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\begin{document}

\title{Effectiveness of posterior aortopexy for the left pulmonary vein
obstruction between the left atrium and the descending aorta}



\author[1]{Kwang Ho Choi}%
\author[1]{Hyungtae Kim}%
\author[1]{Si Chan Sung}%
\author[1]{Hyoung Doo Lee}%
\author[1]{Hoon Ko}%
\author[1]{Joung-Hee Byun}%
\affil[1]{Pusan National University Yangsan Hospital}%


\vspace{-1em}



  
  \date{May 26, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Background: Left pulmonary vein (PV) obstruction can occur due to
compression between the left atrium (LA) and the descending aorta (DA).
One of the effective solutions for this problem is posterior aortopexy.
In this study, we have reported five cases of posterior aortopexy to
relieve left PV obstruction between the LA and the DA. Methods: Since
August 2012, five patients have undergone posterior aortopexy for
compression of the left PV between the LA and the DA. The median age and
weight of the patients at the time of operation were 5.5 months (range,
1-131 months) and 5.2 kg (range, 4.2-29.5 kg), respectively. The left PV
obstruction was initially diagnosed on echocardiography in four patients
and computed tomography angiography in one patient. The median peak
pressure gradient across the obstructed left PV was 7.3 mmHg (range,
4-20 mmHg). Concomitant procedures were ventricular septal defect
closure in one patient and patent ductus arteriosus ligation in one
patient. Results: There was no PV obstruction on echocardiography in any
of the patients after the operation except in the case of one patient
who had diffuse pulmonary vein stenosis. The median follow-up duration
was 34 months (range, 14-89 months), and during follow-up no incidence
of the left PV obstruction was observed in any of the surviving
patients. Conclusions: The posterior aortopexy technique could be a good
surgical option for the left PV obstruction caused by compression
between the LA and the anteriorly positioned DA.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Pulmonary vein (PV) obstruction is a known prognostic risk factor in the
congenital heart surgery \textsuperscript{1}. Left PV obstruction can
occur due to compression between the left atrium (LA) and the descending
aorta (DA), which can be a result of a combination of cardiomegaly and
the anteriorly positioned DA or one of them \textsuperscript{2-5}. One
of the effective solutions for this problem can be a posterior
aortopexy, which is generally used for the management of airway
obstruction \textsuperscript{6-9}. In this study, we have investigated
the effectiveness of the posterior aortopexy technique to relieve left
PV obstruction caused by compression between the LA and the DA.

\textbf{Materials and methods}

The institutional review board at Pusan National University Yangsan
Hospital approved the present study, and the patient consent was waived
for the retrospective data analysis (IRB No. 05-2018-178). We have
adopted the posterior aortopexy technique to treat left PV obstruction
caused by compression between the LA and the DA in five patients (three
female) since August 2012. The median age and weight of the patients at
the time of operation were 5.5 months (range, 1-131 months) and 5.2 kg
(range, 4.2-29.5 kg), respectively. When the patient revealed a
turbulence flow or peak pressure gradient (PG) of 10 mmHg or more, or
showed a continuous, non-phasic flow pattern on the echocardiography,
the condition was deem to be an obstruction of the corresponding
PV\textsuperscript{1,10}, and then the position and shape of the
pulmonary vein obstruction was confirmed by using computed tomography
(CT) angiography \textsuperscript{11}. All five patients but one were
initially diagnosed with the left PV obstruction on the
echocardiography. In one patient, the left PV obstruction was diagnosed
with CT angiography and cardiac catheterization. This patient showed a
distended inferior vena cava in follow-up echocardiography after the
Fontan procedure. The CT angiography performed for further evaluation
showed left PV obstruction between the LA and the DA (Fig. 1A). A sharp
demarcation of the left PV flow at the DA border was also noticed in the
levophase of pulmonary angiogram (Fig. 1B). The compressed PV pattern
was identified on preoperative CT angiography: focal stenosis in three
patients, focal and diffuse stenosis in one patient, and diffuse
stenosis in one patient. The median preoperative peak PG across the
obstructed left PV was 7.3 mmHg (range, 4-20 mmHg) in all five patients,
and concomitant procedures were performed in two patients. Table 1
summarizes the baseline characteristics of the patients.

