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J Thorac Cardiovasc Surg 2000;119:178-180
© 2000 Mosby, Inc.
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From the Division of Cardiovascular Surgery, IWK Grace Health Centre, and The Division of Cardiac Surgery, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada.
Address for reprints: David B. Ross, MD, Cardiovascular Surgery, IWK-Grace Health Centre, 5850/5980 University Ave, PO Box 3070, Halifax, Nova Scotia, B3J 3G9 Canada (E-mail: dross{at}iwkgrace.ns.ca).
The repair of sinus venosus–type atrial septal defect (ASD) is considered a safe procedure. The standard approach has been through an oblique atriotomy. Exposure is often difficult and awkward, and damage can occur to the sinoatrial node, its blood supply, or the atrial tissue, resulting in arrhythmia. This has inspired a number of different surgical techniques, none of which is entirely satisfactory.
1-4 We now approach the repair through a transverse superior vena cava (SVC) incision, a technique not previously described.
Methods
Through the median sternotomy approach, a 1.5 to 2.5 cm by 2 to 3 cm piece of pericardium is harvested and treated with 0.6% glutaraldehyde. After the SVC has been dissected and mobilized to the level of the innominate vein, the aorta is cannulated. The SVC is cannulated at the level of the innominate vein by using a right-angle cannula (Medtronic DLP, Grand Rapids, Mich). The inferior vena cava is also cannulated at the level of the junction with the right atrium(Fig 1). Cardiopulmonary bypass is begun, and the patient’s temperature is allowed to drift to 32°C. The aorta is crossclamped, and the heart is arrested. Snares are applied and tightened around the cavae.
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). The previously harvested and treated pericardium is then fashioned and used to baffle the anomalous veins to the left atrium with a running suture(Fig 2). The patch should be large enough so that it is slightly dome shaped to allow unobstructed flow between the anomalous pulmonary veins and the left atrium. In addition, care must be taken to keep the suture line as posterior as possible to avoid stenosis of the SVC(Fig 3). After de-airing, the SVC incision is closed in a running fashion without patch enlargement(Fig 3).
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To date we have used this technique in 6 patients with a median age of 5.5 years (range, 4-54 years). At follow-up (mean, 2.5 years; range, 2 months to 4 years) all 6 patients are in sinus rhythm and are asymptomatic. Echocardiographic follow-up demonstrated normal flow between the SVC and right atrium and no obstruction of flow in the pulmonary veins.
Conclusion
It is important to cannulate the SVC very high to provide adequate exposure, especially of the anomalous pulmonary veins, which often connect to the SVC or the SVC–right atrial junction. 5 Most other methods involve cannulation through the right atrial appendage. 1,4 It has been demonstrated that selective SVC cannulation can decrease the incidence of postoperative arrhythmias. 3 However, previously described methods involve an atriotomy and/or an incision that crosses the SVC–right atrial junction, which can damage the sinoatrial node, its blood supply, or the atrial tissue. 1,2,4
The careful sizing of the patch and its posterior placement are important to prevent any possible stenosis of the SVC–right atrial junction or the pulmonary veins. The transverse SVC approach provides excellent exposure of the sinus venosus ASD and avoids any disruption to the integrity of the right atrium, the sinus node, or the sinus node artery. The natural connection between the SVC and the right atrium is maintained. The transverse incision avoids the use of an enlarging patch on the SVC to prevent stenosis, which can occur with the use of a longitudinal incision. 4 Although not necessary in our series to date, the SVC could be enlarged with a pericardial patch if it appeared inadequate.
Acknowledgments
We thank medical illustrator Kevin Millar, Msc, BMC.
References
This article has been cited by other articles:
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  G. B. Luciani, F. Viscardi, M. Pilati, R. Crepaz, G. Faggian, and A. Mazzucco Age at repair affects the very long-term outcome of sinus venosus defect. Ann. Thorac. Surg., July 1, 2008; 86(1): 153 - 159. [Abstract] [Full Text] [PDF]
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 G. Webb and M. A. Gatzoulis Atrial Septal Defects in the Adult: Recent Progress and Overview Circulation, October 10, 2006; 114(15): 1645 - 1653. [Full Text] [PDF]
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A. Shahriari, M. D. Rodefeld, M. W. Turrentine, and J. W. Brown Caval Division Technique for Sinus Venosus Atrial Septal Defect With Partial Anomalous Pulmonary Venous Connection Ann. Thorac. Surg., January 1, 2006; 81(1): 224 - 230. [Abstract] [Full Text] [PDF]
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 J. L Russell, J. G LeBlanc, M. L Deagle, J. E Potts, and PhD Outcome Following Repair of Sinus Venosus Atrial Septal Defects in Children Asian Cardiovasc Thorac Ann, September 1, 2002; 10(3): 231 - 234. [Abstract] [Full Text] [PDF]
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