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Modified Senning Operation in the Treatment of Transposition of The Great Arteries

Modified Senning Operation in the Treatment of Transposition of The Great Arteries DOI: 10.2478/v10163-011-0030-0 CASE REPORT Aris Lacis *, Inguna Lubaua**, Lauris Smits*, Valts Ozolins*, Normunds Sikora*, Zane Straume* *Children's University Hospital, Clinic for Paediatric Cardiology and Cardiac Surgery **Riga Stradins University , Pediatric Chair, Riga, Latvia Summary The arterial switch operation has become the procedure of choice for patients with transposition of the great arteries( TGA) in most medical centres. Although atrial switching may occasionally be employed in some centres in cases with delayed diagnosis, pulmonary hypertension and some other unusual entities. We preferred to use the atrial switch operation ­ modified Senning procedure for 6 years 6 months old boy with TGA , small atrial septal defect (ASD) and patent ductus arteriosus ( PDA). Key words: congenital heart disease, transposition of great arteries, modified Senning procedure, myocardial protection. AIM OF THE DEMONSTRATION The aim of this article is to demonstrate a case of successful repair of TGA in case of delayed diagnosis and complicated with high pulmonary hypertension. CASE REPORT On the 26 January 2009 a 6 years 6 months old boy with TGA , small ASD and PDA was repaired using the modified Senning procedure. His body weight was 12,5 kg (­ 3 standart deviations). A patient was referred to us for progressively increasing cyanosis and dyspnoea on exertion. Clinical examination , chest radiography and echocardiography all comfirmed the diagnosis of the TGA with small ASD and PDA. The saturation of oxygen ranged between 51and 57%, hematocrit was 66,6%. Surgical technique The heart was exposed through a median sternotomy incision and purse­ string sutures are placed in the ascending aorta for arterial cannulation and directly upon each vena cava for venous cannulation. Before cardiopulmonary bypass was established, the circumferences of the superior vena cava (SVC) and inferior vena cava (IVC) were measured and recorded. Marking sutures were placed on the interatrial groove to define the cephalic and caudal point extent of the left atriotomy. Cardiopulmoary bypass was established and patient's temperature was decreased to + 24° C. The aorta was cross ­clamped, and cold blood cardioplegia was started. The right atrium was opened superiorly 1 cm anterior to the crista terminalis and the incision was extended anteriorly to the previously placed marking sutures near the junction of the IVC and right atrium. The atrial septum was inspected, and a flap was created from limbic tissue anteriorly toward the superior and inferior aspects each right pulmonary vein. The flap remains attached at the interatrial groove. A small patch of pericardium was sutured to the septal flap to make them adequate size for reconstruction the new septum. The hinged interatrial flap was then sewn along into place using longitudinal bites in the left atrial wall and horizontal bites in the atrial septal flap. The caval pathway was completed anteriorly by stitching ( with continuous 5­0 Prolene sutures) the caudal extent of the right side of the free atrial wall to the atrial tissue about the IVC orifice and continuing to the coronary sinus. The coronary sinus was left to drain with pulmonary venous blood. A second suture was used to complete the superior attachment around the SVC. The perimeter of the left atriotomy was extended by incising the tissues between both right pulmonary veins. The original right atrial incision was extended cephalic. The pulmonary venous atrium was constructed by using the autopericard flap in situ. The suture line was brought across the SVC that the suture line kept superior the area of the sinus node artery.( Figure 1). Cardiopulmonary bypass was finished by using intra aortal "hot­shot" and rewarming. Following the surgical procedure, repeated echocardiography demostrated good potency of tunnel between pulmonary veins and tricuspid valve and between the systemic veins and mitral valve.