The Double Patch Technique by MICS for Partial Anomalous Pulmonary Vein Connection and Sinus Venosus Atrial Septal Defect

A 34-year-old woman with type II dyspnea was diagnosed by echocardiography for partial anomalous vein connection with sinus venosus atrial septal defect, confirmed by an MRI. A two-patch repair technique through a video-assisted minimally invasive approach (MICS) was performed with excellent results.

This video tutorial shows how the authors were able to repair this pathology through a MICS approach. Few videos of this MICS repair technique exist, and the authors believe that this tutorial is a helpful demonstration that even congenital pathologies may be solved through small incisions.

Introduction
Out of all septal atrial defects, 10% are represented by the sinus venosus type and are frequently associated with partial anomalous pulmonary venous connections (PAPVC) (1). The purpose of the procedure is to correct the pulmonary vein flow to the left atrium, however, the consequences of the surgery might be both the superior vena cava stenosis or the injury of the sinus node (SN), thus more frequently associated to the single patch technique or the double-patch technique respectively (2). There are few published articles in the literature about this congenital repair by the double-patch technique through a video-assisted minithoracotomy. The authors aim to show step-by-step how MICS can be performed easily for this congenital population.

Patient Presentation
A 34-year-old woman was delivered by another institution with dyspnea (NYHA II) and findings in the echocardiography (ETT) for septal atrial defect and left atrium enlargement. A new ETT was performed in the authors’ center where enlargement of both right and left atrium and a right superior pulmonary vein connecting to superior vena cava with sinus venosus atrial septal defect (SVASS). A left-to-side shunt was also observed. A magnetic resonance imaging (MRI) corroborated the partial anomalous pulmonary vein connection entering into the right atrium and the atrial septal defect as well. Pulmonary hypertension was mild to moderate. The patient was then submitted to minimally invasive surgery.

Surgical Technique Videos
A right minithoracotomy was performed in the 4th-5th intercostal space (ICS). Two accessory ports (5 mm) were used to insert the Chitwood aortic clamp (right 3rd intercostal space [ICS], midaxillary line) and video camera (right 4th ICS). A Mohr atrial retractor (Geister Medizintecknik GmBH, Tuttlingen, Germany), long-shafted instruments for mini-invasive surgery (Geister), and long-shafted knotters were used. A Storz (Karl Storz SE, Tuttlingen, Germany) video camera was also used. Long arterial and venous cannulas (Edwards Lifesciences, Irvine, CA, USA or Medtronic, Minneapolis, MN, USA) for cardiopulmonary bypass management were inserted through a minimal incision (3-4 mm) in the femoral artery and both jugular and femoral veins, and in all cases, their position was guided and controlled by transesophageal echocardiography (TEE).  A single dose of 2,000 ml Bretschneider cardioplegic solution was given.

Preoperative Echocardiography and Right Atrium Approach
A right superior pulmonary vein connecting to the superior vena cava with sinus venosus atrial septal defect was observed at the TEE. A left-to-side shunt was also observed (QP/qs: 1.4). The right atrium was approached and the pathology was observed directly and clearly.

The Double-Patch Technique
First Patch: Creation of the passageway to the atrial septal defect to deliver anomalous pulmonary venous blood to the left atrium.

Enlargement of the Cavo-Atrial Junction
Second Patch: A second patch was then used to enlarge the cavo-atrial junction with a 4.0 polypropylene. This step is advisable in order to avoid the narrowing of the superior vena cava. It is important to take care of the sinus node and avoid its posterior dysfunction.

Final Transesophageal Echocardiography
Neither left-to-right shunt nor transseptal flow was observed in the postoperative echocardiography. The total procedure, CPB, and cross-clamp time was 240, 180, and 100 minutes respectively.

Outcome and Discussion
The transatrial septal velocity measurement by doppler ETT in the postoperative confirmed the atrial septal defect was solved and the correct flow to the left atrium destiny of the PAPVC. The patient had no postoperative complications and was discharged on the fourth day. A follow-up after six months with a new ETT and electrocardiogram revealed freedom from transatrial flow and SN dysfunction respectively.

The main advantage of the two-patch technique is the lower incidence of SVC stenosis on long-term follow-up, however, as many as 55% may have SN dysfunction while incising the SVC anteriorly. This may be directly related to the SN itself, as well as its supply artery (1). Vikse et al have shown in a meta-analysis of 21455 cadaveric hearts that the SN artery course is precaval in almost 38.4% of the cases, and there is no difference, despite the coronary dominance (3). The authors had not had this complication, but it was an isolated case.

Although this technique may initially affect the SN, there are currently reports showing potential recovery on the long-term follow-up despite compromising the arterial blood supply (1). The authors believe that in the higher junction of the uppermost pulmonary veins with the SVC, it is advisable to use the Warden procedure rather than the two-patch technique in order to avoid the SN dysfunction (4, 5). The minimally invasive access in this pathology is not well-documented and there are even very few tutorial videos. The 1080 HD camera has enabled the authors to clearly record the technique. A weak point to see in this case is the long CPB time, but this might be related to the use of Bretschneider cardioplegic solution and its rewarming time required. Several groups feel more confident with the use of Del Nido cardioplegia solution and they have substantially reduced the CPB time, and this might be a good option in these congenital cases.

References

1. Stewart RD, Bailliard F, Kelle AM, Backer CL, Young L, Mavroudis C. Evolving Surgical Strategy for Sinus Venosus Atrial Septal Defect: Effect on Sinus Node Function and Late Venous Obstruction. Ann Thorac Surg. 2007;84(5):1651-1655.
2. Elzein C, Abdulkarim M, Abbas U, Vricella L, Ilbawi M. Repair of Superior Sinus Venosus Atrial Septal Defect Using a Modified Two-Patch Technique. Ann Thorac Surg. 2020;109(2):583-587.
3. Vikse J, Henry BM, Roy J, Ramakrishnan PK, Hsieh WC, Walocha JA, et al. Anatomical Variations in the Sinoatrial Nodal Artery: A Meta-Analysis and Clinical Considerations. PLoS One. 2016 Feb 5;11(2):e0148331.
4. Warden H, Gufstason R, Tarnay T, Neal WA. An Alternative Method for Repair of Artial Anomalous Pulmonary Venous Connection to the Superior Vena Cava. Ann Thorac Surg. 1984;38(6):601-605.
5. Schuster SR, Gross RE, Colodny AH. Surgical Management of Anomalous Right Pulmonary Venous Drainage to the Superior Vena Cava, Associated With Superior Marginal Defect of the Atrial Septum. Surgery. 1962;51:805-808.

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