Modified Warden operation using aortic homograft
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Central MessageHigh connection of anomalous pulmonary veins to the superior vena cava may warrant modification of classic Warden operation in the form of an interpositional graft. Aortic homograft is a good choice.See Commentaries on pages 274 and 275. High connection of anomalous pulmonary veins to the superior vena cava may warrant modification of classic Warden operation in the form of an interpositional graft. Aortic homograft is a good choice. See Commentaries on pages 274 and 275. A 57-year-old woman presented to the cardiology clinic with exertional dyspnea. Transthoracic echocardiogram demonstrated partial anomalous pulmonary venous connection (PAPVC) of the right upper and middle veins to the superior vena cava (SVC), an intact atrial septum, enlarged right ventricle, moderate tricuspid regurgitation, and pulmonary hypertension. Cardiac magnetic resonance imaging confirmed the diagnosis with the right upper and middle pulmonary veins connecting to the SVC high above the cavoatrial junction and a Qp to Qs ratio of 2. Cardiac catheterization also confirmed significant pulmonary hypertension with indexed pulmonary vascular resistance of 9.4 Woods units/m2 and some reversibility with oxygen. She was treated with pulmonary vasodilator therapy for 2 months before operation. This case report does not contain any patient identifiers and is hence exempt from institutional review board review as per institutional guidelines. Following a median sternotomy, a large patch of autologous pericardium was harvested and treated with glutaraldehyde. The right upper pulmonary veins connected to the SVC about 3 to 4 cm above the cavoatrial junction, which in the context of a short broad right atrial appendage made a conventional Warden procedure technically impossible. The patient was placed on cardiopulmonary bypass via cannulation of aorta, inferior vena cava, and innominate vein and cooled to 30°C. The azygous vein was ligated and divided. Following myocardial arrest, a vertical atriotomy was performed. A large secundum atrial septal defect was created by excision of the fossa ovalis. The SVC was divided immediately above the PAPVC. The distal opening of the SVC was closed primarily. An intracardiac baffle of treated pericardium was created between the opening of the SVC and the atrial septal defect. Given the long distance between the proximal SVC and the right atrial appendage, an interpositional tube graft was deemed necessary. An 18-mm × 5-cm aortic homograft (CryoLife, Inc, Marietta, Ga) was introduced into the field and the proximal valved portion was excised. The remaining nonvalved portion was placed as an interposition conduit between the proximal SVC and an opening in the right atrial appendage (Figures 1 and 2).Figure 2Aortic homograft conduit interposed between proximal superior vena cava and right atrium.View Large Image Figure ViewerDownload (PPT) The right atriotomy was closed, the aortic crossclamp was removed, and the patient was weaned off cardiopulmonary bypass in normal sinus rhythm (Video 1). Inhaled nitric oxide was used intra- and postoperatively. Postoperative echocardiogram demonstrated good function and unobstructed flow in the intracardiac baffle and homograft. Postoperatively, she was treated with aspirin for 3 months and pulmonary vasodilator therapy was continued. Follow-up echocardiogram 5 months following the operation demonstrated laminar flow in the conduit with no gradient and significant reduction in estimated pulmonary artery pressure. PAPVC is failure of 1 or 3 of the major pulmonary veins to connect to the left atrium during fetal development. The most common form is anomalous connection of the right upper and/or middle veins to the SVC. In about 20% of this form of PAPVC, the connection of the upper pulmonary vein to the SVC can be high, making conventional Warden operation difficult.1Said S.M. Burkhart H.M. Dearani J.A. Eidem B. Stensrud P. Phillips S.D. et al.Outcome of caval division techniques for partial anomalous pulmonary venous connections to the superior vena cava.Ann Thorac Surg. 2011; 92 (discussion 985): 980-984Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar In such a situation, the 1-patch technique is not a feasible option and the 2-patch technique is fraught with risk of sinus-node dysfunction.2Stewart R.D. Bailliard F. Kelle A.M. Backer C.L. Young L. Mavroudis C. Evolving surgical strategy for sinus venosus atrial septal defect: effect on sinus node function and late venous obstruction.Ann Thorac Surg. 2007; 84 (discussion 1655): 1651-1655Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar The caval division