Repair of Partial Anomalous Pulmonary Venous Return (Scimitar Vein) via Interposed Polytetrafluoroethylene (PTFE)

A sixty-two-year-old female with a history of chronic cough and exercise intolerance initially presented for elective calcium scoring via cardiac CT. The scan showed previously undiagnosed anomalous pulmonary venous return (scimitar vein) in the patient’s right atrium. Further workup revealed moderate right ventricular dilation and a Qp/Qs ratio of 1.92. The video accompanying this article shows a 3D MRI reconstruction that demonstrates the anomalous venous drainage.  

Given the patient’s hemodynamically significant shunt and evidence of right ventricular overload, she was scheduled for scimitar vein repair via a median sternotomy. 

Surgical procedure 

The patient was opened and cannulated in the standard fashion, and the scimitar vein was readily exposed. The scimitar vein was encircled with umbilical tape. Then the pericardiotomy containing the scimitar vein was expanded in preparation for the conduit. 

Next, the anomalous vein was snared for hemostasis. Then a right atriotomy was performed and extended. An incision was made in the interatrial septum for left atrial exposure. In the video linked above, the pump sucker demonstrates the orifice of the scimitar vein in the right atrium. 

The anomalous vein was transected at the level of the right atrium and then oversewn. The transected vein was sized, and a 20mm conduit was anastomosed to the scimitar vein. The conduit was tunneled into the pericardial space and beveled. 

The septal incision was expanded and retracted for visualization of the left atrial floor. The left atrial floor was inspected, and the site of the conduit-atrial anastomosis was selected and cut. The conduit was tunneled into and anastomosed to the left atrium. A vascular probe was used to ensure patency of the conduit. 

After this, the interatrial septum and right atriotomy were closed primarily. Hemostasis was achieved, and the patient was successfully weaned and decannulated from cardiopulmonary bypass without complication. Finally, the patient was extubated in the OR, and a transesophageal echo was performed. 

The echo demonstrated a patent anastomosis with egress from the conduit to the left atrium. The patient was then transferred to the CVICU in stable condition. 

Post-operation 

The patient’s chest tubes were removed on post-operative day 1. The patient also developed atrial fibrillation, which was controlled with amiodarone and resolved by post-operative day 2. Otherwise, she had an uncomplicated post-operative course. The patient will remain on aspirin and Plavix for three months following the operation. 

Reference

1. Lam TT, Reemtsen BL, Starnes VA, Wells WJ. A novel approach to the surgical correction of scimitar syndrome. The Journal of Thoracic and Cardiovascular Surgery. 2007;133(2):573-574. doi:10.1016/j.jtcvs.2006.10.021

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