Intraatrial Baffle Repair of Partial Anomalous Pulmonary Venous Return via Vertical Right Axillary Thoracotomy
The patient is a four-year-old, 17 kg boy who was diagnosed with a secundum atrial septal defect (ASD) and severe right atrial and right ventricular enlargement. Intraoperatively, he appeared to have a sinus venosus ASD with partial anomalous pulmonary venous return (PAPVR) of the right upper and middle lobar pulmonary veins (PVs) to the superior vena cava (SVC) and its junction with the right atrium.
The procedure was performed through a vertical right axillary thoracotomy (VRAT). First, the right chest was entered through third intercostal space and the PVs were visualized. The pericardium was entered 2 cm anterior to the right phrenic nerve. The anomalous PVs were then confirmed to be entering the SVC/right atrial junction.
Next, cardiopulmonary bypass was initiated via central aortic and single atrial, then bicaval, cannulation. An ascending aorta cardioplegia needle was then placed, and the ascending aorta was cross-clamped. An oblique right atriotomy was then performed and the intracardiac anatomy was confirmed.
A bovine pericardial patch was used to create an intraatrial baffle and surgeons enlarged the original ASD by resecting the septum primum. The bovine pericardial patch was then sewn with running 5-0 Prolene sutures, thus routing the anomalous PVs through the enlarged ASD into the left atrium.
The right atriotomy was then closed with running 5-0 Prolene sutures. The aortic root vent was placed back in the ascending aorta and the heart was deaired. The patient was then weaned off cardiopulmonary bypass without difficulty. Post-bypass transesophageal echocardiogram showed excellent ventricular function, no residual shunt, and unobstructed pulmonary venous and superior vena caval pathways. All cannulae were then removed and protamine was administered, and hemostasis was achieved.
Next, a 19 Fr channeled drain was placed through the right chest, after which the pericardium was closed with three interrupted Prolene sutures, leaving windows in between for drainage. The rest of the closure was done in a routine fashion.
Cardiopulmonary bypass time was 98 minutes and cross-clamp time was fifty-six minutes. The patient was extubated in the operating room and discharged on postoperative day one. He continued to do well during his follow-up.
This case demonstrated that the VRAT technique is superior to median sternotomy in repairing simple congenital heart defects and is associated with far superior cosmetic results and shorter length of stay.
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2. Rao RK, Varadaraju R, Basappa G, Nagaraja PS. Repair of Sinus Venosus Defects With Partial Anomalous Pulmonary Venous Connection in Children by Modified Right Vertical Infra Axillary Thoracotomy. Innovations (Phila). 2019 Nov/Dec;14(6):553-557. doi: 10.1177/1556984519874800. Epub 2019 Sep 11. PMID: 31506015.