Outcomes of the lateral caval flap and conventional techniques for repair of right-sided partial anomalous pulmonary venous connection in adults

Abstract

Objective: In an effort to overcome limitations of conventional techniques for surgical repair of partial anomalous pulmonary venous connection (PAPVC), we developed the lateral caval flap (LCF) technique, which leverages a native endocardial surface to create unobstructed recruitment of the anomalous pulmonary veins to the left atrium. In this study, we report the long-term outcomes of the LCF and conventional techniques for repair of right-sided PAPVC.

Methods: In total, 109 adult patients (mean age 48 years; 57% male) who underwent right-sided PAPVC repair (53 LCF, 34 single-patch, 13 double-patch, 7 pericardial roll, and 2 Warden procedure) from 1997 to 2022 were retrospectively reviewed. Outcomes included operative mortality, major morbidity, arrythmias, systemic and pulmonary venous pathway obstruction, survival, and reintervention.

Results: Operative mortality was 1% and there were no in-hospital deaths after LCF repair; 4 patients had strokes (4%) including 2 nondisabling strokes after LCF repair (4%), 19 patients developed new postoperative atrial fibrillation/flutter (24%) including 9 after LCF repair (24%), and 27 patients developed new early sinus node dysfunction (26%) including 13 after LCF repair (26%). Although sinus-node dysfunction was transient in most patients, 7 required permanent pacemaker implantation (7%). Survival at 1, 5, 10, and 15 years was 95%, 89%, 86%, and 81%, respectively. At a median follow-up of 6 years, 9 patients developed systemic or pulmonary venous pathway obstruction. Freedom from cardiac reintervention at 5 years was 89% overall and 98% after LCF repair.

Conclusions: All of the described techniques for repair of right-sided PAPVC yielded acceptable short- and long-term outcomes. LCF is a valid technique for right-sided PAPVC repair with a low risk of venous pathway obstruction compared with conventional techniques. Sinus node dysfunction and atrial tachyarrhythmias remain challenges.

Keywords: adult congenital heart disease; lateral caval flap repair; partial anomalous pulmonary venous connection; sinus venosus defect.

Lateral caval flap repair of right-sided partial anomalous pulmonary venous connection.

Figure 1

Lateral caval flap technique for repair of right-sided partial anomalous pulmonary venous connection. A, Sinus venosus defect with anomalous right upper pulmonary veins. B and C, A lateral caval flap is mobilized and sutured to reroute the anomalous venous return to the left atrium through the atrial septal defect. D and E, An autologous pericardial patch is used to close and augment the superior vena cava. Note the fine bites taken in the pulmonary veins and endocardium behind the sinoatrial node. SA, Sinoatrial node; SVC, superior vena cava; IVC, inferior vena cava.

Figure 2

Computed tomography imaging of right-sided partial anomalous pulmonary venous connection before (upper panel) and after (middle and lower panels) lateral caval flap repair. RUPV, Right upper pulmonary vein; SVC, superior vena cava.

Figure 3

Actuarial survival after right-sided partial anomalous pulmonary venous connection repair for (A) the overall cohort and (B) stratified by repair technique. Red = lateral caval flap. Green = all other techniques.

Figure 4

Actuarial freedom from cardiac reintervention after right-sided pulmonary venous connection repair for (A) the overall cohort and (B) the lateral caval flap technique.