Practical Safeguards for Repair of Sinus Venosus ASD With PAPVD—The Warden Procedure

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A superior sinus venosus atrial septal defect (ASD) is located superior to the superior limbic band of the fossa ovalis. The superior vena cava (SVC) typically overrides the defect and is often associated with anomalous drainage of the right pulmonary veins, which can drain directly into the SVC or at the cavo-atrial junction. Due to an increased pulmonary-to-systemic flow ratio (QP:QS) that can lead to heart failure, surgical repair is essential. Various techniques have been employed to address this defect, including single patch closure, double patch closure, and the Warden procedure (1). 

Single patch repair may lead to stenosis of the anomalous pulmonary veins, SVC, or both. The double patch technique helps avoid stenotic baffles by augmenting the SVC; however, it has a higher incidence of sinoatrial (SA) node dysfunction. This dysfunction can be linked to injury of the SA node or the SA nodal artery, which often follows a variable course, making it unpredictable. At the authors’ center, the preference is to perform the Warden procedure whenever the anomalous veins drain into the SVC to mitigate these complications (2). 

In this video, the authors demonstrate their approach to performing the Warden procedure for repairing a superior sinus venosus ASD with associated anomalous pulmonary venous drainage. 

The surgical approach involves a median sternotomy. For optimal exposure of the superior vena cava (SVC), the surgeons prefer to resect the right thymic lobe. Central aortic cannulation was performed with bicaval venous cannulation, ensuring that the SVC was cannulated as high as possible using a right-angled cannula. 

The SVC was carefully mobilized, and the azygous vein was identified and snared. Before initiating bypass, the medial and lateral borders of the SVC were marked with simple Prolene stitches. This step was crucial before bypass to maintain the normal orientation of the SVC and prevent twisting. 

Upon applying the aortic cross-clamp, antegrade cardioplegia was delivered. The left ventricle was vented through the ASD following a small right atriotomy. Usually, a small right atriotomy midway between the right atrioventricular groove and the crista terminalis, provides sufficient access for the intracardiac repair. 
 
The SVC was transected distal to the pulmonary veins, and the proximal stump was closed using an autologous pericardial patch. Subsequently, the ASD was closed with a pericardial patch. By incorporating the SVC stump, the pulmonary veins were redirected to the left atrium. It is essential to ensure that the ASD is wide enough to accommodate the pulmonary veins drainage; if not, it can be enlarged toward the fossa ovalis. 

The transected SVC was then connected to the right atrial appendage, ensuring optimal orientation to prevent twists and kinks that could lead to increased pressure gradients. Finally, the right atrium was closed. 

References

1. Warden HE, Gustafson RA, Tarnay TJ, Neal WA. An Alternative Method for Repair of Partial Anomalous Pulmonary Venous Connection to the Superior Vena Cava. Ann Thorac Surg. 38(6):601-605. doi:10.1016/S0003-4975(10)62317-X
2. Shahriari A, Rodefeld MD, Turrentine MW, Brown JW. Caval Division Technique for Sinus Venosus Atrial Septal Defect With Partial Anomalous Pulmonary Venous Connection. 2006;54. doi:10.1016/j.athoracsur.2005.07.015
3. Ardehali, A., & Chen, J. M. (2016). Khonsari's Cardiac Surgery: Safeguards and Pitfalls in Operative Technique (5th ed.)

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