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J Thorac Cardiovasc Surg 2007;133:1135-1136
© 2007 The American Association for Thoracic Surgery

Editorial

The vertical vein: To ligate or not to ligate

Children’s Hospital of Wisconsin, Milwaukee, Wis.

Received for publication September 16, 2006; accepted for publication September 28, 2006.

^_* Address for reprints: James S. Tweddell, MD, Children’s Hospital of Wisconsin, Department of Cardiothoracic Surgery, 9000 W. Wisconsin Ave, MS 715, Milwaukee, WI 53226.

The first 20% of the full text of this article appears below.

This issue of The Journal of Thoracic and Cardiovascular Surgery includes a contribution from the All India Institute of Medical Sciences summarizing a large experience with total anomalous pulmonary venous connection (TAPVC) that tests a protocol for selective ligation of the vertical vein.¹ After weaning from cardiopulmonary bypass, the patients underwent test occlusion of the vertical vein, and if the pulmonary artery pressure increased to systemic or suprasystemic levels, the vertical vein was not ligated. The goal was to limit hemodynamic decompensation in the early postoperative period and therefore improve survival. Several important observations are reported. With vertical vein ligation both pulmonary artery and left atrial pressures increased, whereas with restoration of vertical vein patency, in addition to a reduction in pulmonary artery pressure and left atrial pressure, mean arterial pressure increased and acidosis resolved. This suggests a real impact on cardiac output. During pulmonary hypertensive events, which were frequent in this series (40% of patients), left-to-right shunting was observed in the vertical vein and interpreted by the authors as beneficial. After repair, a patent vertical vein is a connection between the pulmonary venous atrium and the systemic venous system; it functions like an atrial septal defect. The authors also intentionally left an additional atrial septal communication in patients with obstructed TAPVC. The atrial septal defect was left to permit right-to-left shunting during pulmonary hypertensive crises.

An intentional atrial septal communication is commonly created for impaired right-sided heart function, and the benefits are easy to understand; systemic output is maintained, albeit at the expense of some systemic desaturation. This concept is widely applied to patients with a variety of diagnoses, . . . [Full Text of this Article]

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