Posterior aortopexy was carried out through left thoracotomy (the fourth
intercostal space (ICS) in one patient, the fifth ICS in three patients,
and the sixth ICS in one patient). The DA was fixed to the posterior
chest wall using Teflon pledget-buttressed 3-0 or 4-0 polypropylene
sutures (Fig. 2A and B) \textsuperscript{6,12}. To evaluate the
appropriateness of the posterior aortopexy technique, we measured the
change in the angle between the DA and the vertebra on CT angiography
before and after the operation. A horizontal line was made from the
center of the vertebra, and the other line was drawn from the center of
the vertebra to the center of the DA in the axial slice at the level of
left PV obstruction (Fig. 3A, inlet). Subsequently, we checked the angle
between the two lines before and after the operation on CT angiography,
and the change in the angle (Z\selectlanguage{english}a) was calculated by using the formula
mentioned below.

Z\selectlanguage{english}a = a -- a'

a = preoperative angle between the DA and the vertebra (Fig. 3A)

a' = postoperative angle between the DA and the vertebra (Fig. 3B)

If the value of Z\selectlanguage{english}a is positive, the posterior aortopexy is considered
to be performed effectively.

The data were collected and managed with Microsoft Excel 2016
(Microsoft, Redmond, Wash) and the Statistical Package for Social
Sciences, version 25 (SPSS, Inc., Chicago, Ill). The continuous
variables are expressed as a median and range.

\textbf{Results}

There was no early death during the study period. The median
postoperative ventilator support time was 10 hours (range, 0-174 hours).
The median intensive care unit stay was 2 days (range, 1-227 days), and
the median hospital stay was 7 days (range, 6-257 days). None of the
patients showed a phrenic nerve palsy following the operation (Table 2).
The change in the angle between the DA and the vertebra (Z\selectlanguage{english}a) was
measured, and effective aortopexy (Z\selectlanguage{english}a \textgreater{} 0) was observed in
four patients (80\%). A possible reason for the inadequate posterior
aortopexy in patient 5 was related to the surgical approach. We adopted
a posterior aortopexy through the fourth ICS thoracotomy for concomitant
patent ductus arteriosus (PDA) ligation and relief of airway obstruction
on the patient 5. This might have led to an inadequate posterior
aortopexy (Fig. 4A and B, Z\selectlanguage{english}a = -1). The median postoperative peak PG
across the left PV was 3.1 mmHg (range, 0-20 mmHg), and all but one
patient showed a decreased PG after posterior aortopexy (Table 3).

The median follow-up duration was 34 months (range, 14-89 months). There
was one case of late mortality. Patient 2 had the Rastelli operation for
truncus arteriosus, atrial septal defect, and partial anomalous
pulmonary venous return (PAPVR) at the age of 51 days. The patient
showed persistent pulmonary edema and severe pulmonary hypertension, and
the left PV obstruction was identified between the LA and the DA on
postoperative follow-up echocardiography and CT angiography (Fig. 5A).
In this patient, posterior aortopexy for the left PV obstruction was
performed at the age of 5 months. The PV obstruction pattern was
diffuse, and the PG across the obstructed left PV was still high after
the procedure (20 mmHg, Fig. 5B). The patient also showed a moderate
truncal valve regurgitation, and truncal valve and PAPVR repair were
performed subsequently. However, pulmonary hypertension and PV
obstruction persisted, and the patient eventually died at the age of 14
months. The median cardiothoracic ratio (CTR) at the last follow-up
chest radiography was 0.54 (range, 0.47-0.63) in all five patients.
Patient 4 and 5 demonstrated a decrease in the last follow-up CTR as
compared to the preoperative results (0.57 vs. 0.7 and 0.52 vs. 0.62).
In the last follow-up echocardiography, there was no PV obstruction in
any of the patients except for one case of mortality (Patient 2) (Table
4).

\textbf{Discussion}

The left PV obstruction caused by compression between the LA and the DA
has been rarely reported \textsuperscript{2-5,11}. Previous reports
demonstrate that the left lower PV is usually involved, and four out of
five patients exhibited left lower PV obstruction in the present study
as well. Some of the possible factors that affect the left PV
obstruction caused by compression between the LA and the DA should be
considered. First, the abnormally anterior location of the DA can be a
cause. The left PV can be narrowed due to compression from the back by
the DA located forward \textsuperscript{2}. The PV has clearly low
pressure as compared to the DA. Therefore, if the anteriorly located DA
passes just behind the PV, it can cause narrowing of the involved PV.
Second, an enlarged LA can compress the left PV from the front in the
space between the LA and the DA. This phenomenon can be observed in the
heart with left-sided volume loading, such as atrioventricular valvular
(AVV) regurgitation or large left-to-right shunt
lesions\textsuperscript{4,5}. The third possible factor can be a cardiac
compression that is seen posteriorly due to chest wall deformity such as
the pectus excavatum

