Surgical management of tricuspid atresia and anomalous left brachiocephalic vein

Surgical management of lesions encountered in the setting of the retroaortic left brachiocephalic vein

BACKGROUND AND AIM

Although the retroaortic left brachiocephalic vein in isolation is of no clinical importance, its recognition in the setting of associated lesions is important. We sought to address issues concerning the influence of isomerism, the establishment of diagnosis, and its importance in various surgical and interventional procedures.

METHODS

A total of 80 published clinical and necropsy studies in the setting of a retroaortic left brachiocephalic vein described 250 patients. Clinical presentation, radiographic, ultrasonographic findings, contrast echocardiography, computed-tomographic angiocardiography, magnetic resonance imaging, and angiocardiography provided the diagnostic information prior to considering the surgical approach to the associated cardiac anomalies.

RESULTS

Among 250 reported cases, three-quarters had associated congenitally malformed hearts. Of these 189 patients, all but seven had usual atrial arrangement. Right isomerism was reported in five patients and two patients having left isomerism. Almost two-thirds had tetralogy of Fallot or its variants, over four-fifths had malformations involving the outflow tract, two-thirds had a right aortic arch with two patients having a cervical aortic arch, and onepatient had double aortic arch. Various innovative individualized surgical procedures were employed with an overall perioperative mortality of 3.4%.

CONCLUSIONS

Although the retroaortic left brachiocephalic vein is asymptomatic, its recognition during clinical investigation should raise the possibility of an association with other malformations, especially right aortic arch, ventricular septal defect, and anomalies of the outflow tracts. We submit that an increased appreciation of this venous anomaly may facilitate surgical planning, endovascular procedures, placement of central venous lines, and transvenous pacemakers.

In Memoriam: Paul Morris Weinberg, MD

On 15 October, 2020, Dr. Paul M. Weinberg, a true giant in the field of paediatric cardiology, succumbed to a prolonged illness. Dr. Weinberg had a 43-year career and was described as a pillar of The Children's Hospital of Philadelphia and the spirit of the Division of Cardiology, a cherished and beloved teacher, and an outstanding clinician. His impact on the field and on the careers of his students will be remembered for generations to come.In 2019, Dr. Weinberg wrote for Jefferson Medical School's 50th year reunion memory book: "In the true spirit of Hippocrates, I seek to mentor the next generation as I was mentored by the last, without expectation of reward. I am forever indebted to these educators for all the knowledge they imparted to me and for the wisdom that I acquired under their tutelage." These words are a true reflection of his unassuming dedication to teaching the next generation of paediatric cardiologists. His legacy will continue to live on through these trainees and impact the field for generations to come.

Retroaortic innominate vein in a patient with transposition of the great arteries: the surgical implications

We describe the case of a newborn infant with transposition of the great vessels and a retroaortic innominate vein. This is a previously undescribed association. The decision was made to incorporate the retroaortic innominate vein into the Lecompte procedure at the time of surgery to avoid the risk of superior caval vein syndrome.

Anomalous subaortic left brachiocephalic vein associated with tricuspid atresia: a successful bidirectional cavopulmonary connection

Anomalous subaortic left brachiocephalic vein is an uncommon systemic venous anomaly. Here we report a case of this anomaly in a 3-month-old male infant with tricuspid atresia. The patient successfully underwent bidirectional cavopulmonary connection without cardiopulmonary bypass, although extended dissection of the bilateral brachiocephalic veins was required. The association of this venous anomaly with tricuspid atresia is extremely rare, and the presented patient is the second successful surgical case in the literature.