Conventional repair of total anomalous venous drainage without primary sutureless technique: surgical tips to prevent pulmonary vein obstruction

OBJECTIVES

Although primary sutureless technique for total anomalous pulmonary venous drainage has been introduced to reduce postoperative pulmonary vein obstruction (PVO), controversy still exists about superiority of the procedure between the conventional repair and primary sutureless technique at the initial repair. In our unit, the conventional repair has been consistently used based on four important surgical policies: (1) mark incision lines between 2 chambers to gain anatomically natural alignment, (2) place precise stitches by "intima-to-intima" using monofilament suture, (3) adequate orifice size should be guaranteed in greater than expected mitral valve size, (4) do not hesitate to undertake a redo additional anastomosis by a different approach when an echocardiography shows the velocity more than 1.5 m/s. This study aims to evaluate mid-term outcome of the conventional repair for total anomalous pulmonary venous drainage.

METHODS

Between 2004 and 2016, consecutive 15 patients who underwent the conventional repair without the primary sutureless technique were included in this study. Survival, Freedom from reoperation, and PVO were retrospectively reviewed.

RESULTS

Mean follow-up period was 4.6 ± 3.7 years. Except for one patient who died of uncontrollable pleural effusion, all other patients survived with 5-year survival rate of 93.3%. For the 14 survivors, there was no PVO, nor reoperation.

CONCLUSIONS

Following these policies, the mid-term outcome of the conventional total anomalous pulmonary venous drainage repair was excellent without the primary sutureless technique showing no obstruction. The conventional repair can be safely applied at the initial operation when the morphological condition allows for it.

[Postoperative venous thromboembolic complications - real threat and modern preventive methods]

Prospective study included 244 patients, who underwent general surgery, gynecological or urological surgical interventions. The rate of postoperative venous thrombotic complications was analyzed in accordance with preventive strategy. It was shown that high-technology methods (both physical and pharmacological) in combination with other diagnostic and therapeutic interventions can improve the efficacy of PVTC prevention. Diagnostic algorithms for PVTC prevention and early diagnosis were developed and implemented into clinical practice.

Protective effects of S-nitrosoalbumin on lung injury induced by hypoxia-reoxygenation in mouse model of sickle cell disease

Nitric oxide (NO) is a potential new therapeutic agent for sickle cell disease (SCD). We investigated the effects of NO donor on hypoxia-induced acute lung injury that occurs when transgenic sickle cell SAD mice are exposed to chronic hypoxia, a model for lung vasoocclusive sickle cell events. In wild-type and SAD mice, intraperitoneal injection of S-nitrosoalbumin (NO-Alb) produced no significant hematologic changes under room air conditions, whereas it induced mild temporary hypotension and inhibition of platelet aggregation. NO-Alb administration (300 mg/kg ip twice a day, equivalent to 7.5 microM NO) in wild-type and SAD mice exposed to 46 h of hypoxia (8% oxygen) followed by 2 h of normoxia resulted in 1) reduction of the hypoxia-induced increase in blood neutrophil count, 2) prevention of hypoxia-induced increased IL-6 and IL-1beta levels in bronchoalveolar lavage, 3) reduction of the lung injury induced by hypoxia-reoxygenation, 4) prevention of thrombus formation, and 5) prevention of hypoxia-induced increase of lung matrix metalloproteinase-9 gene expression. These effects provide new insights into the possible use of NO-Alb in the treatment of acute lung injury in SCD.

Anti-thrombin III in the management of hematopoietic stem-cell transplantation-associated toxicity

OBJECTIVE

To describe the evidence assessing the use of anti-thrombin III (AT-III) in the management of toxicity associated with hematopoietic stem-cell transplantation (HSCT)-conditioning regimens.

DATA SOURCES

Clinical literature was accessed through conference proceedings, EMBASE, the Cochrane database, and MEDLINE (1966-December 2003).

STUDY SELECTION AND DATA EXTRACTION

Case reports, small case series, case-control and cohort studies, and randomized controlled trials of AT-III in HSCT were evaluated. Publications examining AT-III use in the non-HSCT setting were also explored. Key search terms included AT-III, transplantation, and veno-occlusive disease (VOD).