Direct surgical repair \textsuperscript{13-15}, balloon
dilatation\textsuperscript{16,17}, and stent implantation
\textsuperscript{18,19}can be the treatment options for the PV
obstruction caused by compression between the LA and the DA. Kotani et
al. reported 15 patients with left PV obstruction among 494 consecutive
single-ventricular patients. The authors performed the sutureless repair
in seven patients and failed to achieve the Fontan operation. Posterior
aortopexy was not attempted in any of the patients \textsuperscript{4}.
O'Donnell et al. reported 29 cases (1.5\%) of 1995 patients who
underwent hemodynamic catheterization. Of these, 26 had a left aortic
arch and a left lower PV compression, and three had a right aortic arch,
right-sided descending aorta, and a right lower PV compression. Nineteen
of 29 patients had a single-ventricular physiology. The authors
performed PV stenting in two patients who had single ventricular
physiology with poor results. Other surgical interventions for relief of
PV obstruction including posterior aortopexy were not performed in any
of the patients \textsuperscript{5}. We had a case of successful relief
from PV obstruction with a posterior aortopexy in a post-Fontan patient
(patient 1). Kotani et al. reported a case of successful relief from the
left PV obstruction by posterior aortopexy and plication of a redundant
LA wall in a patient with the complete atrioventricular septal defect
and persistent left superior vena cava. The posterior aortopexy
technique for patients with PV obstruction caused by compression between
the LA and the anteriorly positioned DA has several advantages as
mentioned earlier by Kotani et al. \textsuperscript{3}. First, external
compression of the PV by the anteriorly positioned DA could be
effectively treated. Second, the posterior aortopexy technique is a less
invasive procedure as compared to the intra-cardiac repair of the PV
under cardiopulmonary bypass. Third, avoiding direct surgical
manipulation of the PVs could prevent post-repair PV stenosis.

Using the posterior aortopexy technique we have treated five patients
with left PV obstruction between the LA and the DA. In two patients
(Patient 1 and 3) with focal PV obstruction that was mainly caused by
the anterior location of the DA, posterior aortopexy was effectively
performed. The changes in the angle between the DA and the vertebra
(Z\selectlanguage{english}a) were 37 and 38, respectively. In the patients with LA enlargement
caused by left heart volume loading (Patient 4 and 5), the effectiveness
of the posterior aortopexy was somewhat unclear. In patient 4, the
improvement in the left PV obstruction occurred immediately after the
operation. This improvement can be attributed to either posterior
aortopexy (Z\selectlanguage{english}a = 20) or decreased blood flow to the left lung or both of
them. In the case of patient 5, posterior aortopexy was not effectively
performed (Z\selectlanguage{english}a = -1). The improvement in the left PV obstruction
observed in patient 5 was thought to be due to the reduction in the
volume loading of the heart by the PDA ligation. Finally, in patient 2,
a preoperative CTR was 0.66. The left PV obstruction did not improve
after the posterior aortopexy. In this patient, diffuse left PV
obstruction was observed. The immediate postoperative CTR was still
0.64, showing the cardiomegaly, and the postoperative PG across the left
lower PV was 20 mmHg. The cause of the left PV stenosis could be an
intrinsic diffuse PV stenosis.

Based on our experiences with the five patients, it is hypothesized that
posterior aortopexy is an effective option for the management of the PV
obstruction caused mainly by the anterior location of the DA in the
patients without left heart volume loading. However, the effectiveness
of posterior aortopexy is somewhat unclear in patients with severe left
heart volume loading. A sudden decrease in left lung blood flow can mask
the effectiveness of the posterior aortopexy.

Our current study has some clear limitations. It is a retrospective
study investigating a small number of patients with heterogeneous heart
diseases, and there were no definite operative indications for the
procedure. Also, we measured the CTR to evaluate the volume loading and
enlarged LA of the patients, but it is not enough to show them
sometimes. Moreover, the definition of focal and diffuse stenosis is not
clear. To overcome these limitations, we performed preoperative and
postoperative CT angiography for all 5 patients.

In conclusion, posterior aortopexy could be considered as an effective
treatment option for patients with left PV obstruction that is mainly
caused by the anterior location of the DA without the left heart volume
loading. In patients with large left heart volume loading, the posterior
aortopexy could be recommendable in cases where PV obstruction persists
even after removal of the volume loading.

\textbf{Figures}

Figure 1. Patient 1 showed left pulmonary vein (PV) obstruction in
follow-up computed tomography (CT) angiography and cardiac
catheterization. (A) The follow-up CT angiography showed left PV
obstruction (arrow). (B) Cardiac catheterization showed a sharp
demarcation of the left PV flow at the descending aorta border.

