Case presentation:
A 7-day male neonate presented to our hospital with cyanosis, tachypnea since birth.
Transthoracic Echocardiography (TTE) revealed mixed type TAPVC, small patent foramen ovale (PFO), a large VSD (10 mm), a large patent ductus arteriosus (PDA) with a right to left shunt, and severe pulmonary hypertension (PH). For more anatomical details , computed tomographic angiography (CTA) was performed, and confirmed the diagnosis of a mixed type TAPVC (the common pulmonary confluent was draining both into the coronary sinus and the left innominate vein through a vertical vein) with an obstruction. The obstruction level was at the connection of the vertical vein with the left innominate vein. On the 10th day of life, the neonate developed a sudden cardiac arrest and underwent cardiopulmonary resuscitation with rapid response without the need for mechanical ventilation. The patient was scheduled for urgent surgical repair. The operation was performed through median sternotomy. A large vertical vein was seen on the left side outside the pericardium and connecting with a very small vein to the left innominate vein (representing the site of obstruction) (Figure 1). The vertical vein was dissected and controlled. The pericardium was opened, and a large PDA was controlled and closed by metal clips. Complete cardiopulmonary bypass (CPB) was prepared with bicaval cannulation, the vertical vein was closed at its junction with the left innominate vein, and the heart was arrested by antegrade cold blood cardioplegic solution. The common pulmonary confluent was seen behind the heart. The right atrium was opened parallel to the right atrioventricular groove. A small PFO was seen (representing another site of obstruction). The coronary sinus orifice was cut through to unroof the coronary sinus and establish a wide communication with the left atrial cavity after resecting the atrial septum. A large fresh autologous pericardial patch was used to baffle the created cavity toward the left atrial cavity. A large VSD was closed by a bovine pericardium patch with interrupted sutures. The remainder of the operation was completed uneventfully and the patient was weaned off the CPB easily. The patient suffered from atrial arrhythmias in the intensive care unit (ICU) on the second postoperative day, and was managed appropriately. After one week on mechanical ventilation, the patient was extubated, and on the 15th postoperative day was discharged from the ICU. The patient was followed-up for six months and was in very good general condition with significant improvement and weight gain.