Surgery for total anomalous pulmonary venous connection: primary sutureless repair vs. conventional repair

Despite recent advances in surgical technique and perioperative care, the surgical correction of total anomalous pulmonary venous connection (TAPVC) remains a challenge. The major complication and the main cause of reoperation in TAPVC surgery are the occurrence of pulmonary venous obstruction (PVO). In the 1990s, sutureless repair was introduced as a technique to relieve PVO after TAPVC repair. Following the favorable outcomes for postoperative PVO, the indications for sutureless repair as a primary operation have been expanded to include infants who have preoperative PVO or those at risk of developing PVO after the repair of TAPVC. However, the indications of "prophylactic" primary sutureless repair still remain controversial. Recent studies have shown that normal-risk patients have excellent early and long-term outcomes and a low incidence of reoperation for postoperative PVO. Most patients who survived beyond 2 years after TAPVC surgery were in NYHA class I and offered good outcomes. Although favorable early and mid-term outcomes of primary sutureless repair are reported, the long-term outcomes of this technique are still unclear. The influence of non-contractile pericardial tissue interposed between the PV vessel wall and LA myocardium on the atrial function is also unclear in patients who undergo sutureless repair. Another disadvantage of primary sutureless repair is potential bleeding from the gap between the confluence and pericardium into the posterior mediastinum or pleural cavity. Thus, it might be best for primary sutureless repair to be indicated for high-risk infants, such as those with TAPVC associated with single-ventricular physiology, mixed-type TAPVC, or small PV confluence.