Surgical management of progressive pulmonary venous obstruction after repair of total anomalous pulmonary venous connection

Midterm outcomes of sutureless technique for postoperative pulmonary venous stenosis

BACKGROUND

The efficacy of a sutureless technique for postoperative pulmonary venous stenosis (PVS) following repair of total anomalous pulmonary venous connection (TAPVC) has been reported, though detailed clinical advantages remain unclear. We retrospectively reviewed our surgical experience, and compared outcomes between conventional procedures and a sutureless technique.

METHODS

For relief of postoperative PVS after TAPVC repair, five patients underwent a conventional procedure, such as orifice cutback or resection of a proliferated intima, from 1999 to 2004 (Conventional group, 4 males, median 93 days old, 3.6 kg), then seven underwent a sutureless technique (Sutureless group, 5 males, 119 days old, 3.4 kg) from 2005 to 2011. Patients with a functional single ventricle were excluded. There were no significant differences regarding patient characteristics. Follow-up examinations were completed in all patients.

RESULTS

The rate for cumulative survival at 5 years was 60 % in the Conventional group and 71.4 % in the Sutureless group. Re-stenosis after relief of PVS occurred in 100 % (10/10) of patients in the Conventional group and 31.6 % (6/19) of patients in the Sutureless group (p = 0.0088). For bilateral venous stenosis patients, the survival rate was 66.7 % (4/6) in the Sutureless group and 0 % (0/2) in the Conventional group (p = 0.10). Out of three patients who developed whole 4-vein stenosis, only one in the Sutureless group survived.

CONCLUSIONS

Although overall survival rate was similar in both groups, the Sutureless technique for postoperative PVS following TAPVC repair successfully rescued more pulmonary veins without re-stenosis than conventional procedures. Further follow-up may demonstrate therapeutic advantages.

"Closed-vein" technique for primary sutureless repair of anomalous pulmonary venous connection

Deep hypothermic circulatory arrest or low-flow bypass are commonly used in primary repair of total anomalous pulmonary venous connection, or individual veins may be dissected to allow clamp or snare application, in order to provide a bloodless field for anastomosis by the direct or sutureless marsupialization technique. In the described technical modification, the marsupialization of the opened atrium to the posterior pericardium is completed before opening the pulmonary venous confluence, allowing bloodless exposure during full-flow normothermic bypass. In addition, vein branch dissection is avoided.

Total anomalous pulmonary venous connection: 15 years' experience of a tertiary care center in Taiwan

BACKGROUND

Total anomalous pulmonary venous connection (TAPVC) is a rare congenital heart disease in which the connection between the pulmonary vein (PV) and left atrium needs to be surgically created. This study investigated the spectrum and outcome of a Taiwanese cohort.

METHODS

Isolated TAPVC cases were identified from our institutional database between 1995 and 2009. We reviewed the medical chart and conducted telephone interviews with those lost to follow-up.

RESULTS

There were 78 patients (52% male). The anomalous drainage sites were mainly supracardiac type (42.3%) and cardiac type (39.8%). Before operation, PV stenosis was found in 100% of infracardiac type, and in 69.7% of supracardiac type. Among the 75 patients undergoing operation, the surgical mortality was 9% (7/75). Perioperative arrhythmias (mainly of atrial origin) occurred in 35% of the patients. Of the 68 patients who survived the first operation, 28 (41%) developed pulmonary vein restenosis. Half of them progressed to severe PV stenosis, which required reintervention or resulted in mortality. Preoperative PV stenosis was the most significant predictor for postoperative PV restenosis and PV re-intervention. For the cohort, the 1-year and 5-year survivals were 78.9% and 74.2%, respectively, and the predictor for survival was again preoperative PV stenosis.

CONCLUSION

The surgical mortality of isolated TAPVC is now low. Preoperative PV stenosis not only increased the risk of late PV restenosis and its reintervention, but also the overall mortality. The spectrum of PV drainage, per se, was not associated with worse outcome. PV restenosis remained the most important issue after correction of TAPVC.

