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

This patient is a 62 yo Female with a history of chronic cough and exercise intolerance who presented to an outside hospital for elective Calcium scoring via Cardiac CT. This demonstrated previously undiagnosed anomalous pulmonary venous return (scimitar vein) to her right atrium. She was referred to our adult congenital heart disease program for further workup. Cardiac MRI revealed moderate right ventricular dilation, and a Qp:Qs of 1.92.

3D MRI reconstruction is shown demonstrating the anomalous venous drainage. Given her hemodynamically significant shunt and evidence of right ventricular overload, the patient was consented for scimitar vein repair via median sternotomy.

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 .

The pericardiotomy containing the scimitar vein is expanded in preparation for the conduit.

The anomalous vein is snared for hemostasis.

Right atriotomy is performed and extended.

An incision is made in the interatrial septum for left atrial exposure.

Here, the pump sucker demonstrates the orifice of the scimitar vein in the right atrium.

The anomalous vein is transected at the level of the right atrium and then oversewn.

The transected vein is sized and a 20mm conduit is selected.

The 20mm conduit is anastomosed to the scimitar vein.

The conduit is tunneled into the pericardial space and beveled.

The septal incision is expanded and retracted for visualization of the left atrial floor.

The left atrial floor is inspected, and the site of the conduit-atrial anastomosis was selected and cut .

The conduit is tunneled into the left atrium.

The conduit is anastomosed to the left atrium.

A vascular probe is used to ensure patency of the conduit.

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. The patient was extubated in the OR, and a transesophageal echo was performed.

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

Chest tubes were removed on post-operative day 1. The patient developed atrial fibrillation which was controlled with amiodarone and resolved by post-operative day 2 and she had an otherwise uncomplicated post-operative course, and she will remain on aspirin and Plavix for 3 months following her operation.

This diagram demonstrates the completed operation, with normal cardiopulmonary anatomy and physiology re-established.

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