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Rotation-advancement flap method for correction of partial anomalous pulmonary venous drainage into the superior vena cava
J THORAC
CARDIOVASC SURG
1990;99:308-11
Rotation-advancement flap method for correction of partial anomalous pulmonary venous drainage into the superior vena cava Three patients with partial anolllll1olti pulmonary v~ drainage into the superior vena cava underwent repair by a rotation-advancement flap method. The technique c()IL4listed of atrial partitioning, enlargement of the superior vena cava, and protection of sinus node function. Follow-up studies of aU patients were done between 12 and 15 months after the operation. The superior vena cava was not stenosed and its diameter was normal, as demonstrated by cavograD& Pulmonary venous return appeared normal on angiogntIm, and sinus node function was normal by electropbysiologic studies.
Hideo Okabe, MD, Hitoshi Matsunaga, MD, Motohiro Kawauchi, MD, Akihiko Sekiguchi, MD, Yoshihiro Naruse, MD, Osamu Tanaka, MD, Kimihiro Tanaka, MD, Jun Nakajima, MD, Kazuhiko Higuchi, MD, and Akira Furuse, MD, Tokyo. Japan
In 1956, Kirklin, Ellis, and Wood1 described a technique to repairpartial anomalous pulmonary venous connection to the superiorvenacava.The principal complications after the repairof thisanomalyhavebeenobstruction to the superiorvena cava and chronicatrial arrhythmias.This communication describes a rotation-advancement flap techniquethat was developed to obviate these complications. Patients and methods Three patients were operated on by this technique (Fig. 1). Their ages ranged from 6 to 22 years. In each patient, the branches of the right superior pulmonary vein drained into the superior vena cava above its junction with the right atrium. Two patients had an atrial septal defect of the sinus venosus type, one of whom had only a patent foramen ovale. Two patients had associated persistent left superior vena cava (Table I). Surgical procedure. The heart is exposed through a median sternotomy, the pericardium is opened, and the superior vena cava is dissected free from the pericardium up to the level of the Fromthe DepartmentofThoracicSurgery,UniversityofTokyo, Tokyo, Japan 113. Received for publication Oct. 6, 1988. Accepted for publication March 13, 1989. Address for reprints: HideoOkabe, MD, Departmentof ThoracicSurgery, Tokyo University, 7-3-1, Hongo Bunkyo-Ku, Tokyo, Japan 113.
12/1/13087
308
innominate vein. The azygos vein is temporarily occluded by being encircled with a heavy silk thread. The superior vena cava is cannulated first through the atrial appendage. The inferior vena caval cannula is then inserted through the low right atrium in the usual fashion. The operation is performed with moderate hypothermia at 27° C and induced ventricular fibrillation without crossclamping of the aorta. After the caval snares are secured tightly, the purse-string suture around the cannula on the atrial appendage is cut, and an incision is made superiorly along the crest of the appendage. It is extended onto the anterolateral wall of the superior vena cava up to the level of the most superior anomalous pulmonary vein, where it is curved laterally to open the anterior wall of the superior vena cava (Fig. 1, A). The superior caval cannula is retracted upward, to provide wide exposure of the ostium of the anomalous pulmonary vein draining into the superior vena cava (Fig. 1, B). The incision is also extended inferiorly to the center of the right atrium. When the interatrial communication is small, a large atrial septal defect is created. A sheet of 0.2 mm expanded polytetrafluoroethylene* is sutured so that the anomalous pulmonary venous blood is directed into the left atrium through the septal defect (Fig. 1, C). Since the lateral suture line comes close to the sinus node at the cavoatrial junction, shallow bites are taken around this vulnerable area. The cavoatrial channel is repaired by rotation-advancement of the right atrial wall. The lateral wall of the right atrium is used as a flap to widen the anterior wall of the superior vena cava (Fig. 1, C and D). *Gore-Tex vasculargraft, registered trade mark of W. L. Gore & Associates, Inc., Elkton, Md.
