The “sutureless” neoatrium technique was initially described for anastomotic stenosis occurring after repair of total anomalous pulmonary venous connection (post-repair pulmonary vein stenosis, PRPVS). The procedure is also helpful in patients with congenital pulmonary vein stenosis and has been used in selected patients on the initial presentation of total anomalous pulmonary venous connection. Most of these patients will have a preoperative evaluation with transthoracic echocardiography, cardiac catheterization (to assess pulmonary artery pressure), and magnetic resonance imaging, if available.
After initiation of standard cardiopulmonary bypass with bicaval cannulation and antegrade cold blood cardioplegia, hypothermic blood cardioplegic arrest is induced. Alternatively, uniatrial venous cannulation and deep hypothermic circulatory arrest strategies can be employed.
For patients with PRPVS, the initial approach is through the right atrium and across the atrial septum to allow visualization of the pulmonary vein ostia and clear definition of the location and extent of stenosis. Often the stenosis is localized to the anastomotic region, but occasionally it may extend diffusely through the pulmonary veins in a retrograde direction.
For patients in whom this technique is to be used at the initial presentation of total anomalous pulmonary venous connection (as pictured below), the initial approach is through the left atrium after retraction of the heart to the right. The incision in the left atrium is extended transversely across the back of the left atrium to the edge of the interatrial septum. The pulmonary vein confluence is then incised transversely across its entire length. The incision can be carried into each pulmonary vein out to the second order branches if necessary. Placement of a blade of a Potts scissors in the lumen with the other blade out of the lumen and cutting distally into the lung facilitates this maneuver. The incision should be carried as far into the lung as necessary to get beyond any stenotic regions. Care must be taken to leave the adventitia intact when pulmonary vein incisions are made because the adventitia will contain the pulmonary venous effluent in a “controlled bleed” into the left atrium.
The divided edge of the atrial wall is then sutured to the pericardium (not the pulmonary vein) in a suture line remote from the divided edge of the pulmonary veins using a running fine absorbable suture. This suture line contains the pulmonary venous effluent in a “controlled bleed” while avoiding any direct suturing of the pulmonary veins. The suture line is relatively easy to sew because it connects the left atrial edge to the pericardium in a circle around the pulmonary veins. Consequently, the suture line ignores the complex shapes of the pulmonary vein incisions and simply maintains hemostasis by direct anastomosis of the left atrium to the pericardium.
In cases of isolated left or right pulmonary vein stenosis, the technique can be used in a unilateral fashion. The divided edge of the left atrium is then sewn to the pericardial reflection over the incised pulmonary veins. This suture line is then routed inwards to the confluence of the pulmonary veins to complete hemostasis in the central portion of the anastomosis.
|Schematic Illustration of Type III TAPVC|
At the Hospital for Sick Children in Toronto, this technique was originally described for two patients with bilateral pulmonary vein stenosis following TAPVC repair. Both were surviving at 1.8 years postoperatively . In the Discussion of that paper, at least seven other successful cases were noted. Lacour-Gayet later reported success in five of seven patients (all reoperations). Several other centers have now reported success with this technique. Updated results with the sutureless technique in nearly 40 patients operated on at the Hospital for Sick Children were presented at the 2004 Annual Meeting of The American Association for Thoracic Surgery held in Toronto. Ten patients had PRPVS and 26 patients had no prior operation but were at high risk of stenosis. As compared to conventional management, the sutureless technique was associated with decreased risk of reoperation or death (mean follow-up 3 years) .
Publication Date: 9-Sep-2005
Last Modified: 7-Oct-2009