Composite Reconstruction of the Right Atrium and the Superior Vena Cava With Pericardial Patches and a Vascular Prosthesis

This video demonstrates the surgical treatment of a patient with a right heart angiosarcoma who underwent radical resection followed by composite reconstruction of the right atrium and the superior vena cava (SVC), with bovine pericardial patches and a polytetrafluoroethylene (PTFE) vascular prosthesis. The right atrium is the structure most often affected by cardiac sarcoma.

The patient was a 43-year-old man with no history of serious illness. On the day of onset, he suddenly felt unwell when he was working and he then collapsed. He was brought to a hospital by ambulance. His blood pressure was 60 mm Hg, and his heart rate was 180 beats per minute. A plain computed tomography (CT) scan showed massive pericardial effusion. A thoracentesis was performed, and the tube drained sanguineous fluid. He underwent emergency coronary angiogram. His coronary arteries did not show any stenosis; however, the right coronary angiogram revealed staining of a tumor from the sinus nodal artery. Enhanced CT was performed, which showed a massive tumor occupying most of the right atrium and extending into the SVC. The patient was transferred to another hospital, where he underwent an urgent operation the day after admission.

In the pericardial sac, a hematoma was present, attached to the right atrial appendage. The ascending aorta, the SVC, and the inferior vena cava (IVC) were cannulated. An atrial incision was made just above the IVC. The authors then made a second incision at the SVC. The atrial incision was extended from the IVC to the SVC, while carefully inspecting and feeling the quality of the wall. The aorta was clamped, and the SVC was transected. The right side of the left atrium was incised to resect the atrial septum. The right coronary artery was identified and taped from its origin along the atrioventricular groove toward the acute margin. The sinus nodal artery, which was the tumor-feeding artery in this case, was identified and divided. The atrioventricular groove was dissected, and the entire right atrial wall was resected in one block. The defect of the left atrial wall, including the atrial septum and the roof of the left atrium, was reconstructed using an oval-shaped bovine pericardial patch. The left atrium was deaired and closed.

Regarding the right atrium, the only parts remaining were the tricuspid annulus, the coronary sinus, and the small part of the lower free wall near the IVC. Another bovine pericardial patch was used to reconstruct the right atrium. To the commissure between the anterior leaflet and the septal leaflet, the patch was trimmed in the exact angle of the anteroseptal commissure in order to prevent tricuspid regurgitation, and it was directly sewn to the tricuspid annulus. In the dorsal side, the patch was sewn along the coronary sinus with 4-0 polypropylene sutures with minimal residual tissue of the right atrium. The orifice of the coronary sinus was placed in the neo-right atrium. The authors used a generous-sized patch so that it would bulge with atrial pressure to form a three-dimensional dome as a neo-right atrium. They think it is better to do this, because one theoretical disadvantage of their technique may be the fact that the volume of the reconstructed neo-right atrium is smaller and has less compliance than the native right atrium.

The authors then made an end-to-end anastomosis between a PTFE prosthesis and the SVC. A 16 mm graft was chosen based on the diameter of the distal end of the native SVC. The aorta was unclamped, and the surgeons were able to determine the adequate length of the graft easily. They then trimmed the PTFE prosthesis in an oblique fashion to make a cobra-head anastomosis. The authors made a long incision on the pericardial patch, and then made an end-to-end anastomosis using 5-0 polypropylene running sutures to make a generous cobra head. Their goal was that this smooth and large orifice would contribute to better flow characteristics and a decreased tendency to thrombus formation inside the neo-right atrium. The patient came off cardiopulmonary bypass easily. There were no problems with hemostasis.

Since the superior cavoatrial junction, including the site of the sinus node, had been resected, an epicardial ventricular electrode was implanted. A pathological examination showed angiosarcoma. The postoperative course was uneventful. A pacemaker generator was implanted on the seventh postoperative day. Postoperative CT showed a well-reconstructed left atrium, new right atrium, and SVC. Postoperative echocardiogram showed no significant tricuspid regurgitation.

Extensive right atrial resection is often required in cases of cardiac sarcoma. The authors recommend their technique because it is simple, reproducible, and carries little risk of kinking or deformity.

Suggested Reading

1. Benassi F, Maiorana A, Melandri F, Stefanelli G. A case of primary cardiac angiosarcoma: extensive right atrial wall reconstruction with autologous pericardium. J Card Surg. 2010;25(3):282-284.
2. Furukawa N, Gummert J, Borgermann J. Complete resection of undifferentiated cardiac sarcoma and reconstruction of the atria and the superior vena cava: case report. J Cardiothorac Surg. 2012;7:96.