Volume 99 Number 2
PAPVD
February 1990
Results
[6J
The postoperative course was uneventful in all three patients, and follow-up studies were conducted 12 to 15 months after the operation. All patients were clinically free of symptoms and none had an audible cardiac murmur. On chest roentgenogram, pulmonary vascular markings and cardiothoracic ratio had diminished significantly. On electrocardiogram, right ventricular hypertrophy and right axis deviation had decreased. All patients had regular sinus rhythm. Sinus node function was assessed electrophysiologically. Sinoatrial conduction time and corrected sinus node recovery time were within normal limits (Table II). Right heart catheterization and angiograms were performed on all patients. There were no residual shunts, and the intracardiac pressure was within normal limits (Table
)
b
309
f~' a~
c d
III). The diameter of the new atriocaval tunnel was adequate, and the new pulmonary venous channel was of good size (Fig. 2). Discussion
e
Basically, the repair of this anomaly consists of rerouting the pulmonary venous blood and constructing an unobstructed superior venous channel. The pulmonary venous tunnel may be created either by an autologous atrial baffle or by a patch made of one of several materials. The superiority of the former technique has not been established, because late occurrence of pulmonary venous obstruction has been extremely rare even with the use of a patch. With regard to the construction of the atriocaval channel, however, various surgical procedures have been described. The principal complications of the repair of this anomaly-caval obstruction and atrial arrhythmias-are related to this particular part of the procedure. Atriocavoplasty is most appealing as a means of avoiding superior vena caval obstruction, because it obviates cavoatrial reanastomosis or the use of a foreign material. Some surgeons transect the superior vena cava above the uppermost anomalous vein and then anastomose it with
SN : Sinus node
Fig. 1. Surgical technique. A, Atriotomy. A purse-string suture around the superior caval cannula is cut. The incision is made on the crest of the right atrial appendage (d-e) and then on the anterolateral wall of the superior vena cava (c-b}, curving laterally on the anterior wall of the superior vena cava above the level of the anomalous pulmonary vein (b-a). The incision is also extended inferolaterally (d-e). B, Rerouting. A patch of thin polytetrafluoroethylene is placed to connect the orifice of the anomalous pulmonary vein with the atrial septal defect. Note that the lateral suture line comes very close to the inferior of the sinus node. Shallow bites are taken around this vulnerable area. C, Atriocaval plasty. A right atrial flap is used to widen the atriocaval channel. Points a-a", b-b", and c-c" are approximated for rotation-advancement of the flap. D, Completed repair. SN, Sinus node.
Table I. Patient profiles Case
Age (yr)
I
23
2
6
3
7
Sex
Diagnosis (site of PV drainage)
Associated anomaly
F M F
PAPVR (RPV-SVC) PAPVR (RPV-SVC) PAPVR (RPV-SVC)
PFO, PLSVC ASD, PLSVC ASD
PV. Pulmonary venous; PAPVR, partial anomalous pulmonary venous return; RPV, right pulmonary vein; SVC, superior vena cava; PFO, patent foramen ovale; PLSVC. persistent left superior vena cava; ASD, atrial septal defect.
The Journal of
3 10
Thoracic and Cardiovascular Surgery
Okabe et al.
Table II. Postoperative sinus node function SACT
Case I
Case 2
Case 3
220
167
183
380
200
260
(msec) CSRT
(msec) SCAT. Sinoatrial conduction time; CSRT. corrected sinus node recovery time. Normal range (Nanula 2) : SACT, 201 ± 77 msec; CSRT, 110 ± 525 msec.
Table III. Summary of hemodynamic data Preoperative PAP (nun Hg) RAP (nun Hg) Qp/Qs Postoperative PAP (nun Hg) RAP (nun Hg) SVC pressure (nun Hg)
Case I
Case 2
Case 3
30/10 (18) 7.5/0 (3.5)
38/20 (27) a=8 v = 8 (6)
42/18 (32) a=6 v = 5 (3)
2.75
1.83
2.46
25/10 (15) a=8 v = 6 (6)
28/12 (18) a=4 v = 5 (5)
25/12 (15) a=5 v = 6 (6)
(6)
(5)
(6)
PAP, pulmonaryartery pressure;RAP, right atrial pressure;Qp/Qs, pulmonaryto-systemic bloodflow ratio; SVC, superiorvena cava. Figuresin parenthesesare mean values.
.I
Fig. 2. Case 1. Postoperative angiograms of a 23-year-old woman.
Table IV. Atriocavoplasty First author Chartrand?
