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.