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Hemi-Senning as an Alternative to Hemi-Mustard in Double Discordance

With Small Right Ventricle

Article  in  The Annals of Thoracic Surgery · December 2018

DOI: 10.1016/j.athoracsur.2018.11.060

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Hemi-Senning as an
Alternative to Hemi-Mustard in
Double Discordance With
Small Right Ventricle
François Katrien, MD, PhD, and Bov
e Thierry, MD, PhD
Department of Cardiac Surgery, University Hospital Ghent,
Ghent, Belgium
This report presents a case of anatomic repair in a young
child with double discordance, ventricular septal defect,
and pulmonary atresia. A novel technique of hemi-
Senning is described, combined with a bidirectional
cavopulmonary anastomosis and Rastelli repair. The
possible advantages and applications of this technical
modification are briefly discussed.
(Ann Thorac Surg 2019;108:e21–3)
Ó 2019 by The Society of Thoracic Surgeons
T he current trend in patients with double discordance
is to opt for anatomic repair, usually consisting of an
atrial switch combined with an arterial switch or Rastelli
procedure. In patients with position abnormalities, a
small right ventricle, or dysfunctional tricuspid valve, the
solution of a hemi-Mustard–Rastelli repair with a bidi-
rectional cavopulmonary anastomosis (BCPA) seems to
offer promising results [1–3]. However, for technical
reasons, a hemi-Mustard procedure may sometimes be
cumbersome in small patients.
A 21-month-old boy was admitted to our department for
repair of a congenitally corrected transposition of the
great arteries (ccTGA). Detailed anatomy consisted of
situs solitus, mesocardia, intact interatrial septum, normal
systemic and pulmonary venous return, atrioventricular
discordance with normally functioning atrioventricular
valves, a tricuspid valve of 17 mm for a mitral valve of 26
mm, good biventricular function, ventriculoarterial
discordance with L-transposition of the great arteries, a
large subaortic ventricular septal defect (VSD) of 16 mm,
a normally functioning aortic valve of 12 mm exiting the
right ventricle, pulmonary valvar atresia, confluent pul-
monary branches of 8 mm in diameter without stenosis,
and a left aortic arch.
At the age of 10 days the patient had received a 5-mm
Blalock-Taussig shunt through a right thoracotomy.
Because of increasing cyanosis and recent growth stag-
nation, an anatomic repair was proposed.
On admission, the patient’s weight and height were 10
kg and 83 cm, respectively, and the oxygen saturation was
73%. Preoperative laboratory values were normal, apart
from a hematocrit of 60%.
Accepted for publication Nov 20, 2018.
Address correspondence to Dr Katrien, Department of Cardiac Surgery,
University Hospital Ghent, C. Heymanslaan, 10, 9000 Gent, Belgium;
email: katrien.francois@ugent.be.
Ó 2019 by The Society of Thoracic Surgeons
Published by Elsevier Inc.
In our center the option of anatomic repair for ccTGA
with large VSD is preferred. Usually we would go for
the atrial switch-Rastelli procedure, but because of the
smaller size of the tricuspid valve compared with the
mitral valve in this case, and the right ventricular hy-
pertrophy with a smaller cavity compared with the left
ventricle, our preference was to go for a hemi-Mustard–
Rastelli repair, in combination with a BCPA, as previously
described [1–3].
After median sternotomy and standard aortic and
bicaval cannulation for cardiopulmonary bypass, the
patient was cooled down to 28
C. The shunt was taken
down, and after cross-clamping and cold crystalloid
cardioplegia, the right atrium was opened anteriorly.
The atrial septum was completely excised, and the
coronary sinus was unroofed to allow an unobstructed
flow from the inferior vena cava (IVC) to the tricuspid
valve. We aimed to perform the hemi-Mustard baffle
with a circular polytetrafluoroethylene (PTFE) patch at
the most superiorly located point of the tricuspid
annulus, but because of the small left atrial size and
the leftward position of the pulmonary veins, we
judged that the patch would induce a risk of pulmo-
nary venous outflow obstruction to the mitral valve
alongside the baffle. We removed the Mustard patch
and changed our plan to perform a hemi-Senning
procedure. To separate the pulmonary veins from the
tricuspid valve, a small PTFE patch was inserted to
recreate the excised atrial septum (Fig 1), as would
have been done with the original atrial septum in the
first step of a classical Senning procedure. The
Waterston groove was opened, and the incision was
extended between the two right pulmonary veins. The
hemi-Senning baffle was constructed by using the
Fig 1. Reconstruction of the atrial septum to create the roof of the
posterior compartment of the pulmonary venous atrium. (CS ¼ cor-
onary sinus; IVC ¼ inferior vena cava; MV ¼ mitral valve; RA ¼
right atrium; SVC ¼ superior vena cava; TV ¼ tricuspid valve.)
0003-4975/$36.00
https://doi.org/10.1016/j.athoracsur.2018.11.060
e22 CASE REPORT KATRIEN AND THIERRY
HEMI-SENNING USE IN DOUBLE DISCORDANCE
Fig 2. (A) Suturing of the hemi-
Senning baffle, constructed from
right atrial wall tissue, to direct the
blood from the inferior caval vein
toward the tricuspid valve. (B)
Closure of the anterior pulmonary
venous atrium with a large autolo-
gous pericardial patch. (IVC ¼ infe-