Atrial incision
Most cranial caval incision
Atriocavoplasty
Rerouting
Anterior
Vertical
On lay advancement
Atrial baffle
Anterior
Oblique
Z plasty
Atrial baffle
Lateral Medial
Vertical Horizontal
V-V plasty Rotation-advancement
Atrial baffle Atrial baffle
Cooley" Gerbode? Lewin,'? Stark!' Kirklin'? Okabe
the right atrial appendage.r" The pulmonary venous drainage is rerouted by an intraatrial baffle, However, cavoatrial reanastomosis may result in late stricture. At this time, no suitable prosthesis is available for reconstruction of the vena cava. Even autologous pericardium may shrink late postoperatively. Patients with this anomaly havean enlarged right atrium that issuitablefor flap atriocavoplasty. Onlay advancement plasty of the right atrial appendage,": 8 Z plasty of the right atrium,?"! and V-Yplastyofthe right atrium 12 havealso been proposed (Table IV).
The incision on the right atrium is of paramount importance in the atriocavoplasty, As has been pointed out by Kyger and associates13 and Stark and de Leval;' any method necessitatinglateral right atriotomy between the sinus nodeand interatrial groovecarries a high riskof damaging the sinus node, because the sinus node is locatedin the lateral wallof the atriocavaljunction. In the current technique, we therefore incised the anterolateral wallof the atriocavaljunction. Evenin this method,there is a possibility of injuring the sinusnodeartery, especially at the pointwhereit arisesfrom the right coronaryartery.
Volume 99 Number 2
PAPVD
February 1990
The fact that sinus node function was not depressed postoperatively in any of the patients in this series is highly encouraging. This may be related to the collateral supply of the sinus node in humans. Consideration should also be given to the most cranial part of the incision in the superior vena cava. When the incision is vertical at this location, some degree of stenosis of the cava because of the suture bites is unavoidable at the summit of the suture line. This may not be a problem when the superior vena cava is wide, but when it is narrow, especially with persistent left superior vena cava, late stenosis may develop at the site of caval anastomosis'? To circumvent this problem, we added a horizontal incision at the summit of the caval incision. In two patients with persistent left superior vena cava operated on by the current method, no obstruction was detected by the postoperative angiogram. This new rotation-advancement flap method is a simple procedure for repair of partial anomalous pulmonary venous drainage into the superior vena cava and has good early results. REFERENCES I. Kirklin JW, Ellis FH Jr, Wood EH. Treatment of anomalous pulmonary venous connections in association with interatrial communications. Surgery 1956;39:389-98. 2. Nanula OS. Cardiac arrhythmias, electrophysiology,diagnosis and management. In: Clinical and electrophysiological evaluation of sinus node function. Baltimore: Williams & Wilkins, 1980:176. 3. Long DM, Rios MV, Elias DO, et al. Parietal and septal atrioplasty for total correction of anomalous pulmonary
4.
5. 6.
7.
8. 9.
10.
II.
12.
13.
311
venous connection with superior vena cava. Ann Thorac Surg 1974;18:466-71. Ehrenhaft JL, Theilen EO, Lawrence MS. The surgical treatment of partial and total anomalous pulmonary venous connections. Ann Surg 1958;148:249-58. Groves LK. Correction of anomalous pulmonary venous drainage into the superior vena cava. Ann Thorac Surg 1967;4:301-7. Williams WH, Zorn-Chelton S, Raviele AA, et al. Extracardiac atrial pedicle conduit repair of partial anomalous pulmonary venous connection to the superior vena cava in children. Ann Thorac Surg 1984;38:345-55. Chartrand C, Payot M, Davignon A, Guerin R, Stanley P. A new surgical approach for correction of partial anomalous pulmonary venous drainage into the superior vena cava. J THORAC CARDIOVASC SURG 1976;71:29-34. Cooley DA. Repair of sinus venosus defect. In: Techniques in cardiac surgery. Philadelphia: WB Saunders, 1983:110. Gerbode F, Carr I. Defects of the atrial septum. In: Cardiac surgery I. Vol. 3. Cardiovascular clinics. Philadelphia: FA Davis, 1971:130. Lewin AN, Zavanella C, Subramanian S. Sinus venosus atrial defect associated with partial anomalous pulmonary venous drainage: surgical repair. Ann Thorac Surg 1978; 26:185-8. Stark J, de Leval M. Partial anomalous pulmonary venous drainage into superior vena cava. In: Surgery for congenital heart defects. New York: Grone & Stratton, 1983:264. Kirklin JW, Barratt-Boyes BG. Cardiac surgery, atrioseptal defect, and partial anomalous pulmonary venous connection. New York: John Wiley, 1986. Kyger ER III, Frazier OH, Cooley DA, et al. Sinus venosus atrial septal defect: early and late results following closure in 109 patients. Ann Thorac Surg 1978;25:44-50.
