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J Thorac Cardiovasc Surg 1995;109:389-390
© 1995 Mosby, Inc.

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Adjustable suture of the vertical pulmonary vein for repair of infracardiac total anomalous pulmonary venous connection

Beer-Sheba, Israel

The results of repair of total anomalous pulmonary venous connection (TAPVC) have dramatically improved over recent years. ¹ However, a higher mortality and morbidity still remain significant in patients less than 3 months of age who have right-sided hypertension, pulmonary venous obstruction, and low volume in the left side of the heart. ^2,3 Postoperative low cardiac output may persist because of a small and noncompliant left atrium and ventricle or episodes of reactive pulmonary hypertension.

Several surgical techniques have been suggested to reconstruct an unrestrictive wide connection between the left atrium and pulmonary veins, as this connection will allow the left side of the heart time to adapt and maintain cardiac output. ⁴

Most authors suggest ligation or interruption of the vertical vein just above the diaphragm, although the authors of a past report ⁵ were concerned about the occurrence of acute liver necrosis immediately after the operation. We believe that leaving an adjustable suture during the immediate postoperative period may be useful for venting of the left ventricle, especially if low cardiac output persists despite the creation of an wide left atrium-pulmonary vein anastomosis.

A 4-week-old infant weighing 2 kg was admitted because of increasing cyanosis, pulmonary edema, and hepatomegaly. Two-dimensional echocardiography with Doppler and color flow mapping study and cardiac catheterization demonstrated infracardiac type TAPVC with the portal system. The operation was performed with profound hypothermia and circulatory arrest (31 minutes). The repair was carried out by a wide anastomosis between the common pulmonary vein, with the incision being extended into the upper right pulmonary vein and the posterior left atrial wall. The interatrial communication was closed and an adjustable Prolene suture (Ethicon, Inc., Somerville, N.J.) was placed around the vertical vein below the lower pulmonary veins and just above the diaphragm. The suture was passed through a snare of an 8F polyethylene tube. After it was tightened, the suture was fixed in position with a series of hemoclips placed on the suture and the polyethylene tube, and the end was left beneath the linear alba. During the first 8 hours after the operation the patient had persistent low cardiac output associated with metabolic acidemia and oliguria despite maximal treatment with dopamine, dobutamine, and amrinone. The right atrial pressure ranged between 12 and 15 mm Hg, left atrial pressure between 22 and 25 mm Hg, and mean arterial pressure between 40 and 50 mm Hg. Echocardiography and Doppler flow study demonstrated moderately reduced left ventricular function with no evidence of tamponade or pulmonary hypertension. In addition, liver enzyme levels were highly elevated, indicating acute liver ischemia. At this point, the adjustable suture was completely opened. Rapid hemodynamic improvement ensued, with a significant rise of blood pressure, decrease of left atrial pressure to 15 mm Hg, and improvement of urine output and acid-base balance. In this particular case we elected not to retighten the suture because of documented liver damage. The patient was extubated 7 days later. Liver enzyme levels gradually decreased during the following days. Serial echocardiography and Doppler study (follow-up of 3 months) showed gradual decrease of the blood flow through the vertical vein and increase of left heart volume. We advocate the routine use of an adjustable suture around the common pulmonary vein during repair of TAPVC, especially in the presence of a diminutive noncompliant left atrium.

Footnotes

From the Department of Cardiothoracic Surgery,^a Department of Pediatric Cardiology, ^b Soroka Medical Center, Beer-Sheba, Israel.

J THORAC CARDIOVASC SURG 1995;109:389-90

References

1. Cobanoglu A, Menashe VD. Total anomalous pulmonary venous connection in neonates and young infants: repair in the current era. Ann Thorac Surg 1993;55:43-9.[Abstract]
   
2. Galloway AC, Campbell DN, Clarke DR. The value of early repair for anomalous pulmonary venous drainage. Pediatr Cardiol 1985;6:77-82.[Medline]
   
3. Turley K, Tucker WY, Ullyot DJ, Ebert PA. Total anomalous pulmonary venous connection in infancy: influence of age and type of lesion. Am J Cardiol 1980;45:92-7.[Medline]
   
4. Raisher BD, Grant JW, Martin TC, Strauss AW, Spray TL. Complete repair of total anomalous pulmonary venous connection in infancy. J THORAC CARDIOVASC SURG 1992;104:443-8.[Abstract]
   
5. Appelbaum A, Kirklin JW, Pacifico AD, Bargeron LM. The surgical treatment of total anomalous pulmonary venous connection. Isr J Med Sci 1975;11:89-96.[Medline]
   

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This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joseph Caspi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Caspi, J. Articles by Appelbaum, A. Search for Related Content PubMed PubMed Citation Articles by Caspi, J. Articles by Appelbaum, A.