1. Atrial Switch Operation in a Patient With Dextrocardia, Bilateral Superior Vena Cavae, Left Atrial Isomerism and Unroofed Coronary Sinus 
Sachin Talwar, MCh, Shiv Kumar Choudhary, MCh, Sandeep A. Janardhan, MS, Vishwas Malik, DM, Shyam Sunder Kothari, DM, Gurpreet Singh Gulati, MD, Thittamaranahali Kariyappa Susheel Kumar, MCh, Balram Airan, MCh 
The Annals of Thoracic Surgery 
Volume 87, Issue 6, Pages (June 2009)
DOI: /j.athoracsur
Copyright © 2009 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
(a) External cardiac anatomy shows dextrocardia with left isomerism and juxtaposed atrial appendages (arrows). The atria are not seen on the right side as they are covered completely by the ventricular mass. A stay suture (S) has been placed at the cardiac apex to facilitate displacement of the heart to the left. (Ao = aorta; IVC = inferior vena cava; LSVC = left superior vena cava; RSVC = right superior vena cava.) (b) Cannulation and landmarks. A and A' indicates the site of proposed right atriotomy. The left atrium (LA) indicates the site from where blood will exit out of the pulmonary veins. The heart has been dislocated into the left pleural cavity using the stay suture (not shown). Note the extrapericardial cannulation of the cavae. The pericardial reflection, P and P' over the superior vena cavae (SVC) and IVC is left intact. (c) The right atrium has been opened and the large atrial sepal defect can be seen along with the openings of the four pulmonary veins and a very small opening of the coronary sinus. X and X' indicates the left lip of the right atriotomy and Y and Y' indicates its right lip. (d) Construction of the posterior wall of the systemic venous baffle. A Dacron patch (DuPont, Wilmington, DE) (D) is sutured in front of pulmonary veins and behind the mitral valve. S is the left edge of the atrial septum. R is the right edge of the septum. On the right, the patch is sutured to R. The coronary sinus opening (arrow) has been cut back to open into the left atrium. The thatched area between the Dacron patch (DuPont) and the coronary sinus opening indicates the opened coronary sinus, which now drains towards the mitral valve. (e) Completion of anterior wall of systemic venous pathway. A patch of bovine pericardium (B) is sutured around the caval orifices and the left edge of the interatrial septum (S), and then this patch is sutured to the right edge of the atriotomy (along Y-Y'), thus completing the systemic venous baffle. (f) Construction of the pulmonary venous pathway using the in situ pericardial technique. P is approximated to X and P' to X'. The suture line extends from the pericardium to the atriotomy edges along the SVC and IVC and bites in the cavae must be superficial to avoid narrowing. Also when suturing the pericardium near the SVC, the area around the sino-atrial node should be avoided.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2009 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
(A, B) Computed tomographic angiogram (maximum intensity projection coronal images) to show the constructed systemic venous pathways of the left superior vena cavae (long arrow), right SVC (short arrow), and the inferior vena cava (IVC) (*) drain into the left-sided atrium.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2009 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
Computed tomographic angiogram (maximum intensity projection axial image) of the pulmonary veins (arrows) are directed toward the right-sided atrium by the baffle (*). This atrium connects to the right-sided morphological right ventricle (RV). The left-sided atrium connects to the morphological left ventricle (LV), which is smaller than the RV.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2009 The Society of Thoracic Surgeons Terms and Conditions