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Primary repair of total anomalous pulmo nary venous connection with sutureless strategy 1.This is a 6 day old boy, who was diagnosed with infracardiac total anomalous pulmonary venous connection (TAPVC) with pulmonary venous obstruction, patent ductusarteriosus and patent foreman ovale. 2.He underwent emergent TAPVC repair because of low blood pressure and extremely low arterial saturation. 3.Standard median sternotomy, and cardiopulmonary bypass with aortic cannula and single right atrial cannula.The patent ductusarteriosus was ligated. 4.Cooled down the patient’s core temperature to 18˚C. Afteraortic cross clampandantegradeinfusion of cardioplegia, the circulation was arrested . 5.A right atrial incision was made, and the patent foreman ovale was closed with primary closure. 6.The stay sutures were removed and the right thoracic cavity was opened so that the heart could be rotated and put into the right thoracic cavity. The pulmonary veins and the vertical vein posterior to the pericardium were exposed. 7.The tip of the left atrial appendage was ligated temporarily and retracted to the right side in order to get better exposure, and operation bed was rolled slightly to the right side. 8.Two stay sutures were made. The pericardium and the vertical vein were cut open at once. Make sure that the loose connection between the pulmonary veins and the pericardium was not dissected. 9.To get a clean operating field, the lungs were inflated and deflated several times to squeeze out the blood in lungs. 10.This incision was extended onto each individual pulmonary vein and the vertical vein beyond every stenotic segment. 11. The incision was continued to the pleural pericardial reflection laterally. 12. An incision was made on the posterior wall of the left atrium. The right end of this incision should reach the interatrial septum. 13. The left atrial incision and the pericardial incision were anastomosed together with running sutures. 14.For most patients, we prefer to 7-0 prolene, but for patients under 2 kilograms, we use 8-0 prolene. 15.Most of the sutures will not touch the venous wall because we believe this kind of injury to the pulmonary venous intima may trigger fibrous proliferative response and further lead to new-onset obstruction. 16.However,at the apex of the triangle zone between two individual pulmonary incisions, one or two stitches should suspend the pulmonary venous flaps up to the pericardium below the left atrium to prevent the flaps from dropping down into the lumen. Otherwise, the floating flaps at these sites may exist like shelves, obstructing the corresponding pulmonary vein. 17.The anastomosis was continued with the another arm of the prolene. 18.Since the left atrial incision was not big enough, it was extended sufficiently to guarantee that the atrial incision was bigger than the pulmonary venous incision. 19.When the anastomosis was finished, lungs were inflated and hold to check any possible bleeding. 20.And we prefer to use fibrin glue to prevent needle holes from bleeding. 21.The right atrial incision was oversewed and the venous cannula was inserted to restart the cardiopulmonary bypass, and the heart restarted perfusion. 22.The boy was easily weaned off the cardiopulmonary bypass, and the operation was successfully terminated. 23.There are three key points for the sutureless strategy. 24. First, fully relieve any preoperative pulmonary venous obstruction. The pulmonary venous incisions should be extended outwards ontoeach individual pulmonary vein exceeding every stenotic segment. 25.Second, anastomose the left atrium with the pericardium rather than the pulmonary venous wall. The pulmonary venous incisions are radial and irregular with long circumference, atriopericardial anastomosis can shorten and simplify this step. In the meantime, the pericardium could act as a buffer to alleviate the anastomosing distortion caused by nonparallel axises of the pulmonary venous and the left atrial incisions. 26. Third, "no touch" technique. We believe injury from suture needles may lead to pulmonary venous intimal fibrous proliferative response., The “no touch” technique may alleviate the possibility of new-onset pulmonary venous obstruction caused by this response. 27.Thank you.
   

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