Retrocardiac Repair of Total Anomalous Pulmonary Venous Connection Constantine Mavroudis, Carl L. Backer  Operative Techniques in Thoracic and Cardiovascular Surgery  Volume 6, Issue 1, Pages 12-23 (February 2001) DOI: 10.1053/otct.2001.20447 Copyright © 2001 Elsevier Inc. Terms and Conditions

1 Operative conditions that optimize myocardial protection, systemic perfusion, and anatomic exposure are noted in this figure. The patient is approached in the usual fashion for a median sternotomy with the surgeon on the right side of the table. Appropriate aortobicaval cannulation is performed after the administration of intravenous heparin (3 mg/kg), followed by patent arteriosus ductus ligation, cardiopulmonary bypass (28°C), aortic cross-clamping, and antegrade administration of cold blood cardioplegia (repeated every 20 minutes during the cross-clumping time and augmented by topical iced saline). The surgeon then moves to the left side of the operating table and is confronted with the operative exposure shown here for a patient with type I (supracardiac) TAPVC. As shown, the vertical vein (VV) connects the confluence of the pulmonary veins to the innominate vein (INN v) anterior to the left pulmonary artery (LPA). Other variations, not noted herein, include a retropulmonary artery course of the VV to connect to the superior vena cava or a retropulmonary artery course of the VV to connect to the central portion of the INN v. These latter two variations are usually associated with obstructive physiology. This exposure technique has two main benefits: (1) Bicaval cannulation permits continuous cardiopulmonary bypass, thereby avoiding deep hypothermia and circulatory arrest (DIICA), and (2) aortic cross-clamping with cardioplegia induces cessation of myocardial activity, allows for heart displacement without creation of aortic insufficiency, and prevents unwanted air cmbolism during the repair. The following abbreviations are used here and throughout this section: Ao = aorta; INN v = innominate vein; IVC = inferior vena cava; LLPV = left lower pulmonary vein; LUPV = left upper pulmonary vein; LA = left atrium; LAA = left atrial appendage; LPA = left pulmonary artery; LV = left ventricle; PDA = patent ductus arteriosus; RPV = right pulmonary vein; RV = right ventricle; VV = vertical vein. Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, 12-23DOI: (10.1053/otct.2001.20447) Copyright © 2001 Elsevier Inc. Terms and Conditions

2 Operative exposure from the left side of the operating table for a patient with type I TAPVC during continuous cardiopulmonary bypass and cold blood cardioplegic arrest. The heart is retracted to the right and superiorly out of the pericardial cavity to expose the confluence of the pulmonary veins and the vertical vein. The vertical vein is controlled with a snugger that can be enforced during the anastomosis. The dotted lines represent proposed incisions of the confluence of the pulmonary veins and the left atrium, respectively, for the intended side-to-side anastomosis. Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, 12-23DOI: (10.1053/otct.2001.20447) Copyright © 2001 Elsevier Inc. Terms and Conditions

3 Operative exposure from the left side of the operating table for a patient with type III (infradiaphragmatic or infracardiac) TAPVC. The heart is retracted to the right and superiorly out of the pericardial cavity to expose the confluence of the pulmonary veins and the inferior vertical vein. The vertical vein is controlled with a snugger that can be enforced during the anastomosis. The dotted lines represent proposed incisions of the confluence of the pulmonary veins and the left atrium, respectively, for the intended side-to-side anastomosis. Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, 12-23DOI: (10.1053/otct.2001.20447) Copyright © 2001 Elsevier Inc. Terms and Conditions

4 Often, the confluence of pulmonary veins in patients with type III TAPVC is aligned vertically, as shown here, as opposed to horizontally as shown in 3. This presents a technical challenge to achieve the optimal side-to-side anastomosis between the confluence of the pulmonary veins and the left atrium. Depending on the anatomy, vertical incisions can be planned, as noted by the dotted lines, to accomplish a favorable side-to-side anastomosis and avoid any flow obstruction. Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, 12-23DOI: (10.1053/otct.2001.20447) Copyright © 2001 Elsevier Inc. Terms and Conditions

5 Once retrocardiac exposure is established, the vertical vein is controlled with the snugger, and a left atrial incision is performed from the base of the left atrial appendage centrally toward the interatrial septum corresponding to the confluence of the right upper and lower pulmonary veins. The patent foramen ovale is immediately encountered toward the inferoposterior portion of the left atrium and is closed with running suture technique. Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, 12-23DOI: (10.1053/otct.2001.20447) Copyright © 2001 Elsevier Inc. Terms and Conditions

