Inferior Vena Cava Division to Access Post-Repair Pulmonary Venous Obstruction
Inferior Vena Cava Division to Access Post-Repair Pulmonary Venous Obstruction Mark W. Robertson, BS, David Liu, MD, and Camille L. Hancock Friesen, MD Division of Pediatric Cardiac Surgery, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
FEATURE ARTICLES
Post-repair pulmonary venous obstruction is a complication that may occur after surgical repair of total anomalous pulmonary veins. Obstruction may occur at the site of surgical anastomosis or it may be intrinsic to the pulmonary veins. The optimal approach to post-repair pulmonary venous obstruction remains controversial because of high mortality rates and persistent risk of re-stenosis. We present a previously unde-
scribed, inferior approach to anastomotic post-repair pulmonary venous obstruction. This approach allowed easy access and excellent visualization of the pulmonary confluence. Three years after the reoperation, the patient had a widely patent confluence-to-left atrial anastomosis. (Ann Thorac Surg 2010;89:1310–1) © 2010 by The Society of Thoracic Surgeons
A
riorly and extracardiac, medial to the superior vena cava. A 2-cm defect was made in the anterior wall of the pulmonary venous confluence with a matching left atriotomy and a side-to-side anastomosis was constructed with running 7-0 Prolene (Ethicon, Somerville, NJ). The ventricular septal defect was repaired through a transatrial approach, with a Dacron patch (IMPRA, Tempe, AZ). The atrial septal defect was repaired primarily. After repair, the mean echocardiographic gradient across the anastomosis was 2.1 mm Hg. She convalesced uneventfully and was discharged 30 days postoperatively. On routine follow-up, 5 months postoperatively, the patient presented with a palpable thrill at the lower left sternal border, a right ventricular heave, a widely split S2, and a 2/6 systolic murmur at the lower left sternal border. Transthoracic echocardiogram revealed anastomotic obstruction with peak and mean gradients of 27 mm Hg and 14 mm Hg, respectively. Right ventricular function was preserved. There was minimal pulmonary regurgitation and a small ventricular septal defect patch leak (left ⬎ right shunting). Right ventricular pressure was estimated by tricuspid regurgitant jet to be systemic. She had 3⫹ tricuspid regurgitation, right ventricular hypertrophy, and diastolic flattening of the septum, all consistent with pulmonary arterial hypertension secondary to post-repair pulmonary venous obstruction. Magnetic resonance imaging revealed the confluence, and native pulmonary veins were of good size. An anastomotic suture line narrowing was noted (Figs 1A, 1B), but there was no evidence of intrinsic pulmonary venous stenosis remote to the anastomosis. The patient was taken to the operating room for revision of post-repair pulmonary venous obstruction. Cardiopulmonary bypass was initiated using standard bi-caval and aortic cannulation. The heart was arrested with standard cardioplegia, and body temperature was reduced to a nadir of 20°C. The heart was fully mobilized, as were the aorta and pulmonary arteries. Dense fibrous adhesions prevented effective access to the pulmonary confluence and posterior wall of the LA through a superior approach. To access the anastomosis, the inferior vena cava (IVC) was divided so the heart could be everted to provide direct access to the confluence. With the apex of the heart everted toward to the left shoulder, the entire confluence and the
serious complication of total anomalous pulmonary venous connection is post-repair pulmonary venous obstruction, which occurs in 0 to 18% of neonatal cases [1] and is associated with a mortality rate of 24% [2]. Post-repair obstruction occurs as either anastomotic stricture or intrinsic pulmonary vein stenosis with similar frequency [2]. The optimal surgical approach to postrepair pulmonary venous obstruction is yet to be determined because of the ongoing risk of re-stenosis. In this report, we present a previously undescribed inferior approach to accessing the pulmonary venous confluenceto-left atrial anastomosis in an infant with anastomotic post-repair pulmonary venous obstruction.
