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Recognition and management of obstructed pulmonary veins draining to the coronary sinus
M M DeLeon1, S Y DeLeon, P T Roughneen
1Department of Thoracic and Cardiovascular Surgery, Loyola University Medical School, Maywood, Illinois 60153, USA.
Insights
Pulmonary vein obstruction in total anomalous pulmonary venous drainage to the coronary sinus is more common than previously thought. Early diagnosis with echocardiography and Doppler studies is crucial for successful surgical outcomes.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Medical Imaging
Background:
- Total anomalous pulmonary venous drainage to the coronary sinus (TAPVD-CS) with pulmonary vein obstruction is considered rare.
- Standard surgical unroofing of the coronary sinus may yield poor results if obstruction is present.
Purpose of the Study:
- To investigate the incidence and management of pulmonary vein obstruction in TAPVD-CS.
- To evaluate surgical techniques for improving outcomes in these patients.
Main Methods:
- Retrospective review of four pediatric patients with TAPVD-CS and obstruction over 14 months.
- Preoperative echocardiography and Doppler studies were used to identify obstruction.
- Comparison of outcomes between coronary sinus unroofing and direct common pulmonary vein-left atrial anastomosis.
Main Results:
- Three patients initially treated with coronary sinus unroofing experienced postoperative pulmonary vein obstruction.
- One patient died postoperatively after reoperation; two improved after reoperation.
- A patient undergoing direct common pulmonary vein-left atrial anastomosis showed sustained positive outcomes.
Conclusions:
- Pulmonary vein obstruction in TAPVD-CS is likely underdiagnosed.
- Comprehensive echocardiography with Doppler is essential for preoperative diagnosis.
- Direct common pulmonary vein-left atrial anastomosis offers a superior surgical approach for obstructed TAPVD-CS.
Background:
Obstruction of the pulmonary veins in total anomalous pulmonary venous drainage to the coronary sinus is generally considered rare. However, if it is present, the usual treatment of unroofing the coronary sinus will lead to a poor result.
Methods:
Four patients with total anomalous pulmonary venous drainage to the coronary sinus with obstruction were identified over a 14-month period. Three patients in whom the diagnosis of obstruction was not made underwent coronary sinus unroofing. Retrospective review of the preoperative echocardiograms and Doppler studies showed the presence of obstruction in the vertical vein in 2 patients and in the branches in the other. In the fourth patient, obstruction in the vertical vein was recognized preoperatively with echocardiography and Doppler study. This patient underwent direct common pulmonary vein-left atrial anastomosis.
Results:
All 3 patients who had coronary unroofing were seen with obstructed pulmonary veins 2 to 7 months postoperatively. After reoperation, 1 died, and the other 2 have done relatively well 3 1/2 and 15 months postoperatively. The patient who had an anastomosis between the common pulmonary vein and the left atrium is doing well 18 months postoperatively.
Conclusions:
Obstruction in total anomalous pulmonary venous drainage to the coronary sinus is not as rare as previously reported. To improve outcome, its presence should be sought using complete echocardiography including Doppler studies. When obstruction is present, transection of the vertical vein and common pulmonary vein-left atrial anastomosis through the superior approach is an attractive technique that also eliminates the right-to-left shunting associated with coronary sinus unroofing and simplifies closure of the atrial septal defect.