Primary Sutureless Repair and AnteriorTranslocation of the Atrial Septum for CardiacTotal Anomalous Pulmonary Venous ConnectionHironori Matsuhisa, MD, Yoshihiro Oshima, MD, PhD, Ayako Maruo, MD, PhD,Tomomi Hasegawa, MD, PhD, Akiko Tanaka, MD, and Rei Noda, MD

Department of Cardiovascular Surgery, Kobe Children’s Hospital, Kobe, Japan

The incidence of pulmonary vein stenosis after correc-tion of a cardiac total anomalous pulmonary venousconnection in neonates may be underestimated be-cause of the small population of patients; however, it isassociated with significant mortality and morbidity.

This report describes a primary sutureless repair and

Surgery, Kobe Children’s Hospital, 1-1-1, Takakura-dai, Suma-ku, Kobe,654-0081, Japan; e-mail: matsuhisa_kch@hp.pref.hyogo.jp.

© 2013 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

anterior translocation of the atrial septum to create alarge left atrial cavity and avoid post-repair pulmonaryvein stenosis.

(Ann Thorac Surg 2013;95:729 –30)

© 2013 by The Society of Thoracic Surgeons

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Although the surgical outcomes for total anomalouspulmonary venous connection (TAPVC) have im-

proved over the past several decades, post-repair pulmo-nary vein stenosis (PVS) is still associated with a signif-icant mortality, and prevention of this problem remainselusive [1]. Some institutions use sutureless repair as aprimary procedure for simple TAPVC to prevent thedevelopment of post-repair PVS [2, 3]. Surgery wasperformed on a neonate with cardiac TAPVC using aconventional technique in 2010. She developed post-repair PVS (echocardiographic mean gradient of 13 mmHg). Three-dimensional (3D) computed tomography(CT) showed that the right pulmonary vein was com-pressed by the posterior wall of the right atrium andatrial septum (Fig 1A). Her pulmonary vein stenosis wasreleased by a sutureless technique and the anteriortranslocation of the atrial septum (Fig 1B). This techniquehas been adopted as a primary repair for cardiac TAPVC.This article describes a novel modification for the pri-mary sutureless repair of cardiac TAPVC.

Technique

A median sternotomy was performed and the patientswere placed on cardiopulmonary bypass (CPB) withaortic and bicaval cannulation. During deep hypothermicCPB and aortic clamping, the right atrium was openedlongitudinally. The anterior wall of the coronary sinusand the right pulmonary vein were widely unroofed. Theright pulmonary venous incisions were extended intoboth the upper and lower pulmonary veins out towardthe pleural pericardial reflection. The posterior rightatrial wall above the right pulmonary veins was widely

Accepted for publication Sept 28, 2012.

Address correspondence to Dr Matsuhisa, Department of Cardiovascular

excised. The right pericardial wall was anastomosed tothe lateral wall of the right atrium (Fig 2A). The posterioratrial septum was excised, and an autologous pericardialpatch was used to close the enlarged atrial septal defect.The posterior edge of the patch was secured immediatelybelow the terminal crest, which created a large unob-structed left atrial cavity (Fig 2B).

This procedure was performed on three patients in-cluding two neonates from January 2011 to March 2012.The weights at surgery were 3.0, 3.5, and 4.1 kg, respec-tively. Deep hypothermic circulatory arrest was used forthe first case. The second patient had mild left pulmonaryvein stenosis (a mean echocardiographic gradient of 2mm Hg) because of compression between the left atriumand the descending aorta preoperatively. Her left-sidedpericardium at the level of the left atrium was secured tothe sternum in order to obtain effective lifting of the leftatrium. She also underwent pulmonary artery plasty formain pulmonary artery stenosis.

All patients had a smooth postoperative recovery. Thepostoperative 3D-CT showed a large left atrial cavity andno evidence of PVS. All children were asymptomatic aftera follow-up of 20, 9, and 6 months, respectively. The mostrecent echocardiogram showed no signs of PVS.

Comment

The conventional surgical technique for cardiacTAPVC is the cutback method [4]. Detailed reportsfocusing on cardiac TAPVC are limited because of therelatively small proportion of this anatomic subtype.Nonetheless, PVS after the correction of cardiacTAPVC is a lethal complication [5].

