J Thorac Cardiovasc Surg 2006;132:730
© 2006 The American Association for Thoracic Surgery
Reply to the Editor
Emile Bacha, MD
Harvard Medical School, Boston, Mass
I thank Dr Kostantinov for his thoughtful letter. I entirely agree with the first half of his statement. For complex total anomalous pulmonary venous connection, especially with a poorly developed confluence, the primary sutureless technique (in which the opened edge of the posterior left atrium is sutured to the posterior pericardium, leaving the filleted open pulmonary venous confluence to drain freely in the neo–left atrium) offers many advantages. It has become my default technique when the traditional pulmonary venous confluence to left atrium suture anastomosis is impractical. As of June 2006 (11 months after the operation), the subject of our report is growing well, with no evidence of pulmonary venous obstruction according to echocardiography. Clearly, I also agree that "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," and that it "It is crucial to open the venous confluence widely to ensure an unobstructed connection." Those are surgical tenets. To incise the pleuropericardial junction inadvertently, however, one must be cutting quite deeply into the pulmonary veins themselves. That is something that is rarely required. Usually, an incision of a few millimeters into each vein will suffice. Occasionally, the pulmonary veins themselves are diffusely stenotic and require a deeper incision. That is exceptional, however, and usually occurs in a reoperative situation. I would also caution against using sutures at the level of the pleuropericardial junction and pulmonary veins (Konstantinov's Figure 1, B). The risk of recurrent or residual pulmonary venous stenosis is ever present in these patients, and even a 1- to 2-mm encroachment into the pulmonary venous lumen by a suture intended for hemostasis may have catastrophic consequences. If one feels that a suture at this level is absolutely necessary, then the lumen of the veins should be inspected after tying it.
Related Article
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Primary sutureless repair of total anomalous pulmonary venous connection: The value of intrapleural hilar reapproximation
- Igor E. Konstantinov
J. Thorac. Cardiovasc. Surg. 2006 132: 729-730.
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