How to Do It
Right Atrial Flap Repair for Left Superior Vena Cava Draining into Left Atrium Ersin Erek1
Selim Aydin1
Dilek Suzan1
1 Department of Cardiovascular Surgery, Acibadem University Atakent
Hospital, Istanbul, Turkey Thorac Cardiovasc Surg
Address for correspondence Ersin Erek, MD, Department of Cardiovascular Surgery, Acibadem University Atakent Hospital, Halkali Merkez Mh. Turgut Ozal Bulvari No:16 34303 Kucukcekmece, Istanbul, Turkey (e-mail:
[email protected]).
Abstract Keywords
► congenital heart disease ► right atrial flap repair ► persistent left superior vena cava
There are different surgical methods for the repair of persistent left superior vena cava that connects directly to the left atrium. We describe an extracardiac surgical technique that includes direct anastomosis of persistent left superior vena cava to the right atrium with right atrial flap and autologous pericardium. We have performed this procedure in four cases and there is no obstruction at postoperative control studies. Right atrial flap repair is a feasible extracardiac technique that offers growth potential.
Introduction Persistent left superior vena cava (PLSVC) is a common vascular anomaly usually associated with other congenital heart diseases.1 The most common site of PLSVC drainage is into coronary sinus. In some patients, PLSVC drains directly into the left atrium (LA), which results in significant right to left shunt.2 Surgical repair is generally performed by intracardiac rerouting, using a baffle to divert blood flow from left superior vena cava (SVC) to the right atrium (RA). Extracardiac techniques such as using synthetic tube grafts or pericardial rolls for rerouting are other alternatives. Especially in small children, these techniques have some inherited disadvantages, such as technical difficulty, risk of stenosis, occlusion, and lack of growth potential. In this report, a new extracardiac repair technique with right atrial flap and autologous pericardium is described.
Technique After median sternotomy, pericardium was opened and a large piece of pericardium was harvested and treated with 0.6% glutaraldehyde solution. PLSVC was mobilized from the connec-
received July 29, 2015 accepted September 8, 2015
tion between LA and innominate vein. In case of hemiazygos continuation, it was left in its place; otherwise, hemiazygos vein was doubly ligated and divided. Cardiopulmonary bypass (CPB) was instituted by cannulating ascending aorta, inferior vena cava, and both SVCs. After repair of intracardiac defects, aortic cross-clamp was released. While the heart was beating under CPB, the left SVC was transected at its entrance to LA and then carried over to the ascending aorta. A 2- to 3-cm wide flap was created from the anterior wall of the RA (►Figs. 1a and 2a), and the flap was anastomosed to the posterior side of the PLSVC (►Figs. 1b and 2b). The anterior side of the anastomosis and the anterior wall of the RA were reconstructed with a large autologous pericardial patch (►Figs. 1c and 2c). We performed this procedure in four consecutive cases. Their ages were between 3 months and 4 years. The diagnoses were partial atrioventricular septal defect with left atrial isomerism in two patients, complete atrioventricular septal defect in one patient, and unroofed coronary sinus in one patient. In all cases, PLSVCs were directly draining into LA. One of them had hemiazygos continuation. There was no obstruction in PLSVC flow in early postoperative period as confirmed by echocardiography. CT angiography showed patent PLSVC pathway in one patient at the third postoperative month.
© 2015 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0035-1564931. ISSN 0171-6425.
Right Atrial Flap Repair of Left Superior Vena Cava
Erek et al.
Fig. 1 Operative photo, anesthesiologist view. (a) Marked right atrial flap. (b) Connection of the right atrial flap to the PLSVC. (c) After completion of the reconstruction.
Comment There are alternative surgical methods for the correction of PLSVC that connects directly to the LA. Simple ligation can be performed in small PLSVC cases. Intra-atrial baffle rerouting is usually applicable in big children and adults with large atriums. In small atriums, intra-atrial baffle may obstruct systemic or pulmonary venous return.3 Left bidirectional cava-pulmonary anastomosis can be done in single-ventricle
Fig. 2 Schematic representation of the right atrial flap modification.
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patients with low pulmonary artery pressure. Extracardiac techniques may be technically more straightforward allowing a reduction in CPB time. Direct anastomosis of PLSVC to right atrial appendix is also possible, but in most of the cases, it is difficult to make a tension-free anastomosis. Shumacker et al reported a repair with an autogenous graft from left or right atrial anterior wall.1 In all of the cases, flap excision from the anterior walls of both atriums may have technical difficulties, and especially in small children, this method is nearly
Right Atrial Flap Repair of Left Superior Vena Cava impossible because of small atriums. Reddy et al reported a direct reimplantation of the PLSVC to right SVC through a tunnel that was created between the aortic arch and the pulmonary artery.4 Due to a dilated aorta or pulmonary artery, creating enough space for routing SVC under aortic arch may be difficult in some cases. Ugaki et al reported that anastomosis of the PLSVC to right SVC can be done from the superior part of arcus aorta.2 Although mobilization of the PLSVC is difficult like this, Bilal et al reported bidirectional cava-pulmonary anastomosis in five Fontan cases and anastomosis with polytetrafluoroethylene (PTFE) graft in four cases.5 The use of a PTFE graft may not be suitable for small children because of the low patency rates of the grafts. Right atrial flap modification is easy for reconstruction and applicable for all age groups. This modification can be done on a beating heart while the heart is perfused so that ischemic time is reduced. Another advantage of this procedure is the possible effect of growth potential.
Funding None. Acknowledgment We thank Dr Safa Gode for illustrations.
References 1 Shumacker HB Jr, King H, Waldhausen JA. The persistent left superior
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Conflicts of Interest The authors have declared no conflicts of interest.
Erek et al.
vena cava. Surgical implications, with special reference to caval drainage into the left atrium. Ann Surg 1967;165(5):797–805 Ugaki S, Kasahara S, Fujii Y, Sano S. Anatomical repair of a persistent left superior vena cava into the left atrium. Interact Cardiovasc Thorac Surg 2010;11(2):199–201 Gontijo B, Fantini FA, de Paula e Silva JA, Barbosa JT, Vrandecic MO, Masci MdaG. The use of PTFE graft to correct anomalous drainage of persistent left superior vena cava. J Cardiovasc Surg (Torino) 1990;31(6):815–817 Reddy VM, McElhinney DB, Hanley FL. Correction of left superior vena cava draining to the left atrium using extracardiac techniques. Ann Thorac Surg 1997;63(6):1800–1802 Bilal MS, Sarioglu T, Kinoglu B, et al. Konjenital kalp anomalilerine eşlik eden sol superior vena kava’ya yönelik cerrahi stratejiler. Turk Kardiyol Dern Ars 1995;23:369–374
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