Alternative Technique for Repair of Sinus Venosus Atrial Septa1 Defect J. R. L. Hamilton, FRCSEd (C/Th), S. G. Brooks, FRCS, and D. R. Walker, FRCS Killingbeck Hospital, Leeds, United Kingdom
A technique is described for closure of a sinus venoms atrial septal defect using a single patch held in place by sutures placed from outside the right atrium and underneath the superior vena cava. The superior vena cava does not require enlargement and potential damage to the artery to the sinoatrial node is avoided. (Ann Thorac Surg 1991;51:1444)
S
ince the paper by Neptune, Bailey, and Goldberg [l]in 1953 many ingenious surgical techniques have been described for the redirection of anomalous pulmonary venous drainage from the right lung through a sinus venosus atrial septal defect (ASD) high in the atrial septum. These have included single patches, an inner and outer patch, a U-shaped patch, direct partitioning of the superior vena cava (SVC), and various rotational flaps of right atrial wall [2]. The diagnosis of a sinus venosus defect is occasionally not made preoperatively, the surgeon expecting a straightforward secundum ASD. Closure of a secundum ASD is often considered to be part of general cardiac surgery and thus may be undertaken by surgeons who are not experienced in the surgery of congenital defects. It is for this reason that we describe a simpler technique of dealing with the sinus venosus ASD that we have found applicable to all variations of anatomy.
Material and Methods Over a 10-year period 54 patients (22% of all ASD closures) had repair of a sinus venosus ASD using the technique described here. Median age was 9 years with a range of 1 to 58 years. All operations were performed by a median sternotomy incision, and cardiopulmonary bypass was established using caval cannulas (introduced by the right atrial appendage and the low right atrium, respectively) and caval snares, hypothermia to 32"C, and cold crystalloid potassium cardioplegia. Figure 1 illustrates the oblique right atriotomy beginning at the base of the atrial appendage and extended down toward the inferior vena cava staying well away Accepted for publication Sep 17, 1990. Address reprint requests to Mr Walker, Wingbeck Hospital, York Road, Leeds, LS14 6UQ, United Kingdom.
0 1991 by The Society of Thoracic Surgeons
from both the sinoatrial node and the SVC-right atrial junction. Exposure is aided by retracting the SVC cannula, and horizontal buttressed mattress sutures are placed from outside the heart along the junction between the anomalous right pulmonary veins and the right atrium. Superiorly these sutures are continued medially, passing from outside the heart underneath the SVC, avoiding the artery to the sinoatrial node if this is visible; the sutures are placed in such a way as to avoid narrowing the SVC. Figure 2 illustrates the placement of these sutures through the patch material (over the time period we used xenograft pericardium, Dacron, or Gore-Tex). After placement of the sutures, the patch is slid down into position. If the ASD requires enlargement, this is done inferiorly and then the inferior rim of the patch is sewn to the edge of the septal defect using either interrupted or continuous sutures. In this way the SVC is not narrowed and the anomalous pulmonary venous drainage is directed into the left atrium. Exposure of the top end of the defect, if it extends up into the SVC, is facilitated by retraction on the individual sutures as they are placed. Although the right pulmonary veins drained into the SVC itself in 8 of the 54 patients, enlargement of the SVC was never necessary.
Results There was one death in the perioperative period from complications unrelated to the surgical technique. In the early postoperative period 7 patients had episodes of nodal rhythm and 1 went into atrial fibrillation. In the late follow-up the patient with early postoperative atrial fibrillation remains in atrial fibrillation, and 1 patient has continuing nodal rhythm. There have been no cases of either SVC or pulmonary venous obstruction documented in the follow-up period, which now extends longer than 10 years.
Comment Kyger and associates I31 described an incidence of new postoperative arrhythmias of 21% in 109 patients. All the surgical techniques described previously involve an incision across the junction of the SVC and right atrium, and even if this avoids the sinoatrial node the arterial supply to the node itself may be divided if the artery passes 0003-4975/91/$3.50
HOW TO DO IT
Ann Thorac Surg 1991;51:1446
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Fig 1. ( A ) Operative photograph taken from the surgeon's view and (B)drawing showing the right atriotomy distant from the sinoatrial node and buttressed sutures and separating the anomalous right pulmonary veins from the right atrium. (IVC = inferior vena cava; SVC = superior uena cava .
