Alternative Approach for an Anomalous Pulmonary Venous Connection to the Superior Vena Cava

A mildly symptomatic seven-year-old male patient presented with a high partial anomalous pulmonary venous connection of the right upper and middle veins into the superior vena cava high above the right pulmonary artery with a secundum atrial septal defect. An elective surgical treatment was indicated.

The Surgery

After a midline median sternotomy the ascending aorta, innominate vein, and inferior vena cava were cannulated, and standard cardiopulmonary bypass was established. Surgeons mobilized the SVC and identified the azygous vein and two anomalous pulmonary veins (PVs) from the right upper lobe, entering the SVC nearly 4 cm above the atriocaval junction. 

After initiating electrically induced fibrillation of the heart, a right atriotomy was done. Given the presence of secundum type ASD instead of superior sinus venosus defect, the anticipated distance of the intracardiac baffle would be nearly 6-7 cm. Considering the high risk of either the PVs or the SVC obstruction, surgeons came to an idea to perform direct reimplantation of the PVs into the left atrium.

First, the PVs were controlled and the SVC was cross clamped. The confluence of the anomalous veins was excised from the SVC involving a strip of systemic vein’s wall up to 2 mm wide. The estimated diameter of the PV’s confluence was near 6 mm. The PVs were then mobilized and a wide U-shaped incision in the wall of the left atrium was performed. 

Next, surgeons turned the flap of left atrial tissue towards the pulmonary vein’s confluence. This maneuver, which the surgical team named “the drawbridge technique,” allowed for decreasing the tension on the venoatrial anastomosis. The posterior lip of the pulmonary vein’s confluence was directly attached to the flap of the LA’s tissue.

Anteriorly, the autologous pericardial patch was used to form a baffle from the pulmonary veins to the left atrium. The secundum ASD was closed with direct suture, the heart was defibrillated. The cavotomy was closed with the autologous pericardial patch and the patient was weaned off CPB without difficulty. The rest of the procedure was completed in the standard fashion.

Postoperative Course

The patient was extubated one hour after surgery, received no transfusions, and the remaining postoperative course was uneventful. The patient was discharged on postoperative day seven. At the follow-up six months after surgery, the postoperative MRI showed an unobstructed new right superior pulmonary vein pathway to the left atrium with no signs of systemic venous stenosis.

To conclude, the presented technique of direct reimplantation of the anomalous pulmonary veins into the left atrial wall is applicable in selected patients with high PAPVC. It provides tension free wide unobstructed anastomosis with the left atrium, eliminates the need for any incisions across the cavoatrial junction, and avoids surgical manipulation around the sinus node.

References

1. Sekelyk, R., Kozhokar, D., Safonov, V., Yemets, I. An Alternative Approach for a High Partially Anomalous Pulmonary Venous Connection to the Superior Vena Cava:“A Drawbridge Technique”. World J Pediatr Congenit Heart Surg. 2022 Jul;13(4): 516-518.

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