Warden repair for superior sinus venosus atrial septal defect and anomalous pulmonary venous drainage in children: Anesthesia and transesophageal echocardiography perspectives

Abstract

Objective:Review of intraoperative anesthetic challenges and the role of transesophageal echocardiography in children with sinus venosus atrial septal defect and partial anomalous pulmonary venous drainage undergoing Warden repair.Design:A retrospective observational case series.Methodolgy:Pediatric patients who underwent Warden repair between October 2011-September 2015 were recruited. Their preoperative clinical details, anesthetic techniques, intraoperative TEE findings and postoperative events were recorded from the medical records. The categorical variables and the continuous variables were expressed as number (percentages) and mean ± SD respectively.Results:A total of 35 patients were operated for Warden repair during the study period. Anesthesia was induced with the aim to prevent any fall in pulmonary vascular resistance. The right internal jugular vein was cannulated under ultrasound guidance using a short length cannula to monitor right superior vena cava pressure. Intraoperative TEE revealed the drainage of PAPVC high into RSVC in 22 patients. Persistent LSVC was found in 9 patients. After repair, TEE imaging detected a high gradient at Warden anastomotic site in 5 patients and 3 of them required revision of surgery. Rerouted pulmonary veins required surgical correction in 2 patients in view of obstruction. None of them had pulmonary venous and SVC obstruction in the postoperative period.Conclusion:The primary aim of anesthesia is to avoid any fall in PVR. Right IJV cannulation can be beneficial. The intraoperative TEE can help in delineating the anatomy of lesion and detecting anastomotic site obstruction.

Multimodality imaging in delineation of complex sinus venosus defects and treatment outcomes over the last decade

“…However, there are associated low risks of sinus node dysfunction, atrial arrhythmias, and pulmonary or systemic venous occlusion after surgery. [33][34][35][36][37][38][39][40][41][42][43][44] This study aimed to review the prevalence of complex sinus venosus defects defined as either the presence of multiple anomalous pulmonary venous sites or high insertion of the anomalous pulmonary vein into the superior caval vein, ascertain the imaging modalities employed in delineating the anatomical variants, and the surgical outcome in this cohort of patients.…”

Transcatheter occlusion of sinus venosus atrial septal defect – a new therapeutic option?

“…Despite that, surgery is not free from significant complications, specially arrhythmias, due to sinus node lesion, obstruction of SVC-AD junction and, mainly, pulmonary vein obstruction. 7,9,16,17 Sinus venosus atrial septal defect transcatheter occlusion was first reported by Meier et al and Garg et al in 2014. 8,18,19 Meier managed to implant a regular nitinol ASD device and plugged the RUPV.…”

The Warden procedure for partial anomalous pulmonary venous connection in children: 10 years experience in 65 cases

“…The presence of stenosis at the Warden anastomosis was defined by Doppler gradients across the cavoatrial junction of >5 mmHg or loss of biphasic pattern in the superior caval vein. 5,6 Patients were followed up in the outpatient clinic through clinical examination, transthoracic echocardiography, and Holter monitoring (when needed) at 3 and 6 months post-operatively and then at regular intervals of 1 year. Post-operative sinus node dysfunction was defined as persistent sinus bradycardia (<50 beats/ minutes), pauses of more than 3 seconds, or persistent nodal rhythm > 1 week, especially with the need for permanent pacemaker.…”