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

This is a 3-day-old, 2.6 kg boy who was diagnosed prenatally with supracardiac TAPVC. After birth, he was doing well clinically and had low normal oxygen saturation with no difficulty in feeding so decision at that time was made for watchful waiting. At age 3-months, he was brought to the operating for an elective repair. Cardiac CT at that time showed doubling of the size of his pulmonary venous confluence.

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

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

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

The aortic cross clamp time was 78 minutes and the cardiopulmonary bypass time was 143 minutes.

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.

We do believe the superior approach for repair of supracardiac TAPVC carries several advantages including: minimal-to-no heart manipulation, easily accessible through the transverse pericardial sinus with all parts of the anastomosis readily visible which ensures creation of the largest possible anastomosis with less risk of anastomotic distortion.

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