A SVC cannula
venosus defect
IVC cannula
sucker in defect
anomalous ri
B
behind the SVC to reach the node laterally. Although our incidence of postoperative arrhythmias is low it would be unrealistic to claim this is solely because of the surgical technique. However, the right atrial incision employed in our method does avoid damage in any way to the sinoatrial node. We believe an important feature of this method is its simplicity and that it will be particularly valuable to surgeons encountering a sinus venosus defect unexpectedly. The absence of any long-term problems
with either systemic venous or pulmonary venous obstruction lead us to believe that the more complex maneuvers described in the literature are unnecessary. We are grateful to Anna Durbin, Department of Medical Illustration, Leeds University, for producing the line diagrams from the operative photographs. We are also grateful to Hannah Warren for her help in preparing the manuscript.
146
Ann Thorac Surg
HOW TO DO IT HAMILTON ET AL SINUS VENOSUS ASD
1991;51:144-6
Fig 2. (A) Operative photograph taken from the assistant's position (patient's left) and (B) drawing showing the sutures coming to the patch from outside the heart both on the patient's right and left (from under the superior vena cava (SVC). The patch is about to be slid into position. (IVC = inferior vena cava.)
A forceps
i
retract ion suture
sternal retractor
B
References 1. Neptune WB, Bailey CP, Goldberg H. The surgical correction of atrial septal defects associated with transposition of the pulmonary veins. J Thorac Surg 1953;25:623-634. 2. Robicsek F, Daugherty HK, Cook JW, Selle JG. Sinus venosus
type of atrial septal defect with partial anomalous pulmonary venous return. J Thorac Cardiovasc Surg 1979;78:559-62. 3. Kyger ER, Frazier OH, Cooley DA, et al. Sinus venosus atrial septal defect: early and late results following closure in 109 patients. Ann Thorac Surg 1978;25:4&50.
A technique is described for closure of a sinus venoms atrial septal defect using a single patch held in place by sutures placed from outside the right atrium and underneath the superior vena cava. The superior vena cava does not require enlargement and potential damage to the artery to the sinoatrial node is avoided. (Ann Thorac Surg 1991;51:1444)
S
ince the paper by Neptune, Bailey, and Goldberg [l]in 1953 many ingenious surgical techniques have been described for the redirection of anomalous pulmonary venous drainage from the right lung through a sinus venosus atrial septal defect (ASD) high in the atrial septum. These have included single patches, an inner and outer patch, a U-shaped patch, direct partitioning of the superior vena cava (SVC), and various rotational flaps of right atrial wall [2]. The diagnosis of a sinus venosus defect is occasionally not made preoperatively, the surgeon expecting a straightforward secundum ASD. Closure of a secundum ASD is often considered to be part of general cardiac surgery and thus may be undertaken by surgeons who are not experienced in the surgery of congenital defects. It is for this reason that we describe a simpler technique of dealing with the sinus venosus ASD that we have found applicable to all variations of anatomy.
Material and Methods Over a 10-year period 54 patients (22% of all ASD closures) had repair of a sinus venosus ASD using the technique described here. Median age was 9 years with a range of 1 to 58 years. All operations were performed by a median sternotomy incision, and cardiopulmonary bypass was established using caval cannulas (introduced by the right atrial appendage and the low right atrium, respectively) and caval snares, hypothermia to 32"C, and cold crystalloid potassium cardioplegia. Figure 1 illustrates the oblique right atriotomy beginning at the base of the atrial appendage and extended down toward the inferior vena cava staying well away Accepted for publication Sep 17, 1990. Address reprint requests to Mr Walker, Wingbeck Hospital, York Road, Leeds, LS14 6UQ, United Kingdom.