CARDIOVASC SURG
1990;99:308-11
Rotation-advancement flap method for correction of partial anomalous pulmonary venous drainage into the superior vena cava Three patients with partial anolllll1olti pulmonary v~ drainage into the superior vena cava underwent repair by a rotation-advancement flap method. The technique c()IL4listed of atrial partitioning, enlargement of the superior vena cava, and protection of sinus node function. Follow-up studies of aU patients were done between 12 and 15 months after the operation. The superior vena cava was not stenosed and its diameter was normal, as demonstrated by cavograD& Pulmonary venous return appeared normal on angiogntIm, and sinus node function was normal by electropbysiologic studies.
Hideo Okabe, MD, Hitoshi Matsunaga, MD, Motohiro Kawauchi, MD, Akihiko Sekiguchi, MD, Yoshihiro Naruse, MD, Osamu Tanaka, MD, Kimihiro Tanaka, MD, Jun Nakajima, MD, Kazuhiko Higuchi, MD, and Akira Furuse, MD, Tokyo. Japan
In 1956, Kirklin, Ellis, and Wood1 described a technique to repairpartial anomalous pulmonary venous connection to the superiorvenacava.The principal complications after the repairof thisanomalyhavebeenobstruction to the superiorvena cava and chronicatrial arrhythmias.This communication describes a rotation-advancement flap techniquethat was developed to obviate these complications. Patients and methods Three patients were operated on by this technique (Fig. 1). Their ages ranged from 6 to 22 years. In each patient, the branches of the right superior pulmonary vein drained into the superior vena cava above its junction with the right atrium. Two patients had an atrial septal defect of the sinus venosus type, one of whom had only a patent foramen ovale. Two patients had associated persistent left superior vena cava (Table I). Surgical procedure. The heart is exposed through a median sternotomy, the pericardium is opened, and the superior vena cava is dissected free from the pericardium up to the level of the Fromthe DepartmentofThoracicSurgery,UniversityofTokyo, Tokyo, Japan 113. Received for publication Oct. 6, 1988. Accepted for publication March 13, 1989. Address for reprints: HideoOkabe, MD, Departmentof ThoracicSurgery, Tokyo University, 7-3-1, Hongo Bunkyo-Ku, Tokyo, Japan 113.
12/1/13087
308
innominate vein. The azygos vein is temporarily occluded by being encircled with a heavy silk thread. The superior vena cava is cannulated first through the atrial appendage. The inferior vena caval cannula is then inserted through the low right atrium in the usual fashion. The operation is performed with moderate hypothermia at 27° C and induced ventricular fibrillation without crossclamping of the aorta. After the caval snares are secured tightly, the purse-string suture around the cannula on the atrial appendage is cut, and an incision is made superiorly along the crest of the appendage. It is extended onto the anterolateral wall of the superior vena cava up to the level of the most superior anomalous pulmonary vein, where it is curved laterally to open the anterior wall of the superior vena cava (Fig. 1, A). The superior caval cannula is retracted upward, to provide wide exposure of the ostium of the anomalous pulmonary vein draining into the superior vena cava (Fig. 1, B). The incision is also extended inferiorly to the center of the right atrium. When the interatrial communication is small, a large atrial septal defect is created. A sheet of 0.2 mm expanded polytetrafluoroethylene* is sutured so that the anomalous pulmonary venous blood is directed into the left atrium through the septal defect (Fig. 1, C). Since the lateral suture line comes close to the sinus node at the cavoatrial junction, shallow bites are taken around this vulnerable area. The cavoatrial channel is repaired by rotation-advancement of the right atrial wall. The lateral wall of the right atrium is used as a flap to widen the anterior wall of the superior vena cava (Fig. 1, C and D). *Gore-Tex vasculargraft, registered trade mark of W. L. Gore & Associates, Inc., Elkton, Md.
