Comment
Postoperative pulmonary venous obstruction (PVO) develops in approximately 10% to 20% and is associated with an extremely poor prognosis[3]. Anatomic subtypes, preoperative obstruction, and surgical techniques have been implicated in the occurrence of postoperative PVO[4-5]. In most cases, the obstruction is located at the anastomosis between the left atrium and the pulmonary venous confluence[6]. So, we consider that clear intraoperative exposure and creating the largest possible anastomosis without distortion are crucial to surgical repair.The posterior approach that heart is retracted cephalad and pushed into the right pleural cavity can offer better exposure,and has reported good outcomes in several studies[7-8]. However, this approach carries a potential risk of anastomotic distortion because the anastomosis is performed with the heart not in an anatomic position.We modified the anastomosis technique for posterior approach. The anastomosis was enlarged by resecting the anterior wall of the PVC and part of the posterior wall of the left atrium to form a window-to-window anastomosis.This window-to-window anastomosis can also decrease the risk of anastomosis distortion caused by poor alignment of traditional incision-to-incision anastomosis. A 3D geometry model study demonstrated that window anastomosis had a lower pressure difference of anastomosis and higher energy conversion efficiency than the traditional surgery for supracardiac TAPVC[9].
Sutureless technique have been engaged and proved to be an effective means to relieve postoperative PVO for the primary repair for TAPVC. But sutureless technique has both advantages and disadvantages. We think that sutureless technique has advantages for patients with hypoplastic PVC and pulmonary veins,but it is controversial for patients without preoperative PVO. Primary sutureless technique has a relatively benign type of peripheral PVO could occur[10].In this study, we selected cases without obvious preoperative PVO, so we did not open the individual pulmonary vein and directly anastomosised the left atrium and PVC.
The main limitations of this study were the small number of cases and short follow-up time. A larger patient population and long-term follow-up are needed in the future to assess its outcomes.
In conclusion, we think that the window anastomosis can creat a large and undistorted anastomosis.This anastomosis technique is simple,safe and effective. It could decrease the incidence of postoperative PVO.