Anatomical Correction of Obstructed Mixed TAPVC

This video shows the anatomical correction done for an obstructed mixed TAPVC in a 6-month-old child with failure to thrive.

TTE showed right sided and left lower pulmonary veins forming a common chamber and draining into the coronary sinus through a narrow obstructive communication. The left upper pulmonary vein was draining into the left innominate vein through a left vertical vein.

After sternotomy and pericardiotomy, the patient was put on cardiopulmonary bypass with a single RA cannula. The left vertical vein was noted. The aorta was looped and the PDA was ligated and divided. The left pulmonary artery was mobilized. Stay sutures were taken on the left atrial appendage to facilitate the left atrial incision later. The left vertical vein was dissected free. The left lower pulmonary vein was noted towards which the common pulmonary venous chamber was opened. The innominate vein was cannulated to mobilize the complete superior vena cava later. The right pulmonary artery was completely mobilized and retracted towards the head end. The superior vena cava was entirely mobilized from its bed and retracted towards the surgeon. Dissection was continued both behind and superior to the left atrium without dividing the superior vena cava. This is done to achieve a wide anastomosis between the common chamber and left atrium using both biatrial and superior approaches, which a coronary sinus baffle to left atrium with a patch cannot achieve. The narrow communication between the common chamber and the coronary sinus was dissected free. Marking sutures were taken on the vertical vein for alignment with the left atrial appendage. The left pulmonary vein to vertical vein junction was clamped. The vertical vein was clipped and divided from the innominate vein. The vertical vein was bevelled diagonally opposite to the attachment of the left upper pulmonary vein. The left atrial appendage was incised open. The left atrial appendage to vertical vein anastomosis was completed with no kink in the course of the vertical vein.

After applying aortic cross-clamp root, cardioplegia was given and the patient’s core was cooled to 18°C. The right atrium was opened transversely. The common pulmonary vein to coronary sinus communication was cut and the coronary sinus end was sutured. The right atrial incision was extended towards the midpoint of the posterior limbus under vision and then extended towards the left atrial appendage. Stay sutures were taken. The common pulmonary venous chamber was incised towards the opening of the left lower pulmonary vein. Total circulatory arrest at 18°C was initiated for a bloodless field. Anastomosis was started from the extreme corner of the left atrial appendage and left lower pulmonary vein origin and continued towards the limbus, thus anatomically, all the pulmonary veins will then drain directly into the left atrium.

Once the corner anastomosis was done under vision, circulation was resumed. The atrial septal defect was closed with an untreated pericardial patch to increase the left atrial volume. The right atrium was closed. Sinus rhythm resumed after releasing the cross-clamp. The transoesophageal echo showed a wide anastomosis of common pulmonary vein and left atrium. In the transthoracic echo, a white arrow showed the ASD patch, and the yellow arrow showed the wide unobstructed anastomosis. The anastomosis was larger than the mitral valve area which is possible only under direct vision with this technique. The vertical vein to left atrial appendage anastomosis was also flowing well.

References

1. Shumacker HB Jr, King H. A modified procedure for complete repair of total anomalous pulmonary venous drainage. Surg Gynecol Obstet. 112:763;1961 .
2. Tucker BL, Lindesmith GG, Stiles QR, Meyer BW. The superior approach for correction of the supracardiac type of total anomalous pulmonary venous return. Ann Thorac Surg. 1976;22:374-377.

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