Invited commentary

Abstract

The issue of whether the anomalous vertical vein (VV) should be ligated during repair of total anomalous pulmonary venous connection (TAPVC) is controversial. Traditionally, most surgeons have emphasized routine interruption of the VV at the time of TAPVC repair to prevent the perceived consequence of a residual left-to-right shunt. However, we recently demonstrated that not only is routine VV ligation unnecessary, but this practice may actually be undesirable for patients with small left heart chambers [1]. Previously, it was shown that the left atrium and ventricle are notoriously small and dysfunctional in TAPVC [2, 3]. We therefore maintain that the unligated VV may serve as a temporary “pop-off valve,” allowing the left heart chambers adequate time for growth and functional adaptation. In our series, all long-term survivors in whom the VV was left open demonstrated spontaneous involution of the anomalous venous channel. Only one patient whose VV was not ligated developed a persistent left to right shunt. Interestingly, the basis for persistent VV patency in this child proved to be a stricture at the common pulmonary vein to left atrium anastomosis.