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