Cavo-Atrial Anastomosis Technique for Partial Anomalous Pulmonary Venous Connection to the Superior Vena Cava—The Warden Procedure

Abstract

Partial anomalous pulmonary venous connection to superior vena cava occurs in about 10 to 15% of all patients with an atrial septal defect. Most commonly one or more pulmonary veins from the right lung connect to the superior vena cava or the right atrium, or both. The usual sinus venosus atrial septal defect occurs above the fossa ovalis immediately beneath the orifice of the superior vena cava, which typically overrides the atrial defect to some extent. Rarely there is no atrial septal defect. 1 Because the clinical manifestationsofbothlesionsaresimilar,itisnotunusualtoencounter anomalous pulmonary veins at the time of operation for presumed uncomplicated secundum atrial septal defect. Idealsurgicalrepairdemandscompleteclosureoftheatrial septal defect and redirection of the anomalous pulmonary veins into the left atrium without pulmonary venous or superior vena cava obstruction and without injury to the sinus node or its blood supply. Normally this is simple when the anomalous pulmonary veins are close to the right atrium. However when they enter further up the superior vena cava, the surgical treatment can be more complex. Various techniques have been described using prosthetic grafts, pericardial patches, or atrial wall flaps to baffle the anomalous pulmonary veins into the left atrium. An alternative atrio-caval anastomosis technique has been utilized at our institution for 42 years to lessen the risk of undesirable complications, particularly sinus node dysfunction.