Assessment of pulmonary veins after atrio-pericardial anastomosis by cardiovascular magnetic resonance

BACKGROUND

The atrio-pericardial anastomosis (APA) uses a pericardial pouch to create a large communication between the left atrium and the pulmonary venous contributaries in order to avoid direct suturing of the pulmonary veins during the repair of congenital cardiac malformations. Post-operative imaging is routinely performed by echocardiography but cardiovascular magnetic resonance (CMR) offers excellent anatomical imaging and quantitative information about pulmonary blood flow. We sought to compare the diagnostic value of echocardiography and CMR for assessing pulmonary vein anatomy after the APA.

METHODS

This retrospective study evaluated all consecutive patients between October 1998 and January 2010 after either a primary or secondary APA followed by post-repair CMR.

RESULTS

Of 103 patients who had an APA, 31 patients had an analyzable CMR study. The average time to CMR was 24.6 ± 32.5 months post-repair. Echocardiographic findings were confirmed by CMR in 12 patients. There was incomplete imaging by echocardiography in 7 patients and underestimation of pulmonary vein restenosis in 12, when compared to CMR. In total, 19/31 patients (61%) from our cohort had significant stenosis following the APA as assessed by CMR. Our data suggest that at least 18% (19/103) of all patients had significant obstruction post-repair.

CONCLUSIONS

Echocardiography incompletely imaged or underestimated the severity of obstruction in patients compared with CMR. Pulmonary vein stenosis remains a sizable complication after repair, even using the APA.

Surgical management of post-repair pulmonary vein stenosis

Obstructed pulmonary venous drainage - either in association with total anomalous pulmonary venous drainage, congenital stenosis, or post-repair stenosis - is associated with poor outcome. Post-repair stenosis typically involves fibrotic scar tissue extending from the site of anastomosis. "Sutureless" repair techniques avoid direct left atrial-pulmonary vein suture lines by instead reconstituting atrial tissue to posterior pericardium. Hence, the repair leaves widely decompressed pulmonary veins in the posterior mediastinum draining directly into the left atrium as a 'controlled bleed.' In our experience, late outcomes are significantly more favorable with sutureless repair techniques versus conventional pulmonary vein surgery. Therefore, after these encouraging results, we have now extended the application of this repair strategy to all scenarios of pulmonary vein surgery, including primary repair of unobstructed total anomalous pulmonary venous connection. The sutureless repair is versatile and facile. In particular, complex geometry of multiple decompressed veins can be easily accommodated by wide left atrial-pericardial suture lines. Common pitfalls can be avoided by mobilizing and protecting the phrenic pedicle and preserving the integrity of the areolar connective tissue and pleuro-parietal membrane. Overall, sutureless repair of anomalous or stenotic pulmonary veins appears safe and effective. Furthermore, in patients known to be at high risk of recurrent stenosis, sutureless techniques appear to offer improved freedom from recurrent stenosis.

Serum levels after everolimus-stent implantation and paclitaxel-balloon angioplasty in an infant with recurrent pulmonary vein obstruction after repaired total anomalous pulmonary venous connection

Everolimus-eluting stents and paclitaxel-coated balloons are used in the interventional treatment of coronary artery disease in adults to reduce the restenosis rate and in small-vessel disease. Both substances are released into the circulation. We report systemic drug exposure after implantation of one everolimus-eluting stent and dilation with one paclitaxel-coated balloon in an 8-month-old infant, which was used as an innovative therapy for recurrent pulmonary vein stenosis.

Total Anomalous Pulmonary Venous Connection

Background—

Late mortality after repair of total anomalous pulmonary venous connection is frequently associated with pulmonary venous obstruction (PVO). We aimed to describe the morphological spectrum of total anomalous pulmonary venous connection and identify risk factors for death and postoperative PVO.

