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J Thorac Cardiovasc Surg 2006;132:729-730
© 2006 The American Association for Thoracic Surgery

Letter to the Editor

Primary sutureless repair of total anomalous pulmonary venous connection: The value of intrapleural hilar reapproximation

Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada

To the Editor:

I read with great interest the recent article of Meadows and colleagues¹ describing an elegant approach to the repair of an obstructed total anomalous pulmonary venous connection in a critically ill neonate. As clearly demonstrated, the venous confluence was very poorly developed in the patient, necessitating the use of primary sutureless technique.¹ This technique of suturing the atrium directly to the posterior pericardium around the opened confluence of the pulmonary veins^2,3 is now frequently used for primary repair of the total anomalous pulmonary venous connection in the adhesion-free pericardial cavity.⁴ Despite the absence of retrocardiac adhesions, operative mortality is not increased with sutureless technique as a primary procedure relative to sutureless repair as a reoperation.⁴

When used for primary repair in adhesion-free thin pericardium in a neonate, however, the sutureless technique should be applied with caution. A thorough understanding of the anatomic relationship of the pulmonary venous confluence, posterior pleuropericardial junction, and phrenic nerve is required to perform a complication-free repair.⁵ It is crucial to open the venous confluence widely to ensure an unobstructed connection. Longitudinal incision in the pulmonary veins may, however, occasionally violate the thin pleuropericardial junction (Figure 1, A), with subsequent bleeding into the pleural space.⁴ This complication can be successfully managed by intrapleural hilar reapproximation technique (Figure 1, B). The pleuropericardial flap is retracted toward the midline, and the pleura is reapproximated to achieve hemostasis.

View larger version (46K): [in this window] [in a new window]   Figure 1. Transpericardial incision in pulmonary veins (A) may result in violation of thin pleuropericardial junction (B). Pleuropericardial flap is then retracted toward midline, exposing anterior aspect of pulmonary hilum (B). Parietal and visceral pleura can then be approximated to achieve hemostasis. RPA, Right pulmonary artery; SVC, superior vena cava; Ao, aorta; LPA, left pulmonary artery, LV, left ventricle; IVC, inferior vena cava; PVs, pulmonary veins.

	References

Top References

 

1. Meadows J, Marshall AC, Lock JE, Scheurer M, Laussen PC, Bacha EA. A hybrid approach to stabilization and repair of obstructed total anomalous pulmonary venous connection in a critically ill newborn infant. J Thorac Cardiovasc Surg. 2006;131:e1-e2.[Free Full Text]
   
2. Lacour-Gayet F, Rey C, Planche C. Pulmonary vein stenosis. Description of a sutureless surgical procedure using the pericardium in situ. Arch Mal Coeur Vaiss 1996;89:633-636.[Medline]
   
3. Caldarone CA, Najm HK, Kadletz M, Smallhorn JF, Freedom RM, Williams WG, et al. Relentless pulmonary vein stenosis after repair of total anomalous venous drainage. Ann Thorac Surg. 1998;66:1514-1520.[Abstract/Free Full Text]
   
4. Yun TJ, Coles JG, Konstantinov IE, Al-Radi OO, Wald RM, Guerra V, et al. Conventional and sutureless techniques for management of the pulmonary veins, evolution of indications from postrepair pulmonary vein stenosis to primary pulmonary vein anomalies. J Thorac Cardiovasc Surg. 2005;129:167-174.[Abstract/Free Full Text]
   
5. Freedom RM, Yoo SJ, Coles JG, Konstantinov IE. Total anomalous pulmonary venous connections. In: Freedom RM, editor. The natural and modified history of congenital heart disease. New York: Future Publishing; 2003. pp. 282-289.
   

This Article Full Text (PDF) 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): Igor E. Konstantinov Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Konstantinov, I. E. Search for Related Content PubMed PubMed Citation Articles by Konstantinov, I. E. Related Collections Pleura Congenital - acyanotic Pericardium Related Article