Karamlou and associates [6] reviewed 377 cases ofTAPVC at the Hospital for Sick Children. They sug-gested that the cardiac connection type with pulmo-

nary venous obstruction is an unfavorable anatomic

0003-4975/$36.00http://dx.doi.org/10.1016/j.athoracsur.2012.09.080

730 HOW TO DO IT MATSUHISA ET AL Ann Thorac SurgSUTURELESS REPAIR FOR CARDIAC TAPVC 2013;95:729–30

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characteristic despite the recent improvement of peri-operative care [6]. The current findings are consistentwith this statement.

Yamagishi and colleagues reported another novel re-pair technique for cardiac TAPVC using the anterior roofof the coronary sinus as a flap to close the atrial septaldefect [7]. This technique also transfers the posterior wallof the left atrium and the atrial septum anteriorly; how-ever, it seems to be technically challenging to perform forsmall neonates.

The current technique offers certain theoretic advan-tages: (1) eliminating the right side structures that pose arisk of right pulmonary vein compression, (2) creating alarge left atrial cavity, (3) not having an anastomosis onthe small pulmonary veins, and (4) the technical feasibil-ity of performing a sutureless repair.

Fig 1. (A) Computed tomography after conven-tional repair demonstrating right pulmonary veincompression (arrow) is caused by posterior wall ofthe left atrium and the atrial septum. (B) Com-puted tomography of the same patient after therelease of pulmonary vein stenosis using a suture-less repair and anterior translocation of the atrialseptum. Unobstructed pulmonary venous pathwayand a large left atrium are confirmed.

Fig 2. (A) Schematic representation of the primary sutureless techniquefor cardiac total anomalous pulmonary venous connection. The anteriorwall of the coronary sinus and the right pulmonary vein (light purple)is widely unroofed. The right pericardium is anastomosed to the rightatrial wall (red dotted circle). (CS � coronary sinus; RIPV � right infe-rior pulmonary vein; RSPV � right superior pulmonary vein.) (B) Post-repair. The atrial septum (red) is translocated anteriorly. A large leftatrial cavity and unobstructed pulmonary venous pathway (light pur-ple) are created. (LA � left atrium; LV � left ventricle; RA � right

atrium; RV � right ventricle.)

Of course, this technique does not directly addressthe left pulmonary veins. If significant left pulmonaryvein stenosis is detected, then extensive incisions intothe left pulmonary veins and additional left-sidedsutureless repair are normally required. The anteriorsuspension of the left-sided pericardium may be there-fore effective to prevent left pulmonary vein stenosisdue to compression.

The current experience is limited and early; however,most cases of post-repair PVS occur within the first yearafter surgery. The results of this technique have beenexcellent; therefore, we have described it as a consider-ation for other surgeons.

References

1. Husain SA, Maldonado E, Rasch D, et al. Total anomalouspulmonary venous connection: factors associated with mor-tality and recurrent pulmonary venous obstruction. AnnThorac Surg 2012;94:825–32.

2. Honjo O, Atlin CR, Hamilton BC, et al. Primary suturelessrepair for infants with mixed total anomalous pulmonaryvenous drainage. Ann Thorac Surg 2010;90:862–8.

3. Buitrago E, Panos AL, Ricci M. Primary repair of infracardiactotal anomalous pulmonary venous connection using a mod-ified sutureless technique. Ann Thorac Surg 2008;86:320–2.

4. Tsang VT, Stark J. Total anomalous pulmonary venous returnand cor triatriatum. In: Stark JF, de Leval MR, Tsang VT, eds.Surgery for congenital heart defects. 3rd ed. West Sussex,England: John Wiley and Sons; 2006. p. 327–41.

5. Jonas RA, Smolinsky A, Mayer JE, Castaneda AR. Obstructedpulmonary venous drainage with total anomalous pulmonaryvenous connection to the coronary sinus. Am J Cardiol1987;59:431–5.

6. Karamlou T, Gurofsky R, Al Sukhni E, et al. Factors associatedwith mortality and reoperation in 377 children with totalanomalous pulmonary venous connection. Circulation 2007;115:1591–8.

7. Yamagishi M, Shuntoh K, Takahashi A, Shinkawa T, MiyazakiT, Kitamura N. Intra-atrial rerouting by transference of theposterior left atrial wall for cardiac-type total anomalouspulmonary venous return. J Thorac Cardiovasc Surg 2002;123:

996–9.