Volume 99 Number 2
PAPVD
February 1990
Results
[6J
The postoperative course was uneventful in all three patients, and follow-up studies were conducted 12 to 15 months after the operation. All patients were clinically free of symptoms and none had an audible cardiac murmur. On chest roentgenogram, pulmonary vascular markings and cardiothoracic ratio had diminished significantly. On electrocardiogram, right ventricular hypertrophy and right axis deviation had decreased. All patients had regular sinus rhythm. Sinus node function was assessed electrophysiologically. Sinoatrial conduction time and corrected sinus node recovery time were within normal limits (Table II). Right heart catheterization and angiograms were performed on all patients. There were no residual shunts, and the intracardiac pressure was within normal limits (Table
)
b
309
f~' a~
c d
III). The diameter of the new atriocaval tunnel was adequate, and the new pulmonary venous channel was of good size (Fig. 2). Discussion
e
Basically, the repair of this anomaly consists of rerouting the pulmonary venous blood and constructing an unobstructed superior venous channel. The pulmonary venous tunnel may be created either by an autologous atrial baffle or by a patch made of one of several materials. The superiority of the former technique has not been established, because late occurrence of pulmonary venous obstruction has been extremely rare even with the use of a patch. With regard to the construction of the atriocaval channel, however, various surgical procedures have been described. The principal complications of the repair of this anomaly-caval obstruction and atrial arrhythmias-are related to this particular part of the procedure. Atriocavoplasty is most appealing as a means of avoiding superior vena caval obstruction, because it obviates cavoatrial reanastomosis or the use of a foreign material. Some surgeons transect the superior vena cava above the uppermost anomalous vein and then anastomose it with
SN : Sinus node
Fig. 1. Surgical technique. A, Atriotomy. A purse-string suture around the superior caval cannula is cut. The incision is made on the crest of the right atrial appendage (d-e) and then on the anterolateral wall of the superior vena cava (c-b}, curving laterally on the anterior wall of the superior vena cava above the level of the anomalous pulmonary vein (b-a). The incision is also extended inferolaterally (d-e). B, Rerouting. A patch of thin polytetrafluoroethylene is placed to connect the orifice of the anomalous pulmonary vein with the atrial septal defect. Note that the lateral suture line comes very close to the inferior of the sinus node. Shallow bites are taken around this vulnerable area. C, Atriocaval plasty. A right atrial flap is used to widen the atriocaval channel. Points a-a", b-b", and c-c" are approximated for rotation-advancement of the flap. D, Completed repair. SN, Sinus node.
Table I. Patient profiles Case
Age (yr)
I
23
2
6
3
7
Sex
Diagnosis (site of PV drainage)
Associated anomaly
F M F
PAPVR (RPV-SVC) PAPVR (RPV-SVC) PAPVR (RPV-SVC)
PFO, PLSVC ASD, PLSVC ASD
PV. Pulmonary venous; PAPVR, partial anomalous pulmonary venous return; RPV, right pulmonary vein; SVC, superior vena cava; PFO, patent foramen ovale; PLSVC. persistent left superior vena cava; ASD, atrial septal defect.
The Journal of
3 10
Thoracic and Cardiovascular Surgery
Okabe et al.
Table II. Postoperative sinus node function SACT
Case I
Case 2
Case 3
220
167
183
380
200
260
(msec) CSRT
(msec) SCAT. Sinoatrial conduction time; CSRT. corrected sinus node recovery time. Normal range (Nanula 2) : SACT, 201 ± 77 msec; CSRT, 110 ± 525 msec.
Table III. Summary of hemodynamic data Preoperative PAP (nun Hg) RAP (nun Hg) Qp/Qs Postoperative PAP (nun Hg) RAP (nun Hg) SVC pressure (nun Hg)
Case I
Case 2
Case 3
30/10 (18) 7.5/0 (3.5)
38/20 (27) a=8 v = 8 (6)
42/18 (32) a=6 v = 5 (3)
2.75
1.83
2.46
25/10 (15) a=8 v = 6 (6)
28/12 (18) a=4 v = 5 (5)
25/12 (15) a=5 v = 6 (6)
(6)
(5)
(6)
PAP, pulmonaryartery pressure;RAP, right atrial pressure;Qp/Qs, pulmonaryto-systemic bloodflow ratio; SVC, superiorvena cava. Figuresin parenthesesare mean values.
.I
Fig. 2. Case 1. Postoperative angiograms of a 23-year-old woman.
Table IV. Atriocavoplasty First author Chartrand?