( Figure2). Postoperative period was uneventful. Saturation of oxygen increased until 97%. Electrocardiogramm shows no rhythm disturbances. DISCUSSION The arterial switch operation has become the procedure of choice for patients with TGA in most cardiac surgery centres (4,7). In cases of delayed diagnosis and complicated with high pulmonary hypertension, when arterial switch operation is contraindicated, only atrial switch is the best option for patient. Although atrial switching like Mustard or Senning procedures may occasionally be employed in some centres for this entity, its principal application is in the double switch operation for patients with congenitaly corrected tansposition and some other unusual entities, for example for patient older than 12 months to preserve left ventricular function ( 2,3,5). Brom pioneered the revival of the original Senning operation, with some technical modifications, and this restored interest in this type of venous switching (8, 9). In our case the pulmonary venous atrium was completed by suturing the anterior component of the original right atrial wall to the pericardium in situ( 1). The pericardium in situ technique for completing the pulmonary venous atrium is similar to the technique described by Lacour­ Gayet and others for dealing with pulmonary vein stenosis (6 ). Conflict of interest: None REFERENCES 1. Castaneda AR, Jonas RA, Mayer IE. Cardiac surgery of the neonate and infant // Philadelphia, WB Saunders, 1994; 430 2. Hibino N, Imari Y, Aoki M. Double­switch operation for superior ­inferior ventricles// Ann Thor Surg, 2001; 72: 2119­2121 3. Ilbawi MN, DeLeon SY, Backer CL. An alternative approach to the surgical management of physiologically corrected transposition with ventricular septal defect and pulmonary stenosis or atresia // J Thorac Cardiovasc Surg, 1990; 100: 410­415 Jonas RA, Laussen P. Transposition of the great arteries // In: Comprehensive surgical management of congenital heart disease. Hodder Arnold Publication, 2007; 256­279 Karl TR, Weintraub RG, Brizard CP. Senning plus arterial switch operation for discordant (congenitally corrected) transposition // Ann Thorac Surg, 1997; 64: 495­502 Lacour ­ Gauet F, Rey C, Planche C. Surgical obstruction after repair of total anomalous pulmonary venous connection // J Thorac Cardiovasc Surg, 1999; 117: 679­687 Mee LB. The arterial switch operation // In: surgery for congenital heart defects. 3 rd edition by Stark J, de Leval M, Tsang V. 2006, Jonh wiley and sons Ltd; 471­487 Pacifico AD. Senning operation// In: surgery for congenital heart defects. 3 rd edition by Stark J, de Leval M, Tsang V. 2006, Jonh wiley and sons Ltd; 451­457 Quaegebeur JM, Rahmer J, Brom AG. Revival of the Senning operation in the treatment of transposition of the great arteries // Thorax , 1977; 32: 517­524 RAAP SA node RA incision SVC RUL pv RLL pv LA incision Pericardium in situ RAAP AV node AV node MV CS Tendon Todaro IVC valve incision IVC Septum primum PFO SVC A LUV MV Base LAAP SA node SVC Limbus LLV IVC A E C C Fig. 2. Transthoracic echocardiography apical view demonstrate a tunnel from pulmonary veins to tricuspid valve. PV­ pulmonary veins, RV­ right ventricle, LV ­left ventricle Address: Inguna Lubaua Riga Stradins University, Latvia Dzirciema street 16, Riga , LV-1007, Latvia E-mail: inguna.lubaua@rsu.lv AV node Base LAAP MV B B C A A MV TV B SVC D E LUL pv D IVC RUL pv RLL pv LLL pv pericardial C patch RAAP D F H G SVC G H MV Right atrium Systemic venous ba e completed using all of RA free wall IVC F F Suture line along in situ pericardium in complete puimonary venour atrium G G H H F F RUL pv RLL pv Phrenic nerve Right lung Fig. 1. Cartoons showing performing the modified Senning's procedure A- right and left atrial incisions. B- Inside view of the right atrium. Note the remant of septum in the area of fossae ovalis. C- Construction of the roof of the pulmonary venous pathway. The hinged interatrial flap was sutured above the entrance site of the pulmonary veins and along the line leading to the posteriolateral angle of both the superior and inferior venae cavae and the remant of the interatrial groove. D- Construction of the roof was finished with additional pericardial patch. E- Completed systemic venous pathway. The lateral right atrial flap was sutured around the superior and inferior venae and along the ligament of Torado.The coronary sinus was left to drain into the neo­ left atrium. F- Constructions of the pulmonary venous pathway. The pericardial flap in situ was sutured first around the superior and inferior venae cavae and the right atrial wall. G- The face edge of the medial right atrial flap was sutured to the free edge of the pericardium. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Acta Chirurgica Latviensis de Gruyter

