Rechanneling of totally anomalous pulmonary venous connection
These procedures are required in all of those with right isomerism, even
if the pulmonary veins connect to the heart. Several guidelines have
emerged. Minimal manipulation of the pulmonary veins is advised during
dissection of the pulmonary venous confluence. So as to minimize the
thickness of the anastomosis, small endocardial-to-endocardial bites are
optimal. The extracardiac confluence can usually be explored by lifting
the cardiac apex, dislocating it into the right thoracic cavity. A large
unrestrictive anastomosis can then be made by using a posterior
approach. When the connection is obstructed, routine left atrial
augmentation is usually required. This can be achieved using a
fenestrated Dacron patch. Should the obstructive connection have
resulted in suprasystemic pulmonary arterial pressures, then we prefer
adjustable ligation of the vertical vein. 48,49Circulatory arrest has often been required in neonates to optimize
visualization. The pectinated atrial wall is an additional complicating
factor when seeking to create an unobstructed communication with the
pulmonary venous confluence.48,49