technique described by Warden in 1984 works well for most forms of PAPVC, with a low incidence of sinus-node dysfunction and obstruction of the systemic or pulmonary venous flow.1Said S.M. Burkhart H.M. Dearani J.A. Eidem B. Stensrud P. Phillips S.D. et al.Outcome of caval division techniques for partial anomalous pulmonary venous connections to the superior vena cava.Ann Thorac Surg. 2011; 92 (discussion 985): 980-984Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar,3Warden H.E. Gustafson R.A. Tarnay T.J. Neal W.A. An alternative method for repair of partial anomalous pulmonary venous connection to the superior vena cava.Ann Thorac Surg. 1984; 38: 601-605Abstract Full Text PDF PubMed Scopus (140) Google Scholar,4Shahriari A. Rodefeld M.D. Turrentine M.W. Brown J.W. Caval division technique for sinus venosus atrial septal defect with partial anomalous pulmonary venous connection.Ann Thorac Surg. 2006; 81 (discussion 229-30): 224-229Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar However, high insertion of the pulmonary veins into the SVC with resulting short residual segment of SVC, particularly in association with short right atrial appendage, renders the classic Warden procedure extremely challenging. The risk of SVC stenosis from excessive tension on the suture line is also well described in such situations.1Said S.M. Burkhart H.M. Dearani J.A. Eidem B. Stensrud P. Phillips S.D. et al.Outcome of caval division techniques for partial anomalous pulmonary venous connections to the superior vena cava.Ann Thorac Surg. 2011; 92 (discussion 985): 980-984Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Modifications of the classic Warden procedure have been described to overcome such shortcomings.1Said S.M. Burkhart H.M. Dearani J.A. Eidem B. Stensrud P. Phillips S.D. et al.Outcome of caval division techniques for partial anomalous pulmonary venous connections to the superior vena cava.Ann Thorac Surg. 2011; 92 (discussion 985): 980-984Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar,5Tao K. Pan W. Lin K. Shi Y. Zhu P. Guo Y. et al.Modified cavoatrial anastomosis in Warden procedure.Ann Thorac Surg. 2010; 89: 2047-2048Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Tao and colleagues5Tao K. Pan W. Lin K. Shi Y. Zhu P. Guo Y. et al.Modified cavoatrial anastomosis in Warden procedure.Ann Thorac Surg. 2010; 89: 2047-2048Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar described creation of right atrial flap to reach the cephalad end of the SVC and used a pericardial patch anteriorly to construct the cavoatrial channel. Sinus-node dysfunction and SVC stenosis are risks with this modification. Said and colleagues1Said S.M. Burkhart H.M. Dearani J.A. Eidem B. Stensrud P. Phillips S.D. et al.Outcome of caval division techniques for partial anomalous pulmonary venous connections to the superior vena cava.Ann Thorac Surg. 2011; 92 (discussion 985): 980-984Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar described the use of the short segment of a ringed Gore-Tex (W. L. Gore & Associates, Inc, Flagstaff, Ariz) graft between the SVC and right atrial appendage for patients with high PAPVC with good outcomes. The patients were treated with coumadin (Bristol-Myers Squibb, Princeton, NJ) for 3 months. Our technique of using a nonvalved segment of aortic homograft is technically easy and serves as an alternative to Gore-Tex graft. The aortic homograft is hemostatic, rigid, and has a natural curve that can be used to advantage. The endothelial lining also likely makes it less thrombogenic. However, the long-term consequences of homograft degeneration and calcification, although a short nonvalved segment, in this position are unknown. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJhODY3MWM4N2ZkMjYxY2ZjZmNhN2Y0ZTNlNWQxNjk0YyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjYwNjM4NjU4fQ.HmmdJ-jDbFz0rWEu6bW0Mi0c3fMuz7mWyxhDXTDQMgKfQ-v7lza88hEkRzQ82g3AGNzvPdATX2jj6OMTAl9sBbvzrtVtH2VCCDR340oUQwko3y2MvOAxmbobiIQAGr0557HQ2P7areMXroNQkWN_cf_4IEnsW2rIQbe58D_KIBgmpGXPeGDnZ9G3UjC6btasPtrZCySDsx-V761vovghluhZjvvd5gKHY2iMpUGfTnmHet9c6tmymMpN3te4bt7OyfqrNnHWLFyb6BwdHSovXO_T-crJbq5vK-Ioja2iHkV_wp8RkOUsm1pQNIB0_HWR0jjrenX6NBPSj0CzibL_SA Download .mp4 (3.67 MB) Help with .mp4 files Video 1Video demonstrating final position of aortic homograft interpositional conduit between the superior vena cava and the right atrial appendage. Video available at: https://www.jtcvs.org/article/S2666-2507(20)30428-4/fulltext.Mean platelet volume