Modified Senning Operation in the Treatment of Transposition of The Great Arteries

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Abstract

DOI: 10.2478/v10163-011-0030-0 CASE REPORT Aris Lacis *, Inguna Lubaua**, Lauris Smits*, Valts Ozolins*, Normunds Sikora*, Zane Straume* *Children's University Hospital, Clinic for Paediatric Cardiology and Cardiac Surgery **Riga Stradins University , Pediatric Chair, Riga, Latvia Summary The arterial switch operation has become the procedure of choice for patients with transposition of the great arteries( TGA) in most medical centres. Although atrial switching may occasionally be employed in some centres in cases with delayed diagnosis, pulmonary hypertension and some other unusual entities. We preferred to use the atrial switch operation ­ modified Senning procedure for 6 years 6 months old boy with TGA , small atrial septal defect (ASD) and patent ductus arteriosus ( PDA). Key words: congenital heart disease, transposition of great arteries, modified Senning procedure, myocardial protection. AIM OF THE DEMONSTRATION The aim of this article is to demonstrate a case of successful repair of TGA in case of delayed diagnosis and complicated with high pulmonary hypertension. CASE REPORT On the 26 January 2009 a 6 years 6 months old boy with TGA , small ASD and PDA was repaired using the modified Senning procedure. His body weight was 12,5 kg (­ 3 standart deviations). A patient was referred to us for progressively increasing cyanosis and dyspnoea on exertion. Clinical examination , chest radiography and echocardiography all comfirmed the diagnosis of the TGA with small ASD and PDA. The saturation of oxygen ranged between 51and 57%, hematocrit was 66,6%. Surgical technique The heart was exposed through a median sternotomy incision and purse­ string sutures are placed in the ascending aorta for arterial cannulation and directly upon each vena cava for venous cannulation. Before cardiopulmonary bypass was established, the circumferences of the superior vena cava (SVC) and inferior vena cava (IVC) were measured and recorded. Marking sutures were placed on the interatrial groove to define the cephalic and caudal point extent of the left atriotomy. Cardiopulmoary bypass was established and patient's temperature was decreased to + 24° C. The aorta was cross ­clamped, and cold blood cardioplegia was started. The right atrium was opened superiorly 1 cm anterior to the crista terminalis and the incision was extended anteriorly to the previously placed marking sutures near the junction of the IVC and right atrium. The atrial septum was inspected, and a flap was created from limbic tissue anteriorly toward the superior and inferior aspects each right pulmonary vein. The flap remains attached at the interatrial groove. A small patch of pericardium was sutured to the septal flap to make them adequate size for reconstruction the new septum. The hinged interatrial flap was then sewn along into place using longitudinal bites in the left atrial wall and horizontal bites in the atrial septal flap. The caval pathway was completed anteriorly by stitching ( with continuous 5­0 Prolene sutures) the caudal extent of the right side of the free atrial wall to the atrial tissue about the IVC orifice and continuing to the coronary sinus. The coronary sinus was left to drain with pulmonary venous blood. A second suture was used to complete the superior attachment around the SVC. The perimeter of the left atriotomy was extended by incising the tissues between both right pulmonary veins. The original right atrial incision was extended cephalic. The pulmonary venous atrium was constructed by using the autopericard flap in situ. The suture line was brought across the SVC that the suture line kept superior the area of the sinus node artery.( Figure 1). Cardiopulmonary bypass was finished by using intra aortal "hot­shot" and rewarming. Following the surgical procedure, repeated echocardiography demostrated good potency of tunnel between pulmonary veins and tricuspid valve and between the systemic veins and mitral valve.