rior vena cava; MV ¼ mitral valve;
RA ¼ right atrium; SVC ¼ superior
vena cava.)
major part of the right atrial free wall posterior to the
atriotomy, suturing it around the IVC ostium and the
limbus of the unroofed coronary sinus, and stitching
nearly onto the mitral annulus, anterior to the
tricuspid valve because both atrioventricular valves
were very close to each other (Fig 2A). The right
atriotomy was closed by enlarging it with an untreated
autologous pericardial patch (Fig 2B).
For the Rastelli part of the operation, the right ven-
tricular infundibulum was incised obliquely, and an
ample PTFE baffle was fashioned to connect the VSD to
the aorta. The main pulmonary artery was transected,
the proximal stump was closed, the bifurcation was
brought up to the left of the aorta, and the incision was
extended into the left pulmonary branch. A 17-mm
bicuspidalized pulmonary homograft was inserted in
the right ventricular outflow tract, with a proximal
PTFE extension (Fig 3). The homograft was positioned
to the left of the aorta, not to be compressed by the
sternum.
After unclamping and during rewarming, the azygos
vein was ligated, and a BCPA to the right pulmonary
artery was performed on the beating heart. After weaning
from bypass, the patient’s hemodynamics were satisfac-
tory. The transpulmonary gradient was 7 mm Hg, and the
patient was fully saturated. Cardiopulmonary bypass
time was 258 minutes, and the aortic cross-clamp time 175
minutes.
The patient was extubated on the first postoperative
day, but he developed supraventricular tachycardia and
an acute respiratory distress syndrome, needing rein-
tubation. He was discharged 2 weeks later on aspirin
and diuretics. The echocardiography on discharge
showed unobstructed IVC flow to the tricuspid valve,
Ann Thorac Surg
2019;108:e21–3
laminar BCPA flow, unobstructed flow of the pulmonary
veins to the mitral valve, good biventricular function,
and normal valve functions. The peak gradient across
the pulmonary homograft was 15 mm Hg. One year
later, the patient is active and has grown well. No signs
of superior vena cava (SVC) syndrome are noted. He is
in sinus rhythm, he remains on diuretics and a low dose
of aspirin, and the echocardiographic findings are
unchanged. The flow toward the tricuspid valve remains
unrestricted.
Comment
Anatomic correction of ccTGA has proven to be a prom-
ising strategy in the midterm follow-up compared with
physiologic correction [4, 5]. However, the risk of atrial
baffle complications and the increased occurrence of
sinus node dysfunction after the Senning or Mustard
atrial switch technique [4, 6] have led to the development
of the hemi-Mustard technique for specific anatomic in-
dications [1–3]. The need for an additional BCPA may
subject the patient to chronically elevated SVC pressure,
with the potential for creating venovenous collateral
vessels [6], but this may be neutralized by antegrade flow
to the main pulmonary artery [2].
The hemi-Senning technique proposed here has the
same applications and advantages as the hemi-Mustard
procedure. It can also be used in a smaller right
ventricle or with a mildly dysfunctional tricuspid valve,
by inducing partial right ventricular unloading through
the BCPA. This technique has also proven to prolong the
conduit life in the Rastelli modification [1, 3], and it avoids
intervention in the proximity of the sinus node [6]. With
 Ann Thorac Surg
2019;108:e21–3
Fig 3. Reconstruction of the right ventricular outflow tract with a
pulmonary homograft conduit with a proximal GoreTex (W. L. Gore
& Associates, Flagstaff, AZ) tube extension.
the hemi-Mustard procedure, it shares the disadvantage
of losing transvenous access through the SVC.
Applying a hemi-Senning baffle to the IVC with right
atrial tissue can be used in smaller children because the
possibility of obstructing the pulmonary vein ostia by a
large hemi-Mustard baffle can be avoided. It has the
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CASE REPORT KATRIEN AND THIERRY e23
HEMI-SENNING USE IN DOUBLE DISCORDANCE
inherent advantage of tissue growth, with less chance of
baffle obstruction, but it avoids the possibility of SVC
obstruction often encountered in a complete Senning
procedure [4]. When the original atrial septum can be
used, and by augmenting the pulmonary venous atrium
with an autologous pericardial patch, all foreign material
can be avoided.
The authors wish to thank St
ephanie Philippaerts for the beau-
tiful illustrations.
References
1. Malhotra SP, Reddy VM, Qiu M, et al. The hemi-Mustard/
bidirectional Glenn atrial switch procedure in the double-
switch operation for congenitally corrected transposition of
the great arteries: rationale and midterm results. J Thorac
Cardiovasc Surg 2011;141:162–70.
2. Sojak V, Kuipers I, Koolbergen D, et al. Mid-term results of
bidirectional cavopulmonary anastomosis and hemi-Mustard
procedure in anatomical correction of congenitally corrected
transposition of the great arteries. Eur J Cardiothorac Surg
2012;42:680–4.
3. Shim M, Jun T, Yang J, et al. Clinical outcomes after anatomic
repair including hemi-Mustard operation in patients with
congenitally corrected transposition of the great arteries.
Korean Circ J 2017;47:201–8.
4. Brizard CP, Lee A, Zannino D, et al. Long-term results of
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