Near-Total Anomalous Pulmonary Venous Connection Repair: Left Atrial Appendage to Vertical Vein Anastomosis

The authors present a case of near–total anomalous pulmonary venous connection repair using left atrial appendage to vertical vein anastomosis. This was a 27-year-old woman who presented with exertional intolerance, mild cyanosis, and no comorbidities. Her transthoracic echocardiography revealed enlarged cardiac chambers on her right side, diminution of the left atrium, and a single pulmonary vein draining into the left atrium and common pulmonary venous chamber behind the left atrium. The transoeophageal echocardiography bicaval view showed a second atrial septal defect with a right to left shunt. Cardiac CT defined the anatomy of the anomolaous pulmonary venous return, with left and right upper pulmonary veins draining into a common pulmonary venous chamber, and a vertical vein draining this chamber into the innominate vein. Three-dimensional reconstruction showed a giant venous arch formed by the vertical vein, innominate vein, and the superior vena cava (SVC).

After a median sternotomy, the vertical vein was exposed extrapericardially by excision of the thymic tissues. The vertical vein to innominate junction was demonstrated.The pericardium was opened and suspended to the edges of the sternotomy incision. Cardiopulmonary bypass was established via aortic and bicaval cannulation. The left side of the pericardium was incised to interiorize the vertical vein, which was mobilized from the left mediastinal pleura, taking care of the left phrenic nerve.The heart was then arrested using cold antegrade cardioplegia. Then, the right atrium was opened vertically and the shallow left atrium was examined. Adequacy of the left atrial appendage was assessed, ensuring an orifice close in size to that of the mitral valve orifice.

The left atrial appendage was oriented with 3/0 silk sutures, then the vertical vein was ligated distally. The left atrial appendage tip was excised leaving an adequate aperture. Then, the vertical vein was incised on its medial aspect, extending the incision medially into the common pulmonary venous chamber. The left atrial appendage was anastomosed to the vertical vein using a 4/0 proline stich. Attention was then diverted to the ASD, which was closed by a bovine pericardial patch using a continuous proline suture. The left heart chambers were de-aired and the cross clamp was removed. The heart resumed a normal sinus rhythm on no inotropes.

Reference

Ammannaya GKK, Mishra P, Khandekar JV. Left sided PAPVC with intact IAS-surgically managed with vertical vein anastomosis to LA appendage: a rare case report. Int J Surg Case Rep. 2019;59:217-219.

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