( Figure2). Postoperative period was uneventful. Saturation of oxygen increased until 97%. Electrocardiogramm shows no rhythm disturbances. DISCUSSION The arterial switch operation has become the procedure of choice for patients with TGA in most cardiac surgery centres (4,7). In cases of delayed diagnosis and complicated with high pulmonary hypertension, when arterial switch operation is contraindicated, only atrial switch is the best option for patient. Although atrial switching like Mustard or Senning procedures may occasionally be employed in some centres for this entity, its principal application is in the double switch operation for patients with congenitaly corrected tansposition and some other unusual entities, for example for patient older than 12 months to preserve left ventricular function ( 2,3,5). Brom pioneered the revival of the original Senning operation, with some technical modifications, and this restored interest in this type of venous switching (8, 9). In our case the pulmonary venous atrium was completed by suturing the anterior component of the original right atrial wall to the pericardium in situ( 1). The pericardium in situ technique for completing the pulmonary venous atrium is similar to the technique described by Lacour­ Gayet and others for dealing with pulmonary vein stenosis (6 ). Conflict of interest: None REFERENCES 1. Castaneda AR, Jonas RA, Mayer IE. Cardiac surgery of the neonate and infant // Philadelphia, WB Saunders, 1994; 430 2. Hibino N, Imari Y, Aoki M. Double­switch operation for superior ­inferior ventricles// Ann Thor Surg, 2001; 72: 2119­2121 3. Ilbawi MN, DeLeon SY, Backer CL. An alternative approach to the surgical management of physiologically corrected transposition with ventricular septal defect and pulmonary stenosis or atresia // J Thorac Cardiovasc Surg, 1990; 100: 410­415 Jonas RA, Laussen P. Transposition of the great arteries // In: Comprehensive surgical management of congenital heart disease. Hodder Arnold Publication, 2007; 256­279 Karl TR, Weintraub RG, Brizard CP. Senning plus arterial switch operation for discordant (congenitally corrected) transposition // Ann Thorac Surg, 1997; 64: 495­502 Lacour ­ Gauet F, Rey C, Planche C. Surgical obstruction after repair of total anomalous pulmonary venous connection // J Thorac Cardiovasc Surg, 1999; 117: 679­687 Mee LB. The arterial switch operation // In: surgery for congenital heart defects. 3 rd edition by Stark J, de Leval M, Tsang V. 2006, Jonh wiley and sons Ltd; 471­487 Pacifico AD. Senning operation// In: surgery for congenital heart defects. 3 rd edition by Stark J, de Leval M, Tsang V. 2006, Jonh wiley and sons Ltd; 451­457 Quaegebeur JM, Rahmer J, Brom AG. Revival of the Senning operation in the treatment of transposition of the great arteries // Thorax , 1977; 32: 517­524 RAAP SA node RA incision SVC RUL pv RLL pv LA incision Pericardium in situ RAAP AV node AV node MV CS Tendon Todaro IVC valve incision IVC Septum primum PFO SVC A LUV MV Base LAAP SA node SVC Limbus LLV IVC A E C C Fig. 2. Transthoracic echocardiography apical view demonstrate a tunnel from pulmonary veins to tricuspid valve. PV­ pulmonary veins, RV­ right ventricle, LV ­left ventricle Address: Inguna Lubaua Riga Stradins University, Latvia Dzirciema street 16, Riga , LV-1007, Latvia E-mail: inguna.lubaua@rsu.lv AV node Base LAAP MV B B C A A MV TV B SVC D E LUL pv D IVC RUL pv RLL pv LLL pv pericardial C patch RAAP D F H G SVC G H MV Right atrium Systemic venous ba e completed using all of RA free wall IVC F F Suture line along in situ pericardium in complete puimonary venour atrium G G H H F F RUL pv RLL pv Phrenic nerve Right lung Fig. 1. Cartoons showing performing the modified Senning's procedure A- right and left atrial incisions. B- Inside view of the right atrium. Note the remant of septum in the area of fossae ovalis. C- Construction of the roof of the pulmonary venous pathway. The hinged interatrial flap was sutured above the entrance site of the pulmonary veins and along the line leading to the posteriolateral angle of both the superior and inferior venae cavae and the remant of the interatrial groove. D- Construction of the roof was finished with additional pericardial patch. E- Completed systemic venous pathway. The lateral right atrial flap was sutured around the superior and inferior venae and along the ligament of Torado.The coronary sinus was left to drain into the neo­ left atrium. F- Constructions of the pulmonary venous pathway. The pericardial flap in situ was sutured first around the superior and inferior venae cavae and the right atrial wall. G- The face edge of the medial right atrial flap was sutured to the free edge of the pericardium.

Journal

Acta Chirurgica Latviensisde Gruyter

Published: Jan 1, 2010

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