DATA SYNTHESIS

Severe VOD and ensuing multiple organ dysfunction is associated with high mortality in HSCT. A low AT-III level has been shown to correlate with the development of organ dysfunction. Phase II trials, case series, and one small, randomized, placebo-controlled study suggest a benefit when AT-III therapy is instituted early in the course of VOD/multiple organ dysfunction syndrome. In all of these reports, AT-III use was devoid of adverse events.

CONCLUSIONS

Although further studies are needed to ascertain the optimal target level, method, and duration of administration, AT-III is still a viable alternative for the treatment of severe VOD and ensuing multiple organ dysfunction.

[Surgical treatment of total anomalous pulmonary venous connection--clinical aspects of pulmonary venous obstruction]

During November 1986 and May 1997, 19 patients with total anomalous pulmonary venous connection (TAPVC) underwent repair surgery. 20 operations including two reoperations were performed. 8 of 19 patients were classified as Darling type Ia, 5 as type IIa, 4 as type III and 2 patients were type IV. Two patients were operated under emergency circumstances within 24 hours after admission, 7 patients were after a short term stabilization of 4.4 days, and the other 11 patients received surgical treatment after a mean of 8.8 days as scheduled cases. For the anostomosis, the common pulmonary venous chamber or the vertical vein was connected with the left atrium in type Ia and III cases; in type IIa and IV cases the cut-back method was performed. Persistent pulmonary hypertension and post-operative pulmonary venous obstruction (PVO) affected the post-operative clinical course. Persistent pulmonary hypertension caused the death of one patient with type IIa and III each, just after operation. One type IV patient died 50 days after operation. The autopsy revealed post-operative obstructions of the remote parts of the pulmonary veins on the anostomosis site. Two patients (type IIa, III) successfully underwent reoperation due to PVO. Post-operative cardiac catheterization was performed after 12 month in 12 cases. Persistent pulmonary hypertension was found in 4 patients, and a type III patient was reoperated because of stenosis of the anostomosis site. The other three patients had persistent pulmonary hypertension without any demonstrable PVO. Persistent pulmonary hypertension and PVO are combined as TAPVC complex. The difficulty to reoperated patients with persistent pulmonary hypertension caused by PVO is one major problem. So preoperative prevention of PVO by normalization the morphologic changes of the pulmonary veins by using drugs could be a different view point in TAPVC therapy after the initial operation.

Down syndrome as a factor influencing hemodynamic response to pulmonary artery banding

The hemodynamic response to pulmonary artery banding (PAB) in relation to the preoperative pulmonary/systemic vascular resistance (Rp/Rs) ratio and to the timing of surgery, with special regard to Down syndrome, was investigated in 56 nonconsecutive pediatric patients aged 3 days to 6 months (mean 2.5 months) with simple and complex congenital shunt-related cardiac malformations. Among the non-Down patient group (39 patients; mean age 6.9 weeks) there was a good hemodynamic response in all but three cases, irrespective of the preoperative Rp/Rs ratio; these three poor responders had preoperatively normal or nearly normal Rp/Rs ratios (Rp/Rs < 0.3) and were affected postoperatively by lung complications. In the Down patient group (17 patients; mean age 8.2 weeks) the mean preoperative as well as the mean postoperative Rp/Rs ratio was higher than in the non-Down patient group (preoperative Rp/Rs 0.49 versus 0.32; postoperative Rp/Rs 0.31 versus 0.18). There was a good hemodynamic response in all five patients with Down syndrome who had preoperative normal or nearly normal pulmonary vascular resistance ratios (Rp/Rs < 0.3). Among 12 patients with Down syndrome and preoperative increased resistance ratios (Rp/Rs > 0.3) PAB did not cause a reduction in pulmonary vascular resistance (PVR) in five patients (postoperative Rp/Rs 0.49-1.00), all operated on at more than 6 weeks of age. PAB resulted in effective reduction of postoperative Rp/Rs ratios (range 0.10-0.27) in seven patients, six of them younger and one older than 6 weeks at the time of the banding procedure. In conclusion, patients with Down syndrome and shunt-related cardiac malformations (predominantly total atrioventricular canal cases) in general have higher pre- and postoperative Rp/Rs ratios than non-Down children and also have a higher potential for developing pulmonary vascular obstructive disease despite hemodynamically effective PAB. Especially in children with Down syndrome and pathologically high resistance ratios, PAB, if indicated, should be performed as early as possible.

