AATS – Washington , DC 2007 Anomalies of systemic venous return : Surgical management of LSVC-CS Florentino J. Vargas MD Division of Cardiovascular Surgery Hospital de Ninos P. Elizalde Buenos Aires-Argentina LSVC-CS & CHD Univentricular situations with innominate vein Biventricular situations without inominate vein LSVC-CS & CHD 1. Hemodinamically benign ( minor implicances: venous return on bypass, cannulation issues ) 1. constitutes a pathologic entity which needs to be addressed or, 2. does not constitute a pathologic entity, but does imply modifications in the surgical management LSVC-CS needs to be addressed in: Pathologic entities: • Dilated LSVC-CS causing LV inflow obstruction • Unroofed CS Implications in the surgical technique: • CAVC repair • Cardiac transplantation Dilated LSVC-CS causing LV inflow obstruction • • • • • • Early presentation Could mimic core triatriatum Pulmonary hypertension Isolated or associated with CHD Easy to be overlooked if ignored Might be the ethiology for left sided obstructions - LV underdevelopment? Dilated LSVC-CS the ethiology for left sided obstructions - LV underdevelopment? CS AO LV • • • • Cochrane et al (1994), Macedo et al (1996), Agnoletti et al (1999) Di Bardino et al (2004) Dilated LSVC-CS causing LV inflow obstruction RA AS MV PV LSVC-dilated CS + LV inflow obstruction: Reduction plasty of the CS Cochrane et al, Ann Thorac Surg 1994; 58:1114-6 lsvc rsvc ao m asd C m B azg lsvc cs A lsvc pa laf pv D E raa azg F laa Vargas et al. Ann Thorac Surg 2006;82:191-6 Dilated LSVC-CS causing LV inflow obstruction Dilated LSVC-CS causing LV inflow obstruction Dilated LSVC-CS causing LV inflow obstruction Di Bardino et al: J Thorac Cardiovasc Surg 2004 Dilated LSVC-CS & LV inflow obstruction : Cath findings Diastolic LA-LV gradient LA“a” waves LVEDP O.R. Movie…….. Post operative angiogram done in IIVC LSVC-CS needs to be addressed in: Pathologic entities: • Dilated LSVC-CS causing LV inflow obstruction • Unroofed CS Implications in the surgical technique : • CAVC repair • Cardiac transplantation LSVC + Unroofed CS: absence of septum between CS and LA partial : variable degree of CS-LA connection: defect can be patch-closed complete : LSVC to LA • Coronary veins drain individually • CS type of ASD • Associated CHD • Arterial insaturation LSVC + Unroofed CS LSVC + Unroofed CS: CS type of ASD • CS is absent . • ASD : no inferior border • MV & TV are contiguous, separated by a narrow ridge • The anatomic landmarks for location of the AV node are modified ( the node is more exposed) Unroofed CS: Intracardiac techniques rerouting LSVC flow to RA: (intraatrial tunnel or baffle techniques) • • • • • G. Rastelli 1965 J. Quaegebeur 1979 M. Sand 1986 T. Beyens 1997 H. Komai 1996 Intracardiac repairs: limited exposure . proximity of p.veins-LSVC-mitral valve : risk of baffle obstruction Unroofed CS: Extracardiac techniques (LSVC connections to RSVC, RA , RAA, or PA) Shumacker : LSVC to RAA ( with cuff of LA tissue) Meskishvili : LSVC to RA (with Vein homograft) Gontijo : LSVC to RAA( with PTFE graft ) van Son: LSVC to RSVC (direct anastomosis, retroaortic) Palacios-Macedo: LSVC to RSVC (tube tailored with LAA) Foster: LSVC to PA (left Glenn) Reedy VM, Ann Thorac Surg 1997;63:1800-02 LSVC-CS needs to be addressed in: Pathologic entities: • Unroofed CS • Dilated LSVC-CS causing LV inflow obstruction Implications in the surgical technique: • CAVC repair • Cardiac transplantation LSVC - CS: implications at CAVC repair LSVC- RAA anastomosis : an alternative during CAVC repair & LSVC – CS? AV node CS ( from Kirklin & Barratt-Boyes) LSVC-CS needs to be addressed in: Pathologic entities: • Unroofed CS • Dilated LSVC-CS causing LV inflow obstruction Implications in the surgical technique : • CAVC repair • Cardiac transplantation LSVC: implications in transplantation technique Enlarged LSVC- RAA anastomosis : use during cardiac TX lsvc rsvc rsvc A B lsvc Conclusions • LSVC can be relevant as a pathologic entity itself, or because it modifies the surgical technique. • Extracardiac procedures rerouting LSVC to RAA are a suitable resource. • IIVC-azigos to LSVC challenges the preservation of an unobstructed systemic venous drainage . Conclusions • The enlarged LSVC-RAA anastomosis provides a large anastomotic surface, without tension. • Most of the procedure is done during rewarming. • LSVC-RAA occupies the same place of the original RAA (anterior compression should not be expected) Pediatric Cardiovascular Surgery Hospital de Ninos P. Elizalde Argentina