Outcomes and Technique for Repair of Isolated Left Partial Anomalous Pulmonary Venous Drainage Via Left Posterolateral Thoracotomy Without Cardiopulmonary Bypass
*Tara Karamlou1, Awais Afshaq2, Natalie McCormick1, *Ross Bremner3, *Michael Smith3, Robert Puntel1, *John J Nigro4
1Phoenix Children's Hospital, Phoenix, AZ;2Mayo Clinic, Scottsdale, AZ;3Saint Joseph Hospital and Medical Center, Phoenix, AZ;4Rady Children's Hospital, San Diego, CA
OBJECTIVES: The indications and approach for repair of isolated left partial anomalous pulmonary venous drainage (LPAPVD) varies, with some centers advocating aggressive repair while others prefer medical management. Prior series report repair via a median sternotomy and cardiopulmonary bypass (CPB) or via a left anterior thoracotomy. We believe that repair of this lesion provides significant benefit by reducing volume loading, and perform this repair via a left posterior lateral thoracotomy without CPB. The goal of this study is to describe our technique and report mid-term outcomes and for repair of isolated LPAPVD using this novel approach.
METHODS: Consecutive patients (2005 to 2015) who underwent repair of LPAPVD by a single surgical team were retrospectively reviewed. Patients with right-sided partial anomalous venous return and mixed pulmonary venous return were excluded. However, patients with prior cardiac surgery were included. All patients underwent a left posterolateral thoracotomy with vertical vein ligation and reimplantation of the anomalous pulmonary vein to the left atrial appendage (Figures 1 and 2). Abstracted data included patient demographics, intraoperative details, echocardiographic results (pre-operative and at last follow-up) and clinical status at last follow up.
Eleven consecutive patients (females, N=6, 55%) were identified. The median age was 9 years (range, 0-66 years) and median weight was 22.7 kgs (range, 3.7 - 53 kgs) at repair. Median operative time was 141 minutes (range, 116-156 minutes), No blood products were used intraoperatively and all patients were extubated in the operating room. There were no mortalities. Operative complications included left pleural effusion (N=1, 9%), left vocal cord paresis (N=1, 9%), post pericardiotomy syndrome (N=1, 9%) and readmission due to symptomatic bradycardia (N=1, 9%). Median length of hospital stay was 3 days (range, 2-11 days). Clinical and echocardiographic follow-up was complete at a median of 47 months (range, 10-104 months). No reinterventions were performed. All reimplanted veins were widely patent on echocardiography at follow-up. Right ventricular systolic pressure decreased from a mean of 42 mmHg preoperatively to a mean of 22 mmHg at last echocardiographic follow-up (Figure 3), and all patients were in NYHA Functional Class 1. CONCLUSIONS:
Repair of isolated LPAPVD can be effectively and safely performed via a left posterolateral thoracotomy without CPB with excellent patency and clinical outcomes at intermediate follow-up. Trends in right ventricular systolic pressure suggest decreased hemodynamic burden among repaired patients. A larger patient cohort, longer follow-up, and additional studies such as pre and postoperative exercise testing and magnetic resonance imaging will further elucidate the utility of this procedure.
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