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J Thorac Cardiovasc Surg 1997;114:132-134
© 1997 Mosby, Inc.

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PERICARDIAL PATCH AUGMENTATION OF RESTRICTIVE INNOMINATE VEIN AND DIVISION OF LEFT SUPERIOR VENA CAVA IN UNROOFED CORONARY SINUS SYNDROME

Leipzig, Germany

From Herzzentrum, University of Leipzig, Leipzig, Germany.

Received for publication Oct. 21, 1996 accepted for publication Nov. 12, 1996. Address for reprints: Jacques A. M. van Son, MD, Department of Cardiac Surgery, Herzzentrum Leipzig, Russenstrasse 19, Leipzig D-04289, Germany.

The unroofed coronary sinus syndrome is a spectrum of cardiac anomalies in which part or all of the common wall between the coronary sinus and the left atrium is absent; in most cases the anomaly is associated with a persistent left superior vena cava (SVC). ¹ In the absence of the coronary sinus, the left SVC connects with the left upper corner of the left atrium, between the opening of the left atrial appendage and the orifice of the left superior pulmonary vein. ² A coronary sinus atrial septal defect (ASD) is present in the posteroinferior region of the atrial septum, in the usual position of the coronary sinus orifice. The innominate vein is absent in 80% to 90% of patients with the unroofed coronary sinus syndrome and left SVC. ^3,4

The diagnosis of isolated unroofed coronary sinus syndrome with persistent left SVC usually is an indication for operation to avoid long-term arterial desaturation and its detrimental sequelae. In the absence of an innominate vein, the preferred repair consists of excision of the entire atrial septum except the anterior limbus, which is preserved as a protection for the atrioventricular node and bundle, ⁵ followed by placement of a pericardial patch in such a fashion that all of the pulmonary veins drain under the patch to the mitral valve orifice. A second useful method of repair consists of rerouting the coronary sinus to the roof of the left atrium in addition to reconstruction of the atrial septum. ⁶ In the presence of a physiologically unrestrictive or moderately restrictive innominate vein (defined as absence of a rise in pressure and a rise in pressure in the cranial left SVC to less than 20 mm Hg resulting from temporary occlusion of the distal left SVC, respectively), the left SVC is simply divided and oversewn below the innominate vein and the coronary sinus ASD is closed with a patch. We report an alternative technique of repair of unroofed coronary sinus with left SVC that is applicable in the presence of a physiologically restrictive innominate vein.

A 9-week-old prematurely born female infant with a body weight of 3.1 kg was admitted for surgical correction of an echocardiographically diagnosed unroofed coronary sinus, left SVC, and coronary sinus ASD. The clinical picture was dominated by mild cyanosis (systemic arterial oxygen saturation of 94%).

At operation through a median sternotomy, a left SVC was seen to enter the left superior portion of the left atrium; a small innominate vein (diameter 3 mm) connected the two SVCs. Temporary occlusion of the left SVC close to its entrance into the left atrium increased the pressure in the cranial segment of the left SVC to 24 mm Hg. On the basis of this observation, ligation of the left SVC was deemed inappropriate. A large pericardial patch was harvested; the majority of the patch was stored in saline solution and the remainder in 0.6% glutaraldehyde solution. After aortic and single venous cannulation, the patient was rapidly cooled to a rectal temperature of 18° C, circulatory arrest was established, and the venous and arterial cannulas were removed. An incision was made in the superior aspect of the innominate vein and the proximal 0.5 cm of the medial aspects of the right brachiocephalic vein and the left internal jugular vein, and a large rectangular untreated pericardial patch was sewn in place with 7-0 polypropylene suture (Prolene, Ethicon, Inc., Somerville, N.J.) in a continuous fashion (Fig. 1, A and B). Subsequently, the left SVC was divided close to its entrance into the left atrium and both ends were oversewn with 6-0 Prolene suture. Finally, the coronary sinus ASD was closed with a glutaraldehyde-treated pericardial patch. After the infant was weaned from cardiopulmonary bypass, pressure measurements in the right brachiocephalic vein and the left internal jugular vein demonstrated absence of a pressure gradient between the two. The postoperative course was uncomplicated; notably, there was absence of facial edema, venous engorgement, or chylothorax. At 9-month follow-up, the infant is in excellent physical condition.

View larger version (40K): [in this window] [in a new window]   Fig. 1. Technique of repair of unroofed coronary sinus with persistent left SVC, coronary sinus ASD, and restrictive innominate vein. A, Dashed line indicates incision of superior aspect of innominate vein and proximal and medial aspects of the right brachiocephalic vein and the left internal jugular vein. B, Augmentation of innominate vein with untreated rectangular pericardial patch. The left SVC is divided and both ends are oversewn.

References

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2. Shumacker HB Jr, King H, Waldhausen JA. The persistent left superior vena cava: surgical implications, with special reference to caval drainage into the left atrium. Ann Surg 1967;165:797-805.[Medline]
   
3. Sherafat M, Friedman S, Waldhausen JA. Persistent left superior vena cava draining into the left atrium with absent right superior vena cava. Ann Thorac Surg 1971;11:160-4.[Medline]
   
4. Quaegebeur J, Kirklin JW, Pacifico AD, Bargeron LM Jr. Surgical experience with unroofed coronary sinus. Ann Thorac Surg 1979;27:418-25.[Abstract]
   
5. Chiu IS, Hegerty A, Anderson RH, de Leval M. The landmarks to the atrioventricular conduction system in hearts with absence or unroofing of the coronary sinus. J Thorac Cardiovasc Surg 1985;90:297-300.[Abstract]
   
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This article has been cited by other articles:

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map 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): Jacques A. M. van Son Volkmar Falk Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by van Son, J. A. M. Articles by Mohr, F. W. Search for Related Content PubMed PubMed Citation Articles by van Son, J. A. M. Articles by Mohr, F. W.