Technique A 2-month-old infant girl presented with tachypnea, respiratory distress with feedings, and mild failure to thrive (weight, 3.5 kg; ⬍ third percentile). On physical examination, the patient’s O2 saturation was 88% on air, heart rate was 152 per minute, blood pressure was 104/60 mm Hg, and respiratory rate was 60 breaths per minute. There was a loud S2 and 2/6 systolic murmur, loudest at the lower left sternal border. Transthoracic echocardiogram revealed obstructed supracardiac total anomalous pulmonary venous connection with a mean gradient of 6 mm Hg at the vertical vein to innominate vein connection, a secundum atrial septal defect, a membranous ventricular septal defect, and a small left atrium (LA) with a 9-mm mitral valve annulus (Z score, ⫺3). She was taken to the operating room and underwent an extracardiac approach to repair of total anomalous pulmonary venous connection. Cardiopulmonary bypass was initiated with aortic and bi-caval cannulation. The aorta was cross clamped, and high potassium, cold blood cardioplegia was administered. The patient’s temperature was reduced to a nadir of 24°C. The pulmonary venous confluence was approached supeAccepted for publication June 9, 2009. Address correspondence to Dr Hancock Friesen, Ste 2269, Halifax Infirmary, 1796 Summer St, Halifax, Nova Scotia, B3H 3A7, Canada; e-mail: [email protected].
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/10/$36.00 doi:10.1016/j.athoracsur.2009.06.076
Ann Thorac Surg 2010;89:1310 –1
HOW TO DO IT ROBERTSON ET AL ACCESS TO TAPVC ANASTOMOTIC STRICTURE
1311
Fig 1. Magnetic resonance images of post-repair anastomotic narrowing. Note the narrow pulmonary confluence-to-left atrial anastomosis (thinner, white arrowheads). (A) Coronal section. (B) Axial section. (CPV ⫽ confluence of pulmonary veins; LA ⫽ left atrium.)
Hg) and an unobstructed IVC. She was discharged 6 days postoperatively. Three years after reoperation, the patient is well with echocardiographic follow-up revealing normal pulmonary artery pressures, laminar pulmonary venous flow with no significant gradient from the pulmonary venous confluence into the LA, and an unobstructed IVC.
Comment Various techniques have been described to approach post-repair pulmonary venous obstruction. The inferior approach with IVC division is a novel approach and represents an alternative method of accessing the pulmonary venous confluence. Division of the IVC afforded visualization of an anastomosis that was inaccessible by any other approach. Using this technique, the spatial relationship between the pulmonary venous confluence and the LA was minimally disturbed when the heart was everted, thus facilitating the creation of a widely patent anastomosis. In addition, the posterior pericardium is undisturbed by this technique, and is available for use if a sutureless technique should be required. Inferior vena cava division adds a small risk of postoperative IVC obstruction. We believe this risk is minimal; however, close follow-up is important to detect this complication. The inferior approach with IVC division permits excellent visualization of the pulmonary confluence and should be considered as an alternative to access the anastomotic site when approaching post-repair pulmonary venous obstruction.
We thank Medical Illustrator Kevin Millar, MS, CMI.
References
Fig 2. Illustration of pulmonary venous confluence-to-left atrial anastomosis viewed with the IVC divided and the heart everted. (CPV ⫽ confluence of pulmonary veins; IVC ⫽ inferior vena cava; LA ⫽ left atrium; SVC ⫽ superior vena cava.)
1. van de Wal HJCM, Hamilton DI, Godman MJ, Harinck E, Lacquet LK, van Oort A. Pulmonary venous obstruction following correction for total anomalous pulmonary venous drainage: a challenge. Eur J Cardiothorac Surg 1992;6:545–9. 2. Hancock Friesen CL, Zurakowski D, Thiagarajan RR, et al. Total anomalous pulmonary venous connection: an analysis of current management strategies in a single institution. Ann Thorac Surg 2005;79:596 – 606.