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Aim of the study was to assess possible differences in ANP levels between patients with congestive heart failure (CHF) with and without chronic atrial fibrillation (AF). We studied 12 patients with chronic AF and 17 patients with sinus rhythm (SR), (m 16, f 13, years 67.7 +/- 8.6), with CHF, not hypertensive, without valvular or congenital heart disease, NYHA class II-III, by ANP RIA and echocardiography. Left atrial (LA/m2) dimensions were significantly higher in patients with AF, and ANP was also more increased in AF. Significant linear correlations between heart rate and ANP, ANP and LV shortening fraction and ANP and A/E ratio, assessed by Doppler trans-mitral flow, were observed in SR but not in AF patients. A significant correlation between ANP and left ventricular mass g/m2 was observed only in AF. Higher ANP levels seem associated with left ventricular enlargement, assessed as left ventricular mass, in AF patients; in SR patients, higher ANP levels are associated with depressed systolic function and with decreased left ventricular compliance. Rate dependent ANP incretion seems blunted in chronic AF; neurogenic heart rate control and/or coordinated atrial systoles may be ANP modulators in sinus rhythm CHF.
Atrial natriuretic peptide
valvular heart disease
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Although brain natriuretic peptide (BNP) of myocardial origin is important in cardiovascular and renal function and as a marker of cardiac dysfunction, the expression of BNP in atrial and ventricular myocardium remains controversial both under normal conditions and in heart failure. We therefore determined left atrial and left ventricular (LV) gene expression and tissue concentration as well as circulating BNP during the evolution of rapid ventricular pacing-induced congestive heart failure (CHF) in the dog. Early LV dysfunction after 10 days of pacing was characterized by impaired LV function but maintained arterial pressure, and overt CHF after 38 days of pacing was characterized by further impaired LV function and decreased systemic arterial pressure. Under normal conditions, cardiac BNP mRNA and cardiac tissue BNP were of atrial origin. In early LV dysfunction, BNP mRNA and tissue BNP were markedly increased in the left atrium in association with an increase in circulating BNP but remained below or at the limit of detection in the LV. In overt CHF, BNP mRNA was further increased in the left atrium and first increased in the LV, together with an increase in LV tissue BNP and a further increase in circulating BNP. In the progression of CHF, early LV dysfunction is characterized by a selective increase in atrial BNP expression in association with increased circulating BNP. Overt CHF is characterized by an additional recruitment of ventricular BNP expression and a further increase in circulating BNP. These studies provide important new insight into the local and temporal regulation of cardiac BNP gene expression during the progression of heart failure and underscore the predominant endocrine role of atrial myocardium under normal conditions and in early LV dysfunction.
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Contractility
Brain natriuretic peptide
valvular heart disease
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Atrial fibrillation (AF) is associated with an increased risk of stroke and other thromboembolic events. Left atrial (LA) thrombus formation is closely related to LA dysfunction, particularly to decreased LA appendage flow velocity (LAA-FV) in patients with AF. We estimated LAA-FV using parameters noninvasively obtained by transthoracic echocardiography (TTE) in patients with paroxysmal AF.Echocardiographic and clinical parameters were assessed in 190 patients with nonvalvular paroxysmal AF showing sinus heart rhythm during transesophageal echocardiography (TEE) and TTE.LAA-FV (60 ± 22 cm/s) significantly correlated with the time interval between the initiation of the P-wave on ECG and that of the A-wave of transmitral flow on TTE (PA-TMF, correlation coefficient, -0.32; P < 0.001), LA dimension (LAD, -0.31; P < 0.001), septal a' velocity of tissue Doppler imaging (TDI, 0.35; P < 0.001), E/e' ratio (-0.28, P < 0.001), E velocity of transmitral flow (-0.20, P = 0.008), E/A ratio of transmitral flow (-0.18, P = 0.02), CHA2DS2-VASc score (-0.15, P = 0.04), and BNP plasma level (-0.32, P = 0.002). Multivariate analysis revealed that PA-TMF (standardized partial regression coefficient, -0.17; P = 0.03), a' velocity (0.24, P = 0.004), and LAD (-0.20, P = 0.01) were independent predictors of LAA-FV (multiple correlation coefficient R, 0.44; P < 0.001).Parameters of atrial remodeling, ie, decreased a' velocity, increased LAD, and PA-TMF during sinus rhythm may be useful predictors of LA blood stasis in patients with nonvalvular PAF. LAA-FV can be estimated using these TTE parameters instead of TEE.
