Superior Approach (Tucker's Repair) for Repair of Supracardiac Total Anomalous Pulmonary Venous Connection (TAPVC)

As this article and video demonstrate, the superior approach for repair of supracardiac TAPVC carries several advantages, including minimal-to-no heart manipulation, ease of accessibility through the transverse pericardial sinus, and all parts of the anastomosis readily visible, which ensures creation of the largest possible anastomosis with less risk of anastomotic distortion. 

In this case, a three-day-old, 2.6kg male was diagnosed prenatally with supracardiac TAPVC. After birth, he was doing well clinically and had low, normal oxygen saturation with no difficulty in feeding. The decision was made to wait and watch. After three months, he was brought in for operation for an elective repair. Cardiac CT at that time showed his pulmonary venous confluence was double the normal size. 

The procedure was performed through a median sternotomy, with aorto-bicaval cannulation on mild hypothermic cardiopulmonary bypass. The ductus arteriosus was doubly ligated. The baseline pulmonary arterial pressure was normal. After initiation of cardiopulmonary bypass, the vertical vein was thoroughly mobilized and encircled with a snare. Also, the pulmonary venous confluence was exposed through the transverse pericardial sinus and marked along its entire length parallel to the left atrial roof. Cardioplegic arrest was then achieved with antegrade cardioplegia. Both cavae were snared, and then an oblique, right atriotomy was made. A right-angled clamp placed through the interatrial septum marked the left atrial roof and stay sutures were placed. This was followed by a left atrial roof incision that extended in parallel to the pulmonary venous confluence, all the way to the left atrial appendage.  

Retraction of the ascending aorta was performed all the way to the left facilitates exposure. Snaring the vertical vein facilitated the incision into the pulmonary venous confluence, which was made as wide as possible without extending into any of the pulmonary veins. Direct pulmonary venous confluence-to-left atrial anastomosis was then constructed using running 7-0 Prolene suture. The septum primum was then resected, and a bovine pericardial patch was used to translocate the atrial septum to the right atrial side. 

The heart was de-aired and the-cross clamp removed. This was followed by closure of the right atriotomy. The main pulmonary artery was then incised, and the valve was inspected. There was an adequate orifice. A second bovine pericardial patch was used to close the main pulmonary arteriotomy. 

The patient was weaned off cardiopulmonary bypass without difficulty, and the vertical vein was divided and oversewn at both ends. This was followed by hemostasis and decannulation. The chest was then closed in a routine fashion, and the patient was extubated in the operating room. 

The aortic cross-clamp time was seventy-eight minutes, and the cardiopulmonary bypass time was 143 minutes. The echocardiogram and CT scan showed widely patent left atrial/pulmonary venous confluence anastomosis and no significant gradient across the right ventricular outflow tract. 

The remaining postoperative course was uneventful, and the patient was discharged on the fifth postoperative day. He continued to do well during the postoperative period. 

References

1. Liufu R, Shi G, Zhu F, Guan Y, Lu Z, Chen W, et al. Superior approach for supracardiac total anomalous pulmonary venous connection. Ann Thorac Surg 2018; 105(5): 1429-35
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;22:374–7.
3. Supracardiac total anomalous pulmonary venous connection: the transaortopulmonary approach. Le Bret E, Roubertie F, Belli E, Stos B, Sigal-Cinqualbre A, Roussin R, Serraf A. Ann Thorac Surg. 2009 Sep;88(3):e27-8

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