6 Once the patent foramen ovale is closed, an incision is made in the confluence of pulmonary veins from the junction of the right pulmonary veins to the junction of the left pulmonary veins. Rarely will it be necessary to carry the incision to the individual tributary pulmonary veins. The critical parts of this anastomosis are (1) performing the side-to-side anastomosis in graduated segments as the heart is allowed to fall back into the pericardial cavity and (2) performing the anastomosis without “purse stringing” the suture line, which can lead to stcnosis and the consequences of pulmonary venous and arterial hypertension. Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, 12-23DOI: (10.1053/otct.2001.20447) Copyright © 2001 Elsevier Inc. Terms and Conditions

7 Initiation of the running suture line, which is tied with the knot on the inside of the left atrial-to-pulmonary venous communication. We have found that this technique, although not in keeping with general vascular anastomotic principles, allows concise initiation of the anastomotic suture line. This technique also avoids suture transfer behind the anastomosis when the knot is tied on the outer surface, thereby reducing the risk of disruption and other complications. Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, 12-23DOI: (10.1053/otct.2001.20447) Copyright © 2001 Elsevier Inc. Terms and Conditions

8 Side-to-side confluence of the pulmonary veins to the left atrial anastomosis is then performed in segments as the heart is lowered symmetrically into the pericardial cavity. To achieve this, care is taken to alternate small sections of the suture line reconstruction between the superior and inferior borders. Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, 12-23DOI: (10.1053/otct.2001.20447) Copyright © 2001 Elsevier Inc. Terms and Conditions

9 Completion of the confluence of the pulmonary veins to the left atrial anastomosis. The posterior portion of the heart has now been replaced within the pericardial cavity, and the surgeon can now complete the anastomosis by tying the knot. Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, 12-23DOI: (10.1053/otct.2001.20447) Copyright © 2001 Elsevier Inc. Terms and Conditions

10 When type III TAPVC is encountered, the orientation of the side-to-side anastomosis should be tailored to accommodate a “best lie” configuration. This drawing shows the vertical incision in the confluence of the pulmonary veins and a corresponding incision in the left atrium, which produces the most favorable anatomic and geometric union for unrestricted flow. The anastomosis is started at the far center of the pulmonary vein confluence and left atrium as shown. The knot is left on the inside of the cavity to facilitate the anastomotic suture line, as noted in 7. Note that the inferior vertical vein is ligated and the patent foramen ovale is closed. Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, 12-23DOI: (10.1053/otct.2001.20447) Copyright © 2001 Elsevier Inc. Terms and Conditions

11 The retrocardiac anastomosis performed in the stepwise and segmented technique described in 8. As the anastomosis is being completed from the surgeon's far side to near side, the heart is allowed to fall back into the pericardial cavity, relieving suture line tension. Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, 12-23DOI: (10.1053/otct.2001.20447) Copyright © 2001 Elsevier Inc. Terms and Conditions

12 Occasionally, the confluence of the pulmonary veins is small or the orientation is sufficiently complex to warrant a larger suture line to maximize the length of the anastomosis. Under these circumstances, the inferior vertical vein can be transected to increase the length of the anastomosis. This drawing shows that initiation of the far suture line after the inferior vertical vein has been transected. Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, 12-23DOI: (10.1053/otct.2001.20447) Copyright © 2001 Elsevier Inc. Terms and Conditions

13 The retrocardiac anastomosis is completed in a segmental stepwise fashion, as noted in 8 and 11. The transected inferior vertical vein can now be incorporated into the anastomosis to maximize the circumferential length. Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, 12-23DOI: (10.1053/otct.2001.20447) Copyright © 2001 Elsevier Inc. Terms and Conditions

14 Removal of air from the left side of the heart is a challenge when no left ventricular vent is present. In particular, we have found that operations involving left atrial cavitary exposure harbor air in the peripheral pulmonary veins. We thus retard venous drainage to force blood through the right heart, the lungs, and the left heart while applying gentle negative pressure in the aortic root with a syringe and catheter while the cross-clamp remains engaged. This maneuver, coupled with multiple lung insufflations by the anesthesiologist, will remove air from the left side of the heart and avoid the complications of air embolism. Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, 12-23DOI: (10.1053/otct.2001.20447) Copyright © 2001 Elsevier Inc. Terms and Conditions