Superior Approach for Correction of the Supracardiac Type of Total Anomalous Pulmonary Venous Drainage

Surgical Technique:
Through the standard median sternotomy, the great vessels were fully mobilized and the right pulmonary artery was surrounded with a vessel loop. The aorta and right atrium were cannulated and cardiopulmonary bypass (CPB) was established, and cooling to 18 ºC was accomplished. Patent ductus arteriosus (PDA) was ligated and the persistent vertical vein (PVV) was identified and surrounded with a tie but not occluded. The ascending aorta was clamped and cardiac arrest achieved by antegrade crystalloid cardioplegia. The ascending aorta was transected and the pulmonary artery was mobilized to the left side, leaving an excellent exposure thought the transverse sinus of the common pulmonary venous trunk (CPVT) and the superoposterior aspect of the left atrium (LA).

Total circulatory arrest was started and the venous cannula was removed to obtain optimal exposure. The tie about the PVV was pulled up to occlude it. A parallel incision was made along the CPVT, and the left atrial appendage was completely removed and the incision was enlarged towards the right atrium. A large anastomosis was fashioned between the two structures using a locking continuous suture line with 7/0 polypropylene. The PFO was left open. The CPB was re-established and an end-to-end anastomosis was performed in the ascending aorta. The PVV was tied off and the chest was closed in routine fashion.

Conclusion:

• The superior approach through the transverse sinus affords excellent exposure of the pulmonary venous trunk and left atrium.
  
• Appendage removal ensures a wide anastomosis and prevents a likely compression.
  
• Although not necessary, aortic transection can help an exposure. Alternatively, a tape around the transverse sinus shifts both aorta and pulmonary artery to the left side.