"Sutureless" Pulmonary Vein Stenosis Repair

Patient Selection
The sutureless neoatrium technique was initially described for anastomotic stenosis
occurring after repair of total anomalous pulmonary venous connection post!repair
pulmonary vein stenosis" PRPVS#$ The procedure is also helpful in patients with
congenital pulmonary vein stenosis and has been used in selected patients on the initial
presentation of total anomalous pulmonary venous connection$ %ost of these patients
will have a preoperative evaluation with transthoracic echocardiography" cardiac
catheteri&ation to assess pulmonary artery pressure#" and magnetic resonance imaging"
if available$
'perative Steps
(fter initiation of standard cardiopulmonary bypass with bicaval cannulation and
antegrade cold blood cardioplegia" hypothermic blood cardioplegic arrest is induced$
(lternatively" uniatrial venous cannulation and deep hypothermic circulatory arrest
strategies can be employed$
)or patients with PRPVS" the initial approach is through the right atrium and across the
atrial septum to allow visuali&ation of the pulmonary vein ostia and clear definition of
the location and e*tent of stenosis$ 'ften the stenosis is locali&ed to the anastomotic
region" but occasionally it may e*tend diffusely through the pulmonary veins in a
retrograde direction$
)or patients in whom this technique is to be used at the initial presentation of total
anomalous pulmonary venous connection as pictured below#" the initial approach is
through the left atrium after retraction of the heart to the right$ The incision in the left
atrium is e*tended transversely across the bac+ of the left atrium to the edge of the
interatrial septum$ The pulmonary vein confluence is then incised transversely across its
entire length$ The incision can be carried into each pulmonary vein out to the second
order branches if necessary$ Placement of a blade of a Potts scissors in the lumen with
the other blade out of the lumen and cutting distally into the lung facilitates this
maneuver$ The incision should be carried as far into the lung as necessary to get beyond
any stenotic regions$ ,are must be ta+en to leave the adventitia intact when pulmonary
vein incisions are made because the adventitia will contain the pulmonary venous
effluent in a controlled bleed into the left atrium$
The divided edge of the atrial wall is then sutured to the pericardium not the pulmonary
vein# in a suture line remote from the divided edge of the pulmonary veins using a
running fine absorbable suture$ This suture line contains the pulmonary venous effluent
in a controlled bleed while avoiding any direct suturing of the pulmonary veins$ The
suture line is relatively easy to sew because it connects the left atrial edge to the
pericardium in a circle around the pulmonary veins$ ,onsequently" the suture line
ignores the comple* shapes of the pulmonary vein incisions and simply maintains
hemostasis by direct anastomosis of the left atrium to the pericardium$
-n cases of isolated left or right pulmonary vein stenosis" the technique can be used in a
unilateral fashion$ The divided edge of the left atrium is then sewn to the pericardial
reflection over the incised pulmonary veins$ This suture line is then routed inwards to
the confluence of the pulmonary veins to complete hemostasis in the central portion of
the anastomosis$

Schematic -llustration of Type ---

T(PV,
. Schematic illustration of Type --- T(PV, / all four pulmonary veins connect to a
common pulmonary vein that drains into a vertical vein that penetrates the diaphragm
and empties into the inferior vena cava$
0 The ape* of the heart has been tilted to the right" e*posing the left atrium and the
T(PV,$
1 The vertical vein has been tied off and the common pulmonary vein opened with
incisions carried into all four pulmonary veins$ The left atrium was been incised$ The
sutureless repair has been started by suturing the left atrium to the adventitia of the
pericardium ad2acent to the pulmonary veins" staying away from the actual edge of
the pulmonary veins$
3 Posterior view of the completed anastomosis with the vertical vein divided and
the suturing of the left atrium to the pericardium completed$
Preference ,ard
4quipment5-nstruments
6rop!in suction cannula
)ine ,astro Potts scissors
6ilators to chec+ pulmonary vein si&e
Transesophageal echocardiography
Suture
)ine absorbable suture e$g$" 7!8 or 9!8 P6S 4thicon" Somerville" :;#
(lternatively" <!8 Prolene 4thicon" Somerville" :;#
Tips = Pitfalls
The use of drop!in suction cannula facilitates visuali&ation of the pulmonary
veins$
,irculatory arrest is typically unnecessary" but hypothermia is helpful to allow
temporary reduction in perfusion rates to assist with visuali&ation of the pulmonary
veins$
Suturing of the atrium to the pericardium over the pulmonary veins puts the
phrenic nerve at ris+$ Sutures should be superficial in this area$
Remember that the anastomosis will contain a very low pressure chamber and"
therefore" the strength of the sutures will be far less important than obtaining
hemostasis through meticulous attention to detail$
>leeding after completion of the anastomosis can be visuali&ed after weaning
from cardiopulmonary bypass to fill the neo!left atrium#$ (ggressive incision of the
pulmonary veins can lead to violation of the pleural cavity in the hilar region" leading
to uncontrolled hemorrhage into the pleural cavity n?3#$ ( technique of intrapleural
hilar reappro*imation was developed$ @sing this technique" the pericardium is incised
at the level of the diaphragm posteriorly to the level of the phrenic nerve$ The
pericardium is then retracted to the midline to e*pose the anterior hilum$ The defect in
the pleura is then reappro*imated with a fine running suture with care ta+en to avoid
in2ury to the phrenic nerve$
(ccess to the inferior and lateral suture line can be obtained by gently tipping the
heart upwards using techniques commonly employed in off!pump myocardial
revasculari&ation$
(ccess to the superior portion of the suture line can be obtained through the
transverse sinus via the space between the aorta and superior vena cava$
6ivision of inferior vena caveA Be liberally use division of the inferior vena cava
to improve surgical e*posure n?.0#$ This leaves the heart tethered by the aorta and
pulmonary artery$ ,onsequently" retraction of the heart out of the mediastinum is
possible" providing ample e*posure as the anastomosis is constructed$
Results
(t the Cospital for Sic+ ,hildren in Toronto" this technique was originally described for
two patients with bilateral pulmonary vein stenosis following T(PV, repair$ >oth were
surviving at .$D years postoperatively E1F$ -n the 6iscussion of that paper" at least seven
other successful cases were noted$ Gacour!Hayet later reported success in five of seven
patients all reoperations#$ Several other centers have now reported success with this
technique$ @pdated results with the sutureless technique in nearly 38 patients operated
on at the Cospital for Sic+ ,hildren were presented at the 0883 (nnual %eeting of The
(merican (ssociation for Thoracic Surgery held in Toronto$ Ten patients had PRPVS
and 09 patients had no prior operation but were at high ris+ of stenosis$ (s compared to
conventional management" the sutureless technique was associated with decreased ris+
of reoperation or death mean follow!up 1 years# E<F$