FEATURE ARTICLES
posterior wall of the LA were well visualized (Fig 2). A lateral right atriotomy was also performed, and the atrial septum was incised, allowing transatrial visualization of the scar tissue causing the anastomotic stricture. The previous anastomosis was taken down, and the original incision in the confluence was lengthened to 2 cm. The incision in the posterior wall of the LA was equally widened, and an anastomosis was re-created between the pulmonary venous confluence and LA using a running, intermittently locking 7-0 Prolene (Ethicon, Somerville, NJ). The atrial septal defect was patched with a redundant patch of bovine pericardium, and the ventricular septal defect patch leak was repaired with a single suture. The atriotomy was then closed and the IVC was reapproximated to the right atrial junction with a running continuous 6-0 Prolene (Ethicon, Somerville, NJ). Total cross-clamp time was 193 minutes. Bypass time was 272 minutes. The patient weaned cardiopulmonary bypass on 7.5 mcg/kg/min of dopamine. Transthoracic echocardiogram revealed a patent pulmonary confluence-to-left atrial anastomosis (mean gradient, 1.2 mm
FEATURE ARTICLES
Post-repair pulmonary venous obstruction is a complication that may occur after surgical repair of total anomalous pulmonary veins. Obstruction may occur at the site of surgical anastomosis or it may be intrinsic to the pulmonary veins. The optimal approach to post-repair pulmonary venous obstruction remains controversial because of high mortality rates and persistent risk of re-stenosis. We present a previously unde-
scribed, inferior approach to anastomotic post-repair pulmonary venous obstruction. This approach allowed easy access and excellent visualization of the pulmonary confluence. Three years after the reoperation, the patient had a widely patent confluence-to-left atrial anastomosis. (Ann Thorac Surg 2010;89:1310–1) © 2010 by The Society of Thoracic Surgeons
A
riorly and extracardiac, medial to the superior vena cava. A 2-cm defect was made in the anterior wall of the pulmonary venous confluence with a matching left atriotomy and a side-to-side anastomosis was constructed with running 7-0 Prolene (Ethicon, Somerville, NJ). The ventricular septal defect was repaired through a transatrial approach, with a Dacron patch (IMPRA, Tempe, AZ). The atrial septal defect was repaired primarily. After repair, the mean echocardiographic gradient across the anastomosis was 2.1 mm Hg. She convalesced uneventfully and was discharged 30 days postoperatively. On routine follow-up, 5 months postoperatively, the patient presented with a palpable thrill at the lower left sternal border, a right ventricular heave, a widely split S2, and a 2/6 systolic murmur at the lower left sternal border. Transthoracic echocardiogram revealed anastomotic obstruction with peak and mean gradients of 27 mm Hg and 14 mm Hg, respectively. Right ventricular function was preserved. There was minimal pulmonary regurgitation and a small ventricular septal defect patch leak (left ⬎ right shunting). Right ventricular pressure was estimated by tricuspid regurgitant jet to be systemic. She had 3⫹ tricuspid regurgitation, right ventricular hypertrophy, and diastolic flattening of the septum, all consistent with pulmonary arterial hypertension secondary to post-repair pulmonary venous obstruction. Magnetic resonance imaging revealed the confluence, and native pulmonary veins were of good size. An anastomotic suture line narrowing was noted (Figs 1A, 1B), but there was no evidence of intrinsic pulmonary venous stenosis remote to the anastomosis. The patient was taken to the operating room for revision of post-repair pulmonary venous obstruction. Cardiopulmonary bypass was initiated using standard bi-caval and aortic cannulation. The heart was arrested with standard cardioplegia, and body temperature was reduced to a nadir of 20°C. The heart was fully mobilized, as were the aorta and pulmonary arteries. Dense fibrous adhesions prevented effective access to the pulmonary confluence and posterior wall of the LA through a superior approach. To access the anastomosis, the inferior vena cava (IVC) was divided so the heart could be everted to provide direct access to the confluence. With the apex of the heart everted toward to the left shoulder, the entire confluence and the
serious complication of total anomalous pulmonary venous connection is post-repair pulmonary venous obstruction, which occurs in 0 to 18% of neonatal cases [1] and is associated with a mortality rate of 24% [2]. Post-repair obstruction occurs as either anastomotic stricture or intrinsic pulmonary vein stenosis with similar frequency [2]. The optimal surgical approach to postrepair pulmonary venous obstruction is yet to be determined because of the ongoing risk of re-stenosis. In this report, we present a previously undescribed inferior approach to accessing the pulmonary venous confluenceto-left atrial anastomosis in an infant with anastomotic post-repair pulmonary venous obstruction.