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Doppler imaging
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Brain natriuretic peptide
Coronary arteries
Elevation (ballistics)
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Left atrial enlargement
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Objective:This study was performed to explore the correlation among plasma levels of natriuretic peptides and the left ventricular function and structure in patients with chronic heart failure(CHF),and to evaluate the value of plasma levels of natriuretic petides in the CHF diagnosis.Method:We enrolled 48 patients with CHF,among them,10 with coronary artery disease,22 with dilated cardiomyopathy,16 with hypertensive heart disease.Accoriding to the New York Heart Association(NYHA) class,15 patients were classified NYHA Ⅱ,24 NYHA Ⅲ,9 NYHA Ⅳ.Plasma levels of atrial and brain and C\|type natriuretic peptides (ANP,BNP,CNP) were measured by radioimmunoassay and immunoradiometric assay in these patients and 10 age and gender\|matched healthy controls.Doppler echocardiography was performed to measure left ventricular function and structure.Result:Plasma levels of ANP and BNP were significantly eleyated in CHF pATIENTS ( P all 0\^01),and levels increased in proportion to the severity of left ventricular dysfunction.In patients with LVEF45%,plasma level of BNP had a negative correlation with LVEF( P 0\^05),both ANP and BNP levels has positive correlations with pulmonary artery systolic pressure ( P 0\^05 or 0\^01),and BNP plasma level had a positive correlation with left ventricular end\|diastolic diameter and left ventricular mass index ( P all 0\^05). However,the CNP plasma level was not significantly elevzted in CHF patients ( P 0\^05).Conclusion:ANP and BNP plasma levels were good markers used to reflect left ventricular function,whereas BNP level was more sensitive and specific and had close relationship with left ventricular structure.Measurement of BNP plasma level was useful to reflect the immediate change of left ventricular function.
Immunoradiometric assay
Brain natriuretic peptide
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Left ventricular remodeling (LVR), an increase in left ventricular end-diastolic volume index > or = 20%, is an adverse consequence of myocardial infarction. The aim of this study was to assess the association between LVR and adiponectin, which has been shown to protect against myocardial ischemia-reperfusion injury.In 75 patients echocardiographic examination was performed one year after ST-segment elevation myocardial infarction, successfully treated with primary percutaneous coronary intervention (pPCI). Two groups of patients were analyzed: those with LVR (n = 15) and those without LVR (n = 60).The predictors of LVR were: anterior myocardial infarction, glucose at admission, baseline C-reactive protein, adiponectin, and echocardiographic parameters: left ventricular end-diastolic and end-systolic volume indices, ejection fraction < 40% and left ventricular wall motion score index (WMSI) at discharge. On multivariable regression analysis, lower adiponectin level (OR = 0.67, 95% CI 0.49-0.91, p < 0.05) and higher WMSI (OR = 20.14, 95% CI 2.62-154.82, p < 0.01) were the only independent negative predictors of LVR. The optimal cut-off for adiponectin for predicting LVR was < or = 4.7 mg/mL (sensitivity: 73%, specificity: 85%) and this level increased the risk of LVR 15-fold (95% CI 4.05-59.87, p = 0.0001).Baseline low blood adiponectin concentration, along with WMSI, can be considered as a predictor of the LVR in male patients one year after myocardial infarction and pPCI.
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