Home Journal Watch Single institution outcomes of surgical repair of infra cardiac total anomalous pulmonary venous connection

Single institution outcomes of surgical repair of infra cardiac total anomalous pulmonary venous connection

Guocheng Shi, MD; Fang Zhu, MD; Chen Wen, MD; Lisheng Qiu, MD; Haibo Zhang, MD, PhD; Zhongqun Zhu, MD, PhD; Huiwen Chen, MD, PhD

The Journal of Thoracic and Cardiovascular Surgery, 161(4), 1408-1417. https://doi.org/10.1016/j.jtcvs.2020.06.023

Abstract

Homs Objective
This contemporary study sought to describe the outcomes of patients undergoing biventricular repair of infracardiac total anomalous pulmonary venous connection.

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A retrospective study was performed on patients with infracardiac total anomalous pulmonary venous connection who underwent sutureless technique or conventional repair between 2006 and 2018. Risk factors for survival and post-repair pulmonary vein stenosis (PVS) were assessed with Cox regression model. Time-to-event analysis was conducted using Kaplan-Meier estimates.

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This study included 82 consecutive patients with the median age of 21 days (interquartile range, 9-40 days). The median follow-up was 29 months (interquartile range, 12.5-59 months) and was available in 95% of the survivors at the end of the study period in 2019. Overall, 8 deaths (8.5%) occurred in the conventional repair group. There was a trend of higher mortality in the conventional repair group, although it did not reach a statistical difference (P = .2). Postrepair PVS occurred at a median of 2 months (interquartile range, 1.2-3.6 months) postoperatively and all occurred in the conventional repair group. Time-to-event analysis with the event of postrepair PVS showed significantly higher freedom from restenosis in the sutureless technique group (P = .0004). Adjusted hazard ratios from time-dependent Cox model described the association between postrepair PVS and pulmonary venous confluence of antler configuration (hazard ratio, 2.14; 95% confidence interval, 1.03-5.47; P = .002) and the use of sutureless technique (hazard ratio, 0.72; 95% confidence interval, 0.39-0.97; P = .003).

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Sutureless technique is associated with a lower risk of postrepair PVS in patients with infracardiac total anomalous pulmonary venous connection. pulmonary venous confluence configuration of antler appearance appears to be associated with restenosis and mortality.

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Commentary

The authors address an ongoing concern with the surgical management of Total Anomalous pulmonary venous connection; the post-operative occurrence of pulmonary venous stenosis (PVS).  The authors concluded that “Sutureless” repair of TAPVC is associated with a lower risk of postoperative PVS. As our understanding of the pathophysiology of PVS has continued to evolve, it now seem clear that this disease is the result of a neo proliferative response to interventions on the individual veins. This this in mind, we would caution the aggressive incision in to the individual pulmonary veins, as described be the authors. I incision into the confluence with inclusion of the descending vertical vein should provide adequate area for the unobstructed flow of pulmonary venous blood to the heart. Of course, much more granular follow-up is needed to substantiate this more conservative approach.

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