Technique A 2-month-old infant girl presented with tachypnea, respiratory distress with feedings, and mild failure to thrive (weight, 3.5 kg; ⬍ third percentile). On physical examination, the patient’s O2 saturation was 88% on air, heart rate was 152 per minute, blood pressure was 104/60 mm Hg, and respiratory rate was 60 breaths per minute. There was a loud S2 and 2/6 systolic murmur, loudest at the lower left sternal border. Transthoracic echocardiogram revealed obstructed supracardiac total anomalous pulmonary venous connection with a mean gradient of 6 mm Hg at the vertical vein to innominate vein connection, a secundum atrial septal defect, a membranous ventricular septal defect, and a small left atrium (LA) with a 9-mm mitral valve annulus (Z score, ⫺3). She was taken to the operating room and underwent an extracardiac approach to repair of total anomalous pulmonary venous connection. Cardiopulmonary bypass was initiated with aortic and bi-caval cannulation. The aorta was cross clamped, and high potassium, cold blood cardioplegia was administered. The patient’s temperature was reduced to a nadir of 24°C. The pulmonary venous confluence was approached supeAccepted for publication June 9, 2009. Address correspondence to Dr Hancock Friesen, Ste 2269, Halifax Infirmary, 1796 Summer St, Halifax, Nova Scotia, B3H 3A7, Canada; e-mail: [email protected].
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/10/$36.00 doi:10.1016/j.athoracsur.2009.06.076
Ann Thorac Surg 2010;89:1310 –1
HOW TO DO IT ROBERTSON ET AL ACCESS TO TAPVC ANASTOMOTIC STRICTURE
1311
Fig 1. Magnetic resonance images of post-repair anastomotic narrowing. Note the narrow pulmonary confluence-to-left atrial anastomosis (thinner, white arrowheads). (A) Coronal section. (B) Axial section. (CPV ⫽ confluence of pulmonary veins; LA ⫽ left atrium.)
Hg) and an unobstructed IVC. She was discharged 6 days postoperatively. Three years after reoperation, the patient is well with echocardiographic follow-up revealing normal pulmonary artery pressures, laminar pulmonary venous flow with no significant gradient from the pulmonary venous confluence into the LA, and an unobstructed IVC.
Comment Various techniques have been described to approach post-repair pulmonary venous obstruction. The inferior approach with IVC division is a novel approach and represents an alternative method of accessing the pulmonary venous confluence. Division of the IVC afforded visualization of an anastomosis that was inaccessible by any other approach. Using this technique, the spatial relationship between the pulmonary venous confluence and the LA was minimally disturbed when the heart was everted, thus facilitating the creation of a widely patent anastomosis. In addition, the posterior pericardium is undisturbed by this technique, and is available for use if a sutureless technique should be required. Inferior vena cava division adds a small risk of postoperative IVC obstruction. We believe this risk is minimal; however, close follow-up is important to detect this complication. The inferior approach with IVC division permits excellent visualization of the pulmonary confluence and should be considered as an alternative to access the anastomotic site when approaching post-repair pulmonary venous obstruction.
We thank Medical Illustrator Kevin Millar, MS, CMI.
References
Fig 2. Illustration of pulmonary venous confluence-to-left atrial anastomosis viewed with the IVC divided and the heart everted. (CPV ⫽ confluence of pulmonary veins; IVC ⫽ inferior vena cava; LA ⫽ left atrium; SVC ⫽ superior vena cava.)
1. van de Wal HJCM, Hamilton DI, Godman MJ, Harinck E, Lacquet LK, van Oort A. Pulmonary venous obstruction following correction for total anomalous pulmonary venous drainage: a challenge. Eur J Cardiothorac Surg 1992;6:545–9. 2. Hancock Friesen CL, Zurakowski D, Thiagarajan RR, et al. Total anomalous pulmonary venous connection: an analysis of current management strategies in a single institution. Ann Thorac Surg 2005;79:596 – 606.
FEATURE ARTICLES
posterior wall of the LA were well visualized (Fig 2). A lateral right atriotomy was also performed, and the atrial septum was incised, allowing transatrial visualization of the scar tissue causing the anastomotic stricture. The previous anastomosis was taken down, and the original incision in the confluence was lengthened to 2 cm. The incision in the posterior wall of the LA was equally widened, and an anastomosis was re-created between the pulmonary venous confluence and LA using a running, intermittently locking 7-0 Prolene (Ethicon, Somerville, NJ). The atrial septal defect was patched with a redundant patch of bovine pericardium, and the ventricular septal defect patch leak was repaired with a single suture. The atriotomy was then closed and the IVC was reapproximated to the right atrial junction with a running continuous 6-0 Prolene (Ethicon, Somerville, NJ). Total cross-clamp time was 193 minutes. Bypass time was 272 minutes. The patient weaned cardiopulmonary bypass on 7.5 mcg/kg/min of dopamine. Transthoracic echocardiogram revealed a patent pulmonary confluence-to-left atrial anastomosis (mean gradient, 1.2 mm