Minimally Invasive Repair of Supracardiac Total Anomalous Pulmonary Venous Connection

The minimally invasive approach has been utilized to correct numerous congenital cardiac anomalies, such as ASD, Partial AV canal, Subaortic web resection, VSD, and PAPVC with good results (1). This approach is described for the supracardiac TAPVC here. To the best of the authors’ knowledge, this is the first report pertaining to this particular type of operation. 

The patient was a 5-month-old male weighing 4.6 kilograms. Echo and CT angiographic studies indicated nonobstructive supracardiac TAPVC, along with a large vertical vein, moderate-sized ASD, and severe pulmonary hypertension (PH). 

The procedure was performed through a small vertical axillary incision on the right side, which is the authors’ routine approach for most minimally invasive pediatric cardiac surgeries. The pericardium was retracted to the sides to expose the cardiac structures. Using this approach, the posterior chamber with the pulmonary venous drainage was easily visible behind the right and left atria. 

Access to the vertical vein, which is located in the left hemithorax, was one important concern. The vertical vein was easily accessible by simply pulling and retracting the left side of the pericardium. The large vertical vein was exposed behind the pericardium, with the phrenic nerve over the visceral pleura. The pleura and phrenic nerve were meticulously dissected and separated from the vertical vein. The vein was controlled by passing a thick Ethibond suture around it, without enclosing the nerve. 

Cardiopulmonary bypass was started by cannulating the aorta, the inferior vena cava, and the superior vena cava. Cardioplegia was administered and recovered from the right atrium, and the cardioplegic catheter was then removed to have a better operating field. The dissection of the pericardial attachments between the left atrium posteriorly and the pulmonary venous chamber anteriorly was performed. 

A large opening was formed in the posterior wall of the left atrium. The opening site on the posterior chamber was then marked and cut, just opposite the left atrial incision. A wide anastomosis was achieved by widening the openings. The anastomosis between the posterior common chamber and the left atrium was performed starting from the left corner and completed in the right corner. The lateral thoracotomy incision provided a good direct horizontal view, making this anastomosis easy and fast.  

The ASD was then closed. To establish a modest safety connection between the left and right sides of the circulation, it is advised to either create a hole in the ASD patch or leave the vertical vein patent but banded to 5 mm. The authors routinely employ the second approach. This pathway can guarantee the passage of blood to flow between the right and left sides early after the operation, resulting in stable hemodynamics in the event of pulmonary hypertensive crisis or high left atrial pressure, respectively. However, it is susceptible to being occluded by a transcatheter device years later. 

The atrium was then closed, the aorta was unclamped, and the procedure was concluded. The post-operative echo showed no stenosis in the pathway and a small flow through the vertical vein banding. The patient experienced a smooth recovery and was extubated the day after the operation. 

References

1. Said SM, Greathouse KC, McCarthy CM, Brown N, Kumar S, Salem MI, Kloesel B, Sainathan S. Safety and efficacy of right axillary thoracotomy for repair of congenital heart defects in children. World Journal for Pediatric and Congenital Heart Surgery. 2023 Jan;14(1):47-54.

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