Brit. J. Anaesth. (1966), 38, 945 TOTAL ANOMALOUS PULMONARY VENOUS CONNECTION: POSTOPERATIVE PULMONARY COMPLICATIONS BY W. R. MACRAE AND A. H. B. MASSON Department of Anaesthetics, Royal Infirmary and Edinburgh University, Edinburgh SUMMARY The most serious postoperative complication following complete repair of supracardiac total anomalous pulmonary venous connection is pulmonary oedema. 24-36 hours may elapse before frank pulmonary oedema appears and active measures must be instituted early to combat this complication. Given temporary assistance, the body is capable of adapting to the altered haemodynamic situation. Six case reports are described. Supracardiac total anomalous pulmonary venous connection (TAPVC) is a congenital anomaly in which all the pulmonary venous blood enters the right atrium. Anatomically, the pulmonary venous blood collects in a chamber-like structure which lies behind the left atrium but has no connection with it. The commonest route through which this blood reaches the right atrium is by a vein, often referred to as a "left superior vena cava" which runs anterior to the aortic arch and joins the beginning of the left innominate vein. Physio- logically this results in an enormous left-to-right shunt of blood. The mixture of all the blood from the pulmonary and systemic systems reaches the right atrium and from there passes into the right ventricle and at the same time through an atrial septal defect into the left atrium. The blood in the right ventricle passes through the lungs and returns again to the right atrium. The systemic circulation comes entirely from the right atrium through the atrial septal defect, and prolonged survival therefore depends on this defect being of adequate si2e. There are many different types of total anomalous pulmonary venous connection and their embryological backgrounds have been described by Brody (1942), Edwards (1953) and Keith and associates (1954). The clinical features of this anomaly resemble those of atrial septal defect. Heart murmurs are not pathognomonic but chest radiographs show the classical "figure of eight" configuration of the cardiomediastinal shadow as described by Snellen and Albers (1952), the so-called "cottage loaf heart" (fig. 1). There is a high oxygen saturation of the blood in the right atrium. In some cases the pulmonary and systemic arterial blood are found to have the same oxygen saturation though in others the oxygen saturation of blood in the pulmonary artery may actually exceed that of FIG. 1 The "cottage loaf heart" of total anomalous pulmonary venous connection with a cardiac catheter demons- trating the presence of an atrial septal defect.
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