Infracardiac and mixed total anomalous pulmonary venous connection: Surgical challenges and practical solutions

Background Total anomalous pulmonary venous connection (TAPVC) remains a complex congenital cardiac malformation. Despite improved survival, infracardiac and mixed variants continue to carry disproportionate risks of early mortality, postoperative pulmonary venous obstruction (PVO), and reintervention. Methods This narrative review examines the anatomic and technical challenges of infracardiac and mixed TAPVC, mechanisms and consequences of postoperative PVO, and contemporary strategies to reduce residual or recurrent obstruction, with particular emphasis on primary sutureless repair and anatomy-specific surgical approaches. Results Contemporary operative mortality for TAPVC is approximately 3–10% but remains higher in patients with preoperative obstruction. Postoperative PVO occurs in approximately 5–15% and is an important determinant of reintervention and late mortality. In infracardiac TAPVC, obstruction may occur along with the descending vertical vein, producing severe pulmonary venous hypertension and physiologic instability. Mixed TAPVC presents additional challenges from heterogeneous drainage, multiple or small confluences, isolated veins, and complex geometry. Primary sutureless repair has evolved from treatment of recurrent PVO to a preventive strategy in high-risk primary TAPVC by avoiding pulmonary venous suture lines and facilitating wide, unobstructed drainage. Conclusions Management of infracardiac and mixed TAPVC requires an anatomy-specific approach focused on preventing postoperative PVO. Important strategies include selective preoperative stabilization, primary sutureless reconstruction in high-risk anatomy, a no-touch approach to selected isolated veins in 3 + 1 mixed TAPVC, and complete reconstruction of the cardiac component when appropriate.