[A case report of Darling's classification Ib total anomalous pulmonary venous return with an unusual left pulmonary vein]

A radical correction involving Vargas's method and a direct anastomosis between the left pulmonary vein (PV) and left atrium (LA) was performed in a 29 day-old infant with supracardiac type Ib total anomalous pulmonary venous return (TAPVR) and an unusual form of the left PV. the left upper and lower PVs drained into a left "common" PV that was just behind the LA, and then into the right pleural cavity. The left common PV was located cephalad to the normal course and received blood from the right lower and upper PVs and drained into the supra-vena cava (SVC). The junction of the SVC and the right PV was slightly stenotic. Vargas's method is a useful technique for Darling's classification Ib TAPVR even in cases without the common PV situated behind the LA. But this patient had a left common PV and it was possible either to anastomose the common PV and LA directly or to perform Vargas's technique. We performed both procedures to prevent left PV obstruction (PVO). Cineangiography performed 2 months after surgery showed that a large amount of blood from the right and left PV drained into the LA through the common PV-LA route. These procedures, which create a dual PV channel, reduce the risk of PVO, so they are useful for radical correction of Darling's Ib type TAPVR.

Absorbable polydioxanone suture and results in total anomalous pulmonary venous connection

BACKGROUND

Despite theoretical advantages of absorbable suture in the growing vascular anastomosis, there has not been a documented advantage over nonabsorbable suture in preventing late anastomotic stenosis in total anomalous pulmonary venous connection (TAPVC).

METHODS

We reviewed our experience from 1982 to 1994 with 65 hospital survivors of total TAPVC repair to examine the influence of suture type on survival and incidence of late pulmonary venous obstruction. From 1982 until 1988, we used continuous nonabsorbable polypropylene suture for the pulmonary venous-left atrial anastomosis in supracardiac, infracardiac, and mixed types of TAPVC: In 1989, we adopted a running absorbable polydioxanone suture technique. Cardiac catheterization and echocardiography were used to evaluate late pulmonary venous obstruction.

RESULTS

Late pulmonary venous obstruction occurred in 17% (4/23) of survivors after repair with polypropylene suture compared with 3.2% (1/32) after repair with polydioxanone suture (p < 0.05). There were no instances of late pulmonary venous obstruction in the intracardiac TAPVC group (0/10). All late pulmonary venous obstructions occurred within 16 months after operation. The actuarial 3-year and 5-year freedom from late pulmonary venous obstruction was 100% for intracardiac TAPVC, 96% for the polydioxanone group, and 81% for the polypropylene group. Five patients died late (5/65, 7.7%), 3 in the polypropylene suture group (3/23, 13%) and 2 in the polydioxanone group (2/32, 6%).

CONCLUSIONS

Continuous absorbable polydioxanone suture for the repair of TAPVC results in a low incidence of late pulmonary venous obstruction and death and appears to offer advantages over a continuous nonabsorbable suture. A continuous nonabsorbable suture may limit growth of a vascular anastomosis, particularly one involving a "low-pressure" anastomosis such as in the repair of TAPVC:

Efficacy of pulmonary artery banding in the prevention of pulmonary vascular obstructive disease

In 57 nonconsecutive pediatric patients (mean age: 2.6 months) with shunt-related pulmonary hypertension, the efficacy of pulmonary artery banding (PAB) was analysed retrospectively with special reference to the development of pulmonary vascular obstructive disease (PVOD). The patients were grouped in accordance to morphology, hemodynamics and incidence of PVOD. Efficacy of PAB was assessed by pulmonary to systemic pressure, flow and resistance ratios obtained by heart catheterization performed pre- and postoperatively. PAB was very effective in 49 out of 57 patients (= 85.9%), in 8 cases a progression or possible progression of PVOD must be suggested. Only Down syndrome can be considered as a predisposing factor for the development of PVOD. Based on our results we conclude that PAB is a high effective procedure in the prevention of PVOD; however, despite the surgical effectiveness of PAB, PVOD can occur. Strict post-PAB examination of pulmonary flow and resistance parameters is recommended and the definite surgical repair should be performed as early as possible.