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The Senning operation: A new technique to prepare the septal flap
The Senning Operation: A New Technique to Prepare the Septa1 Flap Renato S. Assad, MD, Hermes S. Felipe, MD, Miguel B. Marcial, MD, and Adib D. Jatene, MD Heart Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
We describe a modification of the use of the left atrial appendage for the construction of the new atrial septum in the Senning operation. (Ann Thorac Surg 1991;51:678-9)
A
lthough the currently preferred treatment for transposition of the great arteries is the arterial switch operation, the Senning operation continues to provide an important alternative in select patients. One of the complications of the Senning operation has been venous pathway obstruction [l, 21, which in part may be due to the use of intracardiac prosthetic material. After the Rashkind procedure or the Blalock-Hanlon operation, the native atrial septum may be insufficient for use in the Senning reconstruction. Use of the left atrial appendage for the construction of part of the new atrial pathway in the Senning operation has been described [3-51. We propose a modification of this technique, using the inverted and opened left atrial appendage as an autologous septal flap for the reconstruction of part of the new atrial pathway.
Technique Cardiopulmonary bypass is carried out as usual for the Senning operation. After aortic cross-clamping and infusion of cardioplegic solution, the right atrium is opened approximately 2 cm anterior and parallel to the interatrial groove toward the crista terminalis superiorly and the eustachian valve inferiorly. Through the opened right atrium, the remnants of the atrial septum are excised completely. The left atrial appendage is then inverted by gentle traction on its apex. Excessive traction may distort the atrioventricular groove, and the subsequent incision may therefore compromise the circumflex coronary artery. A T-shaped incision is made on the anterior wall of the inverted left atrial appendage (Fig 1). The longitudinal incision is carried from the apex to the base of the appendage and extended transversely, parallel to the appendage-atrial junction. If necessary, some pectinate trabeculae are divided to enlarge the flap. The incision along the base of the left atrial appendage creates an opening that must be closed (Fig 2). The autologous left
Fig 1. The left atrial appendage (LAA) is inverted and a T-shaped incision is made on the anterior wall. (IVC = inferior vena cava; MV = mitral valve; PV = pulmonary valve; SVC = superior vena cava; TV = tricuspid valve.)
atrial flap is then sutured along the conventional landmarks to form the floor of the new systemic venous atrium (Fig 3). The remainder of the operation follows the customary routines for the Senning operation.
Comment This technique creates a large autologus septal flap, eliminating the use of prosthetic material in the construction
Accepted for publication Dec 31, 1990. Address reprint requests to Dr Assad, Instituto do Coracao, Divisao de Cirurgia, Av. Dr. Eneas C. Aguiar, 44, Sao Paulo, Brazil 05403. 0 1991 by
The Society of Thoracic Surgeons
Fig 2. Suture of the opened left atrial appendage (LAA) along the base. (Abbreviations as in Figure 1 .)
0003-4975/!)1/$3.50
Ann Thorac Surg 1991;51:67%9
HOW TO DO IT ASSAD ET AL NEW ATRIAL SEPTATION
679
venous pathways and preserved contractile function of the new atrial septum. The use of this procedure will substantially increase the number of patients who can benefit from the Senning operation without the use of intracardiac prosthetic materials. We gratefully acknowledge Dr Aldo R. Castaneda and Dr Frank L. Hanley for suggestions during the preparation of the manuscript.
References
Fig 3 . The autologous flap (LAA) is sutured along the conventional landmarks of the atrial septution in the Senning operation. (Abbreviations as in Figure I .)
of the atrial pathways in the Senning operation. A further advantage is the potential growth of this autologous tissue and perhaps also some contractile capacity of the flap. We have used this technique successfully in a 7-month-old patient with the diagnosis of transposition of the great arteries associated with atrial septa1 defect. After the operation, two-dimensional echocardiography showed no stenosis of the newly created systemic and pulmonary
1. DeLeon VH, Hougen TJ, Nonvood WI, Lang P, Marx GR, Castaneda A. Results of the Senning operation for transposition of great arteries with intact ventricular septum in neonates. Circulation 1984;7O(Suppl 1):21-5. 2. Satomi G, Nakamura K, Takao A, Imai Y. Two-dimensional echocardiographic detection of pulmonary venous channel stenosis after Senning’s operation. Circulation 1983;68:5459. 3. Eufrate S, Luisi VS. A further modification of the Senning operation. Thorac Cardiovasc Surg 1981;29:8%90. 4. Hamilton JRL, Wilson N, Dickinson DF, Walker DR. A modification of the Senning procedure for complete transposition. In: Crupi G, Parenzan L, Anderson RH, eds. Perspectives in pediatric cardiology; vol2. Mt Kisco, NY: Futura, 1989:4%51. 5. Levinsky L, Srinivasan V, Alvarez-Diaz F, Subramanian S. Reconstruction of the new atrial septum in the Senning operation. J Thorac Cardiovasc Surg 1981;81:131-4.
