Commentary: The genius of Ake Senning

Central MessageRepair of rare, complex congenital cardiac lesions may require the thoughtful modifications of unusual techniques for success.See Article page 223. Repair of rare, complex congenital cardiac lesions may require the thoughtful modifications of unusual techniques for success. See Article page 223. In 1959, Ake Senning reported on the remarkable correction of transposition of the great arteries (TGA) using a so-called atrial inversion technique.1Senning A. Surgical correction of transposition of the great vessels.Surgery. 1959; 45: 966-980PubMed Google Scholar It is perhaps the most difficult operation to describe but not particularly difficult to perform. This innovative operation was a game-changing development in the treatment of congenital heart disease and likely served as a catalyst for further innovations that followed. Although no longer the treatment of choice for TGA, the principles of this operation are occasionally used, often in the setting of very complex congenital lesions in which separation of the pulmonary and systemic circulation is very challenging. The article in this issue of the JTCVS Techniques describes 4 patients with TGA and total anomalous pulmonary venous return who presented very late for treatment; one was 22 years of age.2Mishra A. Garg P. Agrawal V. Rana Y. Transposition of great arteries with total anomalous pulmonary venous connection: a modified Senning procedure for late presentation.J Thorac Cardiovasc Surg Tech. 2020; 4: 223-226Scopus (2) Google Scholar The authors describe a clever way to deal with this problem in 3 of the patients (the fourth also had a ventricular septal defect and underwent arterial switch/ventricular septal defect closure and repair of total anomalous pulmonary venous return) using a modification of the pioneering technique described by Senning. These 3 patients survived and did well, at least in the short term. Case reports such as this serve a couple of purposes. When successful, they provide information on an extremely rare congenital cardiac lesion and how one center approached this unusual lesion, should the opportunity arise in which this rare condition is seen again by others. Do I think that I will ever see a patient with TGA and total anomalous pulmonary venous return presenting at greater 1 year of age? No. I have never heard of such a case in the 30 years I have been a practicing congenital heart surgeon before reading this article. The other important point of case reports in congenital heart surgery is that they demonstrate the ongoing need to be innovative, to think “outside the box” (a phrase I dislike), and to continue to strive to figure out how to care for children with very complicated problems. This may occasionally require digging out procedures long since buried by newer techniques. This article by Mishra and colleagues does just that. Transposition of great arteries with total anomalous pulmonary venous connection: A modified Senning procedure for late presentationJTCVS TechniquesVol. 4PreviewCardiac surgeons frequently deal with transposition of the great arteries (d-TGA) and total anomalous pulmonary venous connection (TAPVC), common cyanotic congenital heart diseases (CHDs). However, the association of d-TGA with TAPVC is rare. It is a medical condition that arises when the pulmonary venous blood is delivered to the systemic ventricle without pulmonary overcirculation. The blood flowing to the left ventricle is delivered through the atrial septal defect. This complex association leads to late clinical presentation and faster regression of the left ventricle.