0 1991 by The Society of Thoracic Surgeons
from both the sinoatrial node and the SVC-right atrial junction. Exposure is aided by retracting the SVC cannula, and horizontal buttressed mattress sutures are placed from outside the heart along the junction between the anomalous right pulmonary veins and the right atrium. Superiorly these sutures are continued medially, passing from outside the heart underneath the SVC, avoiding the artery to the sinoatrial node if this is visible; the sutures are placed in such a way as to avoid narrowing the SVC. Figure 2 illustrates the placement of these sutures through the patch material (over the time period we used xenograft pericardium, Dacron, or Gore-Tex). After placement of the sutures, the patch is slid down into position. If the ASD requires enlargement, this is done inferiorly and then the inferior rim of the patch is sewn to the edge of the septal defect using either interrupted or continuous sutures. In this way the SVC is not narrowed and the anomalous pulmonary venous drainage is directed into the left atrium. Exposure of the top end of the defect, if it extends up into the SVC, is facilitated by retraction on the individual sutures as they are placed. Although the right pulmonary veins drained into the SVC itself in 8 of the 54 patients, enlargement of the SVC was never necessary.
Results There was one death in the perioperative period from complications unrelated to the surgical technique. In the early postoperative period 7 patients had episodes of nodal rhythm and 1 went into atrial fibrillation. In the late follow-up the patient with early postoperative atrial fibrillation remains in atrial fibrillation, and 1 patient has continuing nodal rhythm. There have been no cases of either SVC or pulmonary venous obstruction documented in the follow-up period, which now extends longer than 10 years.
Comment Kyger and associates I31 described an incidence of new postoperative arrhythmias of 21% in 109 patients. All the surgical techniques described previously involve an incision across the junction of the SVC and right atrium, and even if this avoids the sinoatrial node the arterial supply to the node itself may be divided if the artery passes 0003-4975/91/$3.50
HOW TO DO IT
Ann Thorac Surg 1991;51:1446
HAMILTON ET AL SINUS VENOSUS ASD
145
Fig 1. ( A ) Operative photograph taken from the surgeon's view and (B)drawing showing the right atriotomy distant from the sinoatrial node and buttressed sutures and separating the anomalous right pulmonary veins from the right atrium. (IVC = inferior vena cava; SVC = superior uena cava .
A SVC cannula
venosus defect
IVC cannula
sucker in defect
anomalous ri
B
behind the SVC to reach the node laterally. Although our incidence of postoperative arrhythmias is low it would be unrealistic to claim this is solely because of the surgical technique. However, the right atrial incision employed in our method does avoid damage in any way to the sinoatrial node. We believe an important feature of this method is its simplicity and that it will be particularly valuable to surgeons encountering a sinus venosus defect unexpectedly. The absence of any long-term problems
with either systemic venous or pulmonary venous obstruction lead us to believe that the more complex maneuvers described in the literature are unnecessary. We are grateful to Anna Durbin, Department of Medical Illustration, Leeds University, for producing the line diagrams from the operative photographs. We are also grateful to Hannah Warren for her help in preparing the manuscript.
146
Ann Thorac Surg
HOW TO DO IT HAMILTON ET AL SINUS VENOSUS ASD
1991;51:144-6
Fig 2. (A) Operative photograph taken from the assistant's position (patient's left) and (B) drawing showing the sutures coming to the patch from outside the heart both on the patient's right and left (from under the superior vena cava (SVC). The patch is about to be slid into position. (IVC = inferior vena cava.)
A forceps
i
retract ion suture
sternal retractor
B
References 1. Neptune WB, Bailey CP, Goldberg H. The surgical correction of atrial septal defects associated with transposition of the pulmonary veins. J Thorac Surg 1953;25:623-634. 2. Robicsek F, Daugherty HK, Cook JW, Selle JG. Sinus venosus
type of atrial septal defect with partial anomalous pulmonary venous return. J Thorac Cardiovasc Surg 1979;78:559-62. 3. Kyger ER, Frazier OH, Cooley DA, et al. Sinus venosus atrial septal defect: early and late results following closure in 109 patients. Ann Thorac Surg 1978;25:4&50.