Methods and Results—

We conducted a retrospective, international, collaborative, population-based study involving all 19 pediatric cardiac centers in the United Kingdom, Ireland, and Sweden. All infants with total anomalous pulmonary venous connection born between 1998 and 2004 were identified. Cases with functionally univentricular circulations or atrial isomerism were excluded. All available data and imaging were reviewed. Of 422 live-born cases, 205 (48.6%) had supracardiac, 110 (26.1%) had infracardiac, 67 (15.9%) had cardiac, and 37 (8.8%) had mixed connections. There were 2 cases (0.5%) of common pulmonary vein atresia. Some patients had extremely hypoplastic veins or, rarely, discrete stenosis of the individual veins. Sixty (14.2%) had associated cardiac anomalies. Sixteen died before intervention. Three-year survival for surgically treated patients was 85.2% (95% confidence interval 81.3% to 88.4%). Risk factors for death in multivariable analysis comprised earlier age at surgery, hypoplastic/stenotic pulmonary veins, associated complex cardiac lesions, postoperative pulmonary hypertension, and postoperative PVO. Sixty (14.8%) of the 406 patients undergoing total anomalous pulmonary venous connection repair had postoperative PVO that required reintervention. Three-year survival after initial surgery for patients with postoperative PVO was 58.7% (95% confidence interval 46.2% to 69.2%). Risk factors for postoperative PVO comprised preoperative hypoplastic/stenotic pulmonary veins and absence of a common confluence.

Conclusions—

Preoperative clinical and morphological features are important risk factors for postoperative PVO and survival.

Infantile form of scimitar syndrome with contralateral pulmonary vein stenosis

Infantile scimitar syndrome (SS) carries significant mortality. Consistent management guidelines have not been well established, and outcomes continue to be disappointing. We present our experience managing an SS patient with complex anatomy who developed stenosis of the pulmonary veins contralateral to the hypoplastic lung.

Factors Associated With Mortality and Reoperation in 377 Children With Total Anomalous Pulmonary Venous Connection

Background— We sought to determine era-specific changes in the incidence of mortality and reoperation in children with total anomalous pulmonary venous connection.

Methods and Results— We reviewed the records of 377 children presenting from 1946 to 2005 with total anomalous pulmonary venous connection. Multivariable parametric regression models determined the incidence and risk factors for death and reoperation after repair. Pulmonary venous connection was supracardiac in 44%, infracardiac in 26%, cardiac in 21%, and mixed in 9%. Pulmonary venous obstruction was present in 48% at presentation, most frequently with infracardiac connection type ( P <0.001). In total, 327 patients were repaired (median age, 1.7 months). Overall survival from repair was 65±6% at 14 years, with a current survival of 97%. Significant ( P <0.01) incremental risk factors for postrepair death were cardiac connection type, earlier operation year, younger age at repair, use of epinephrine postoperatively, and postoperative pulmonary venous obstruction. More recent operation year was associated with younger age at repair ( P <0.001), decreased use of deep hypothermic circulatory arrest ( P <0.001), and use of specific drugs postoperatively ( P <0.001). Risk-adjusted estimated 1-year survival for a patient repaired at birth with unfavorable morphology in 2005 is 37% (95% CI, 8 to 80) compared with 96% (95% CI, 91 to 99) for a patient with favorable morphology repaired at 1 year of age. Freedom from reoperation was 82±6% at 11 years after repair, with increased risk associated with mixed connection type ( P =0.04) and postoperative pulmonary venous obstruction ( P <0.001).

Conclusions— Mortality after total anomalous pulmonary venous connection repair has decreased but remains highest in young patients and in those with cardiac connection type or pulmonary venous obstruction. Unfavorable anatomic characteristics remain important determinants of postrepair survival despite improved perioperative care.

Successful release of recurrent pulmonary venous obstruction after repair of totally anomalous pulmonary venous connection by transcatheter implantation of stents

We report a 3-month-old female infant, in whom pulmonary venous obstruction occurred after repair of totally anomalous pulmonary venous connection, and which was successfully released by a transcatheter implantation of a stent using the transseptal approach. Close follow-up is required, since the long-term outcome is still unclear. Nevertheless, transcatheter implantation of stents is a promising option for treating this challenging lesion.

Management of congenital and acquired pulmonary vein stenosis

BACKGROUND

Pulmonary vein (PV) stenosis, whether congenital or after repair of total anomalous pulmonary venous connection (TAPVC), continues to carry a poor prognosis.