Atrial incision
Most cranial caval incision
Atriocavoplasty
Rerouting
Anterior
Vertical
On lay advancement
Atrial baffle
Anterior
Oblique
Z plasty
Atrial baffle
Lateral Medial
Vertical Horizontal
V-V plasty Rotation-advancement
Atrial baffle Atrial baffle
Cooley" Gerbode? Lewin,'? Stark!' Kirklin'? Okabe
the right atrial appendage.r" The pulmonary venous drainage is rerouted by an intraatrial baffle, However, cavoatrial reanastomosis may result in late stricture. At this time, no suitable prosthesis is available for reconstruction of the vena cava. Even autologous pericardium may shrink late postoperatively. Patients with this anomaly havean enlarged right atrium that issuitablefor flap atriocavoplasty. Onlay advancement plasty of the right atrial appendage,": 8 Z plasty of the right atrium,?"! and V-Yplastyofthe right atrium 12 havealso been proposed (Table IV).
The incision on the right atrium is of paramount importance in the atriocavoplasty, As has been pointed out by Kyger and associates13 and Stark and de Leval;' any method necessitatinglateral right atriotomy between the sinus nodeand interatrial groovecarries a high riskof damaging the sinus node, because the sinus node is locatedin the lateral wallof the atriocavaljunction. In the current technique, we therefore incised the anterolateral wallof the atriocavaljunction. Evenin this method,there is a possibility of injuring the sinusnodeartery, especially at the pointwhereit arisesfrom the right coronaryartery.
Volume 99 Number 2
PAPVD
February 1990
The fact that sinus node function was not depressed postoperatively in any of the patients in this series is highly encouraging. This may be related to the collateral supply of the sinus node in humans. Consideration should also be given to the most cranial part of the incision in the superior vena cava. When the incision is vertical at this location, some degree of stenosis of the cava because of the suture bites is unavoidable at the summit of the suture line. This may not be a problem when the superior vena cava is wide, but when it is narrow, especially with persistent left superior vena cava, late stenosis may develop at the site of caval anastomosis'? To circumvent this problem, we added a horizontal incision at the summit of the caval incision. In two patients with persistent left superior vena cava operated on by the current method, no obstruction was detected by the postoperative angiogram. This new rotation-advancement flap method is a simple procedure for repair of partial anomalous pulmonary venous drainage into the superior vena cava and has good early results. REFERENCES I. Kirklin JW, Ellis FH Jr, Wood EH. Treatment of anomalous pulmonary venous connections in association with interatrial communications. Surgery 1956;39:389-98. 2. Nanula OS. Cardiac arrhythmias, electrophysiology,diagnosis and management. In: Clinical and electrophysiological evaluation of sinus node function. Baltimore: Williams & Wilkins, 1980:176. 3. Long DM, Rios MV, Elias DO, et al. Parietal and septal atrioplasty for total correction of anomalous pulmonary
4.
5. 6.
7.
8. 9.
10.
II.
12.
13.
311
venous connection with superior vena cava. Ann Thorac Surg 1974;18:466-71. Ehrenhaft JL, Theilen EO, Lawrence MS. The surgical treatment of partial and total anomalous pulmonary venous connections. Ann Surg 1958;148:249-58. Groves LK. Correction of anomalous pulmonary venous drainage into the superior vena cava. Ann Thorac Surg 1967;4:301-7. Williams WH, Zorn-Chelton S, Raviele AA, et al. Extracardiac atrial pedicle conduit repair of partial anomalous pulmonary venous connection to the superior vena cava in children. Ann Thorac Surg 1984;38:345-55. Chartrand C, Payot M, Davignon A, Guerin R, Stanley P. A new surgical approach for correction of partial anomalous pulmonary venous drainage into the superior vena cava. J THORAC CARDIOVASC SURG 1976;71:29-34. Cooley DA. Repair of sinus venosus defect. In: Techniques in cardiac surgery. Philadelphia: WB Saunders, 1983:110. Gerbode F, Carr I. Defects of the atrial septum. In: Cardiac surgery I. Vol. 3. Cardiovascular clinics. Philadelphia: FA Davis, 1971:130. Lewin AN, Zavanella C, Subramanian S. Sinus venosus atrial defect associated with partial anomalous pulmonary venous drainage: surgical repair. Ann Thorac Surg 1978; 26:185-8. Stark J, de Leval M. Partial anomalous pulmonary venous drainage into superior vena cava. In: Surgery for congenital heart defects. New York: Grone & Stratton, 1983:264. Kirklin JW, Barratt-Boyes BG. Cardiac surgery, atrioseptal defect, and partial anomalous pulmonary venous connection. New York: John Wiley, 1986. Kyger ER III, Frazier OH, Cooley DA, et al. Sinus venosus atrial septal defect: early and late results following closure in 109 patients. Ann Thorac Surg 1978;25:44-50.