We describe a modification of the use of the left atrial appendage for the construction of the new atrial septum in the Senning operation. (Ann Thorac Surg 1991;51:678-9)
A
lthough the currently preferred treatment for transposition of the great arteries is the arterial switch operation, the Senning operation continues to provide an important alternative in select patients. One of the complications of the Senning operation has been venous pathway obstruction [l, 21, which in part may be due to the use of intracardiac prosthetic material. After the Rashkind procedure or the Blalock-Hanlon operation, the native atrial septum may be insufficient for use in the Senning reconstruction. Use of the left atrial appendage for the construction of part of the new atrial pathway in the Senning operation has been described [3-51. We propose a modification of this technique, using the inverted and opened left atrial appendage as an autologous septal flap for the reconstruction of part of the new atrial pathway.
Technique Cardiopulmonary bypass is carried out as usual for the Senning operation. After aortic cross-clamping and infusion of cardioplegic solution, the right atrium is opened approximately 2 cm anterior and parallel to the interatrial groove toward the crista terminalis superiorly and the eustachian valve inferiorly. Through the opened right atrium, the remnants of the atrial septum are excised completely. The left atrial appendage is then inverted by gentle traction on its apex. Excessive traction may distort the atrioventricular groove, and the subsequent incision may therefore compromise the circumflex coronary artery. A T-shaped incision is made on the anterior wall of the inverted left atrial appendage (Fig 1). The longitudinal incision is carried from the apex to the base of the appendage and extended transversely, parallel to the appendage-atrial junction. If necessary, some pectinate trabeculae are divided to enlarge the flap. The incision along the base of the left atrial appendage creates an opening that must be closed (Fig 2). The autologous left
Fig 1. The left atrial appendage (LAA) is inverted and a T-shaped incision is made on the anterior wall. (IVC = inferior vena cava; MV = mitral valve; PV = pulmonary valve; SVC = superior vena cava; TV = tricuspid valve.)
atrial flap is then sutured along the conventional landmarks to form the floor of the new systemic venous atrium (Fig 3). The remainder of the operation follows the customary routines for the Senning operation.
Comment This technique creates a large autologus septal flap, eliminating the use of prosthetic material in the construction
Accepted for publication Dec 31, 1990. Address reprint requests to Dr Assad, Instituto do Coracao, Divisao de Cirurgia, Av. Dr. Eneas C. Aguiar, 44, Sao Paulo, Brazil 05403. 0 1991 by
The Society of Thoracic Surgeons
Fig 2. Suture of the opened left atrial appendage (LAA) along the base. (Abbreviations as in Figure 1 .)
0003-4975/!)1/$3.50
Ann Thorac Surg 1991;51:67%9
HOW TO DO IT ASSAD ET AL NEW ATRIAL SEPTATION
679
venous pathways and preserved contractile function of the new atrial septum. The use of this procedure will substantially increase the number of patients who can benefit from the Senning operation without the use of intracardiac prosthetic materials. We gratefully acknowledge Dr Aldo R. Castaneda and Dr Frank L. Hanley for suggestions during the preparation of the manuscript.
References
Fig 3 . The autologous flap (LAA) is sutured along the conventional landmarks of the atrial septution in the Senning operation. (Abbreviations as in Figure I .)
of the atrial pathways in the Senning operation. A further advantage is the potential growth of this autologous tissue and perhaps also some contractile capacity of the flap. We have used this technique successfully in a 7-month-old patient with the diagnosis of transposition of the great arteries associated with atrial septa1 defect. After the operation, two-dimensional echocardiography showed no stenosis of the newly created systemic and pulmonary
1. DeLeon VH, Hougen TJ, Nonvood WI, Lang P, Marx GR, Castaneda A. Results of the Senning operation for transposition of great arteries with intact ventricular septum in neonates. Circulation 1984;7O(Suppl 1):21-5. 2. Satomi G, Nakamura K, Takao A, Imai Y. Two-dimensional echocardiographic detection of pulmonary venous channel stenosis after Senning’s operation. Circulation 1983;68:5459. 3. Eufrate S, Luisi VS. A further modification of the Senning operation. Thorac Cardiovasc Surg 1981;29:8%90. 4. Hamilton JRL, Wilson N, Dickinson DF, Walker DR. A modification of the Senning procedure for complete transposition. In: Crupi G, Parenzan L, Anderson RH, eds. Perspectives in pediatric cardiology; vol2. Mt Kisco, NY: Futura, 1989:4%51. 5. Levinsky L, Srinivasan V, Alvarez-Diaz F, Subramanian S. Reconstruction of the new atrial septum in the Senning operation. J Thorac Cardiovasc Surg 1981;81:131-4.