METHODS

A retrospective review identified 36 patients who underwent repair of PV stenosis between December 1989 and June 2003. Fourteen with congenital PV stenosis underwent scar excision and primary repair (n = 2), intraoperative stent placement (n = 4), or sutureless pericardial marsupialization (n = 8). Twenty-two with acquired PV stenosis after TAPVC repair underwent anastomotic revision and/or vein repair (n = 11) or sutureless pericardial marsupialization (n = 11). Follow-up ranged from 1 month to 14 years (median, 30 months).

RESULTS

Among the 14 patients with congenital PV stenosis, 8 died (3 early deaths, 4 late deaths with restenosis, and 1 late noncardiac death). Among the six survivors, five (4 after marsupialization) have not developed restenosis. Among 11 of 22 patients with acquired PV stenosis undergoing anastomotic revision or vein repair, there were 5 deaths (2 early, 2 late with restenosis, and 1 late noncardiac death) and 1 of the six survivors has developed restenosis. Of the remaining 11 undergoing marsupialization, there was one late death (with restenosis) and 10 survivors have no restenosis. Congenital etiology, use of marsupialization technique, presence of associated defect, and extent of disease were identified as risk factors for poor outcome.

CONCLUSIONS

Patients with pulmonary vein stenosis continue to have a guarded prognosis. Sutureless pericardial marsupialization was associated with satisfactory midterm results and appears superior to other conventional techniques.

Surgery for pulmonary venous obstruction after repair of total anomalous pulmonary venous return

The major complication and the main cause of reoperation following surgery for total anomalous pulmonary venous return (TAPVR) is the occurrence of pulmonary venous obstruction. Outcomes after surgical repair of TAPVR have greatly improved in the last 10 years; however, the complex forms of TAPVR, particularly when associated with single ventricle and heterotaxy, still carry a high risk of failure. The pathology of pulmonary venous obstruction following TAPVR surgery is a fibrous intimal hyperplasia associated with some medial hypertrophy. There is an increasing severity in the spectrum of lesions from anastomotic stricture to pulmonary vein ostial stenosis and diffuse pulmonary vein stenosis. For anastomotic lesions, revision of the TAPVR anastomosis by patch enlargement of the left atrial anastomosis provides good results. On the contrary, conventional techniques in cases of pulmonary vein ostial stenosis had very poor results. The sutureless repair technique introduced in 1996 provides better midterm results than any other technique, with freedom from mortality and recurrence improving from 65% to 90%. The sutureless technique is described in detail, with emphasis on the need for resection of the pulmonary vein scar tissue and on the different techniques needed respectively on the right and the left side. In our experience, using an atraumatic technique at the initial repair has greatly decreased the occurrence of late pulmonary venous obstruction.

Pulmonary vein stenosis following repair of total anomalous pulmonary venous connection

Pulmonary vein stenosis may occur following the repair of total anomalous pulmonary venous connection and carries a poor prognosis. Conventional surgical therapies have been complicated by a high rate of re-stenosis. Sutureless pericardial marsupialization has been introduced as a technique to reduce the rate of re-stenosis. This report describes a retrospective review of a group of patients undergoing repair of acquired pulmonary vein stenosis. Presence of single-ventricle anatomy was found to be the primary preoperative risk factor for a poor outcome. The use of sutureless pericardial marsupialization was found to be associated with a significant improvement in disease-free survival.

Pulmonary vein stenosis: initial experience with cutting balloon angioplasty

OBJECTIVE

To determine the safety and effectiveness of cutting balloon angioplasty for pulmonary vein stenosis (PVS).

DESIGN AND SETTING

Retrospective review of case notes and cardiac catheterisation data at the Royal Brompton Hospital.

MAIN OUTCOME MEASURES

Diameter of pulmonary vein, tricuspid regurgitant jet velocity on echocardiogram, and percutaneous oxygen saturation before and after cutting balloon angioplasty.

