Modified Deep Transgastric Bicaval View for Revealing Superior Vena Caval Obstruction in a Patient Undergoing Sinus Venosus Atrial Septal Defect Repair A Case Report.pdfVIP

Modi?ed Deep Transgastric Bicaval View for Revealing Superior Vena Caval Obstruction in a Patient Undergoing Sinus Venosus Atrial Septal Defect Repair: A Case Report Neelam Aggarwal, MD,* Koniparambil P. Unnikrishnan, MD,* Puthuvasseri Raman Suneel, MD,* and Thomas Mathew, MS, McH? SUPERIOR SINUS VENOSUS atrial septal defect (SVASD) is an interatrial defect with partial anomalous pulmonary venous connection (PAPVC) draining into the right atrium (RA). The principle for SV-ASD surgical repair involves redirecting the pulmonary venous blood back to the left atrium and closure of the atrial septal defect without causing systemic venous and pulmonary venous obstruction. Closing the ASD with a single intracardiac patch that includes PAPVC can result in superior vena cava (SVC) or pulmonary vein obstruction.1,2 This has led to the evolution of other surgical options, such as double-patch repair and caval division repair (Warden’s procedure). In double-patch repair, an atriocavoplasty is done in addition to the intracardiac patch to augment the SVC, thus avoiding SVC stenosis. However, the atriocavoplasty across the SVC-RA junction may result in sinoatrial node dysfunction by disrupting the sinoatrial node or the sinoatrial node artery. To avoid the risk of sinoatrial node injury, caval division repair (Warden’s procedure) has evolved. The Warden procedure routes the proximal portion of the SVC (draining the anomalous pulmonary veins) through the atrial septal defect to the left atrium. The distal portion of the SVC is connected to the right atrial appendage to reestablish SVC blood ?ow to the right atrium. Intraoperative transesophageal echocardiography (TEE) has an important role in the immediate post-cardiopulmonary bypass (CPB) period to assess the adequacy of the repair and rule out any systemic or pulmonary venous obstruction. It is thought to be dif?cult to get a gradient across the SVC-RA junction using the described conventional TEE views because of a lack of prop