Modified Warden procedure using aortic homograft for superior vena caval
translocation: Where is the evidence?
Background: Partial anomalous pulmonary venous connection (PAPVC) occurs
when at least one pulmonary vein drains into the right atrium or its
tributaries rather than the left atrium, most commonly connecting with
the superior vena cava (SVC). The Warden procedure involves transecting
the SVC proximal to the uppermost connection of the pulmonary vein
followed by proximal SVC reattachment to the right atrial appendage.
However, descending thoracic aortic homograft replacement for SVC
translocation has recently been introduced as a modified technique.
Aims: This commentary aims to discuss the recent study by Said and
colleagues who reported their experiences with 6 PAPVC cases undergoing
a modified Warden procedure using thoracic aortic homograft SVC
translocation. Methods: A comprehensive literature search was performed
using multiple electronic databases in order to collate the relevant
research evidence. Results: The Warden procedure is associated with a
10% incidence of SVC obstruction with many requiring reintervention.
Meanwhile, using the aortic homograft for SVC translocation, Said et al.
observed no SVC obstructions. In addition, this modified technique does
not require anticoagulation and has demonstrated an improvement in
long-term SVC patency. Nevertheless, it can be considered an expensive
procedure. Moreover, since the thoracic aortic homograft utilised is
biological tissue, only long-term follow-up will determine whether
calcification and graft degeneration is an issue. Conclusion: It can be
concluded that the modified Warden procedure is a safe and effective
method to reconstruct the systemic venous drainage into the right atrium
when a direct anastomosis under tension might be prone to re-stenosis.