RESULTS

Three patients had congenital PVS and three had PVS associated with total anomalous pulmonary venous drainage. A total of 27 PVSs were treated during 12 catheterisation procedures. Median patient age at the time of procedure was 12.5 months (range 1.5-36 months) and weight was 7.1 kg (range 2.8-11.1 kg). Minimum pulmonary vein diameter increased significantly on angiography after cutting balloon angioplasty, from mean (SD) 2.3 (0.7) mm to 4.2 (1.9) mm, mean of differences 1.9 mm (95% confidence interval (CI) 0.9 to 2.9 mm, p = 0.0013). Mean (SD) oxygen saturation rose from 79.6 (12.9)% to 83.9 (9.0)%, mean of differences 4.3% (95% CI 0.7% to 8.0%, p = 0.0238). All children's symptoms improved subjectively. Tricuspid regurgitant jet velocity did not change significantly. The longest time interval before repeat intervention was six months. There were no acute deaths; one patient had a small pulmonary haemorrhage and developed a small aneurysm adjacent to the site of angioplasty.

CONCLUSION

Cutting balloon angioplasty is safe in the palliation of PVS in children. It gives some acute relief but often needs to be repeated, as improvement is rarely sustained.

Pulmonary venous stenosis as an associated manifestation of left-sided obstructive lesions in an infant with partial atrioventricular canal defect

Patients with partial atrioventricular canal defect (PAVC) who present with congestive heart failure within the first year of life are usually found to have associated left-sided obstructive lesions. We present a case of a child with PAVC who subsequently developed progressive pulmonary venous stenosis as a manifestation of her disease.

Conventional and sutureless techniques for management of the pulmonary veins: Evolution of indications from postrepair pulmonary vein stenosis to primary pulmonary vein anomalies

OBJECTIVE

We have previously reported a limited but favorable experience with a novel sutureless technique for surgical management of postoperative pulmonary vein stenosis occurring after repair of total anomalous pulmonary venous drainage. Because this technique requires integrity of the retrocardiac space for hemostasis, extension of the technique to the primary repair of pulmonary vein anomalies requires evaluation. This analysis reviews our experience with the sutureless technique in patients with postrepair pulmonary vein stenosis, as well as our extension of the technique into primary repair of pulmonary vein anomalies.

METHODS

Retrospective univariable-multivariable analysis of all pulmonary vein stenosis procedures and sutureless pulmonary vein procedures over a 20-year period was performed. Cox proportional hazards modeling was used to identify variables associated with freedom from reoperation or death.

RESULTS

Sixty patients underwent 73 procedures, with pulmonary vein stenosis present in 65 procedures. The sutureless technique was used in 40 procedures. Freedom from reoperation or death at 5 years after the initial procedure was 49%. Unadjusted freedom from reoperation or death was greater with the sutureless technique for patients with postrepair pulmonary vein stenosis ( P = .04). By using multivariable analysis, a higher pulmonary vein stenosis score was associated with greater risk of reoperation or death. After adjustment, the sutureless repair was associated with a nonsignificant trend toward greater freedom from reoperation or death ( P = .12). Despite the absence of retrocardiac adhesions, operative mortality was not increased with the sutureless technique ( P = .64). Techniques to control bleeding (intrapleural hilar reapproximation) and improve exposure (inferior vena cava division) were identified.

CONCLUSION

The sutureless technique for postrepair pulmonary vein stenosis is associated with encouraging midterm results. Extension of the indications for the technique to primary repair appears safe with the development of simple intraoperative maneuvers.

Total anomalous pulmonary vein connection: Diagnosis, management, and outcome

Total anomalous pulmonary venous connection (TAPVC) is a congenital cardiac malformation that requires surgical therapy. The majority of patients will present either in the neonatal period or early infancy, with cyanosis and signs of cardiac failure (eg, tachypnea, feeding difficulties, diaphoresis, failure to thrive). Surgical repair is best carried out on diagnosis, as an elective procedure, to avoid potential long-term problems associated with right heart volume and pressure overload, or long-standing cyanosis. Occasionally, in severely sick patients with obstructed forms of pulmonary venous drainage, emergency surgical repair may be required. The operative mortality for isolated TAPVC using current management techniques is less than 10%, and the long-term outlook for the majority of patients is excellent. In contrast, patients with associated complex cardiac malformations have a less favorable prognosis, determined both by the need to palliate the associated defects and the often underdeveloped pulmonary vascular bed. The major long-term complication is pulmonary venous obstruction, which may be recurrent in up to 10% of patients. This requires aggressive management strategies, involving reoperation, and balloon angioplasty or stent implantation. The prognosis for these patients is determined by the number of vessels involved and the degree of stenosis, which can often be recurrent and progressive. Late tachy- and bradyarrhythmias have also been described, requiring antiarrhythmic drug therapy or pacemaker implantation, emphasizing the need for continued long-term follow-up of all patients with TAPVC.

