Commentary: What's old is new again: Atrial baffle for complex cardiac transplantation

Central MessageAn atrial baffle technique can be used to achieve levocardia heart transplantation in patients with complex single ventricle congenital heart disease with dextrocardia and a common atrium.See Article page 189. An atrial baffle technique can be used to achieve levocardia heart transplantation in patients with complex single ventricle congenital heart disease with dextrocardia and a common atrium. See Article page 189. The history of surgical repair of transposition of the great vessels is replete with innovative palliative surgical procedures, including the Blalock–Hanlon atrial septectomy1Blalock A. Hanlon C.R. The surgical treatment of complete transposition of the aorta and the pulmonary artery.Surg Gynecol Obstet. 1950; 90: 1PubMed Google Scholar and the Rashkind balloon atrial septostomy.2Rashkind W.J. Miller W.W. Creation of an atrial septal defect without thoracotomy: a palliative approach to complete transposition of the great arteries.JAMA. 1966; 196: 991Crossref PubMed Scopus (561) Google Scholar The era of surgical correction began with a number of procedures aimed at physiologic repair, including the Baffes operation described by Dr Lillehei.3Baffes T.G. A new method for surgical correction of transposition of the aorta and pulmonary artery.Surg Gynecol Obstet. 1956; 102: 227PubMed Google Scholar These so-called atrial switch procedures redirect the systemic venous return to the left ventricle and the pulmonary venous return to the right ventricle. The 2 most commonly applied techniques used autologous atrial and septal flaps (Senning procedure)4Senning A. Surgical correction of transposition of the great vessels.Surgery. 1959; 45: 966PubMed Google Scholar or a pericardial baffle (Mustard procedure)5Mustard W.T. Successful two-stage correction of transposition of the great vessels.Surgery. 1964; 55: 469PubMed Google Scholar to achieve rerouting of the pulmonary and systemic venous return. In this issue of JTCVS techniques, Nakamura and colleagues6Nakamura Y. Ayoubi A. Ashwath R. Exil V. Ricci M. An atrial switch procedure for heart transplantation in an infant with heterotaxy-dextrocardia.J Thorac Cardiovasc Surg Tech. 2021; 8: 189-191Scopus (2) Google Scholar use a technique similar to the Mustard atrial baffle to achieve levocardia heart transplantation in a patient with complex single-ventricle congenital heart disease. The anatomic obstacles the authors had to overcome included dextrocardia, a common atrium, and a left-sided inferior vena cava and superior vena cava. In their report, a pericardial baffle was used to septate a common atrium and re-route the right-sided pulmonary venous return to a common left-sided orifice with the left pulmonary veins. This approach for managing atrial septation has been well described by Huddleston and others for patients with situs inversus totalis.7Huddleston C.B. Richey S. Fiore A.C. Heart transplantation for congenital heart disease.Oper Tech Thorac Cardiovasc Surg. 2019; 24: 103-120Abstract Full Text Full Text PDF Scopus (2) Google Scholar There are 2 particular points of emphasis from the Huddleston technique that readers should keep in mind for the current report. These are demonstrated in the Figure 1. First, resection of the atrial wall (left panel, Figure 1) between the left and right pulmonary venous ostia is important to provide an unobstructed pulmonary venous pathway, particularly from the right pulmonary veins. Second, creation of a large opening in the left interatrial groove (right panel, Figure 1) for anastomosis to the left atrium of the donor organ is an important technical modification that will also limit the potential for pulmonary venous pathway obstruction. While there are similar elements to the Mustard atrial baffle for transposition, this technique of atrial rerouting of the systemic and venous return has clear distinctions from that procedure. The most obvious distinguishing feature is that the Nakamura baffle procedure resulted in a systemic left ventricle unlike the physiologic correction of transposition, whereas the Mustard procedure leaves the patient with a systemic right ventricle. Second, in the report by Nakamura and colleagues, the patient had a common atrium unlike most patients with complete transposition of the great vessels. The drawbacks of the atrial baffle procedure remain. Specifically, the surgeon must ensure a technical result that limits the potential for systemic and pulmonary venous outflow obstruction. The application of time-honored surgical techniques to emerging clinical problems emphasizes the need to remain vigilant in our knowledge and understanding of surgical history because what is old may become new again. An atrial switch procedure for heart transplantation in an infant with heterotaxy-dextrocardiaJTCVS TechniquesVol. 8PreviewWe report an infant with heterotaxy-dextrocardia who underwent heart transplantation using an atrial switch procedure.