Acquired pulmonary vein stenosis as a cause of life-threatening pulmonary hypertension

We report the case of an infant born prematurely at 27 weeks gestational age with life-threatening pulmonary hypertension crisis as a result of left upper pulmonary vein stenosis. Surgical treatment consisted of a lobectomy, which is a safe and effective procedure. Evidence strongly suggests that the venous stenosis may have resulted from hypertonic drugs infused through an umbilical catheter facing the upper left venous-atrial junction.

Recurrent unilateral bacterial pneumonias and interstitial fibrosis associated with pulmonary vein atresia: successful treatment with endovascular stent implantation

A variety of pulmonary vascular disorders, such as hemangiomatosis, telangectasia, and veno-occlusive disease, may be involved in the pathogenesis of interstitial lung diseases. We describe the case of a girl with recurrent bacterial pneumonia and progressive interstitial fibrosis affecting the right lung. Morphologic evaluation of the lung biopsy showed structural changes of the vessel walls suggesting pulmonary hypertension. The echocardiogram showed the presence of centripetal blood flow in the right pulmonary artery from the periphery of the lung to the heart. A selective right angiography demonstrated the presence of pulmonary venous obstruction at the veno-atrial junction, successfully treated by endovascular stent implantation during cardiac catheterization.

Total anomalous pulmonary venous connection: long-term appraisal with evolving technical solutions

OBJECTIVES

To evaluate late outcome of non-isomeric total anomalous pulmonary venous connection (TAPVC) repair, controlling for anatomic subtypes and surgical technique.

METHODS

Between 1983 and 2001, 89 patients (median age 54 days) underwent repair for supracardiac (38), cardiac (26), infracardiac (16) or mixed (nine) TAPVC. Ten patients (11.2%) presented associated anomalies other than PDA. Twenty-eight patients (31.5%) were emergencies, due to obstructed drainage. Supracardiac and infracardiac TAPVC repair included the double-patch technique with left atrial enlargement in 29 patients and side-to-side anastomosis between the pulmonary venous (PV) confluence and the left atrium in 29 patients. Coronary sinus unroofing was preferred for cardiac TAPVC repair. Total follow-up was 727.16 patient-years (mean 8.55 years, 98.8% complete).

RESULTS

Early mortality was 7.86% (7/89). Ten patients (11.2%) underwent reintervention, including reoperation (eight), balloon dilation (one) and intraoperative stents placement (one), for anastomotic (four) or diffuse PV stenosis (six), with four late deaths. Kaplan-Meier survival is 87.3+/-0.036 SE% at 18.07 years with no difference according to anatomic type or surgical technique. Freedom from PV reintervention for operative survivors is 86.7+/-0.052 SE% at 18.07 years. Cox proportional hazard indicates associated anomalies (P=0.008) and reoperation for intrinsic PV stenosis (P=0.034) as independent predictors of mortality. According to logistic analysis, preoperative obstruction predicts higher risk of reintervention for intrinsic PV stenosis (P=0.022), while the double-patch technique increased the risk of late arrhythmias (P=0.005).

CONCLUSIONS

Side-to-side anastomosis provides excellent results for TAPVC repair while left atrial enlargement procedures appear to be associated with higher risk of late arrhythmias. Although early and aggressive reintervention for recurrent PV obstruction is mandatory, intrinsic PV stenosis remains a predictor of adverse outcome.

In situ pericardium repair of pulmonary venous obstruction after repair of total anomalous pulmonary venous connection

A 13-month-old boy with recurrent pulmonary venous obstruction (PVO) after repair of total anomalous pulmonary venous connection (TAPVC, Darling IIa + Ia) was treated successfully with in situ pericardium repair consisting of unroofing coronary sinus at 2 months. At 8 months, stenosis of the right upper and lower pulmonary veins (PV) and left lower PV were detected, and PVO was relieved via resection of the stenosis site and recutback. Echocardiography 3 months later showed obstructed bilateral PVs and connection between left PVs and vertical veins. At reoperation, we conducted in situ pericardium repair for right PVO and anastomosed left PVs to the left atrial appendage. The postoperative course was satisfactory. Echocardiography 12 months later showed no evidence of PVO, but cardiac catheterization 12 months later showed mild obstruction on the right side and normal venous drainage on the left. Although the long-term prognosis is unknown, this sutureless technique is effective in recurrent PVO.

Surgical management of congenital and acquired pulmonary vein stenosis

Pulmonary vein stenosis describes a variety of entities with a variable clinical course. The basic pathologic process appears to be fibrous intimal thickening, which can gradually cause obliteration of the lumen of the pulmonary veins at the atrial junction. In its most severe form, congenital pulmonary vein stenosis is a progressive disease with rapid pulmonary hypertension and rare survival beyond the first year of life. Surgical intervention has not been successful in this group. Other forms of pulmonary vein stenosis, including unilateral types associated with congenital heart disease, may be managed by various surgical treatments or pneumonectomy in some cases. Although multiple surgical techniques have been described for repair of congenital vein stenosis, the "sutureless" techniques recently described may have a place in the surgical treatment of this condition. In the most severe forms, lung transplantation appears to be an important option that should be considered early in the course of the disease. Copyright 1999 by W.B. Saunders Company

Helical computed tomographic angiography in obstructed total anomalous pulmonary venous drainage

Helical computed tomographic angiography with differential color imaging technique clearly demonstrated pulmonary venous obstruction in an infant with total anomalous pulmonary venous drainage before and after operation. This technique is less invasive and provides precise spatial information of complicated vascular anomalies.

Surgery for congenital heart disease

General agreement has been reached on the indications for treating most congenital cardiac malformations. Strong disagreement exists, however, about timing and methods of treatment, either for congenital heart defects, for which the approach should be standardized after years of use, and even more when a new technique or a new approach is introduced to replace the existing ones. The ideal solution should be to perform prospective, randomized studies, with long-term follow-up, possibly with preliminary experimental studies to support the hypothesis. Unfortunately this is rarely possible, either because of the nonreproducibility of the malformation in an experimental environment, or because prospective, randomized studies with adequate follow-up are rarely feasible, due to the relatively small number of children with the same congenital heart defect. An updated review of the current trends in congenital heart surgery, based on the papers published in the past year, is presented here.

Surgical management of progressive pulmonary venous obstruction after repair of total anomalous pulmonary venous connection

BACKGROUND

The occurrence of a progressive pulmonary venous obstruction after the repair of the total anomalous pulmonary venous connection is a severe complication.

OBJECTIVES

The objectives of this study were to retrospectively review the patients with this condition and to report our experience with a new surgical technique with a sutureless in situ pericardium repair.

METHODS

Of 178 patients who underwent correction of total anomalous pulmonary venous connection, 16 patients (9%) experienced the development of a progressive pulmonary venous obstruction in a median interval of 4 months (5 weeks-12 years). Three patients had isolated anastomotic stenosis, 4 patients had isolated pulmonary venous ostial stenosis, and 9 patients had both. Pulmonary venous obstruction was bilateral in 7 patients. The surgical procedures used at reoperation included 8 patch enlargements, 5 ostial endarterectomies, 1 intraoperative stenting, and 7 sutureless in situ pericardium repairs.

RESULTS

There were 4 deaths after reoperation (4 of 15 patients; 27%). The only significant mortality risk factor was the bilateral location of the pulmonary venous obstruction (P =.045). In patients with isolated anastomotic stenosis or with only 1 pulmonary venous ostial stenosis (n = 5), there was no death, except the patient presenting with a single ventricle. In patients with 2 or more pulmonary venous ostial stenoses (n = 10), there were 3 deaths; 5 of the 7 survivors were successfully treated with the in situ pericardial technique, with normalized pulmonary artery pressure at a mean follow-up of 26 months.

CONCLUSION

Progressive pulmonary venous stenosis after repair of total anomalous pulmonary venous connection remains a severe complication when bilateral. The sutureless in situ pericardial repair offers a satisfactory solution, particularly on the right side.