Figure 2. Posterior aortopexy technique. (A) Descending aorta (DA) was
fixed to the posterior chest wall using Teflon pledget-buttressed
polypropylene sutures. (B) The DA was relocated posteriorly after snares
were tightened.

Caud = caudad; Ceph = cephalad.

Figure 3. Computed tomography (CT) angiography findings (A) before
(inset, schematic drawing of the axial CT image at the level of the left
pulmonary vein obstruction) and (B) after posterior aortopexy in patient
3 (preoperative (a) and postoperative (a') angle between the descending
aorta and the vertebra)

DA = descending aorta; LA = left atrium; PV = pulmonary vein; V =
vertebra.

Figure 4. Computed tomography angiography findings (A) before and (B)
after posterior aortopexy in patient 5.

Figure 5. Computed tomography angiography findings (A) before and (B)
after posterior aortopexy in patient 2 show diffuse left lower pulmonary
vein stenosis (arrows)

\textbf{Tables}

Table 1. Baseline characteristics of the patients\selectlanguage{english}
\begin{longtable}[]{@{}lllllllll@{}}
\toprule
\begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
Patient no.\strut
\end{minipage} & \begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
Diagnosis\strut
\end{minipage} & \begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
Age (months)\strut
\end{minipage} & \begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
Weight (kg)\strut
\end{minipage} & \begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
Sex\strut
\end{minipage} & \begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
Initial PVO diagnosis tool\strut
\end{minipage} & \begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
Affected PV pattern\strut
\end{minipage} & \begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
Peak PG across left PV (mmHg)\strut
\end{minipage} & \begin{minipage}[b]{0.11\columnwidth}\raggedright\strut
Concomitant procedures\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
PA/IVS s/p Fontan operation\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
131\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
29.5\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
F\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
CT angiography and cardiac catheterization\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
LPV, focal\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
None\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
Truncus arteriosus s/p Rastelli operation\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
5.5\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
4.7\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
M\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
Echocardiography\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
LLPV, diffuse\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
20\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
None\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
CoA with VSD s/p total correction\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
80.5\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
15.9\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
F\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
Echocardiography\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
LLPV, focal\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
9\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
None\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
VSD, ASD, and PHT\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
4.2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
M\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
Echocardiography\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
LLPV, focal + diffuse\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
7.3\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
VSD closure\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
PDA, left main bronchus stenosis\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
2.4\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
5.2\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
F\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
Echocardiography\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
LLPV, focal\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
6.6\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
PDA ligation\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

ASD = atrial septal defect; CoA = coarctation of the aorta; CT =
computed tomography; IVS = intact ventricular septum; LLPV = left lower
pulmonary vein; LPA = left pulmonary artery; LPV = left pulmonary vein;
PA = pulmonary atresia; PDA = patent ductus arteriosus; PG = pressure
gradient; PV = pulmonary vein; s/p = status post; VSD = ventricular
septal defect.

Table 2. Postoperative findings\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Patient no.\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Postop. Ventilator care (hours)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
ICU stay (days)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Hospital stay (days)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Postop. Phrenic n. palsy\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0 (extubation in OR)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
174\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
227\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
257\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
48\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
10\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

ICU = intensive care unit; OR = operating room.

Table 3. Clinical data before and after posterior aortopexy\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Patient no.\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Angle between DA and vertebra Preop. (a) Postop. (a')\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Z\selectlanguage{english}a\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Postoperative peak PG across PV (mmHg)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
50\selectlanguage{ngerman}° 13°\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
37\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
18\selectlanguage{ngerman}° 0°\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
18\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
20\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
60\selectlanguage{ngerman}° 22°\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
38\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2.5\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
31\selectlanguage{ngerman}° 11°\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
20\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
5.8\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
25\selectlanguage{ngerman}° 26°\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
-1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.1\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

DA = descending aorta; LLPV = left lower pulmonary vein; LPV = left
pulmonary vein; PG = pressure gradient; PV = pulmonary vein.

Table 4. Follow up data of the patients undergoing posterior aortopexy\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
\begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Patient no.\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Preop. CTR\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Immediate Postop. CTR\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Immediate postop. PV obstruction\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
F/U duration (months)\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Last F/U CTR\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
PV obstruction in last F/U echocardiography\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Death\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.44\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.44\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
89\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.47\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.66\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.64\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
+\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
14\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.63\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
+\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
+\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.46\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.51\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
45\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.54\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.7\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.71\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
22\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.57\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.62\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.58\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
34\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.52\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

CTR = cardiothoracic ratio; F/U = follow-up; PV = pulmonary vein.

\textbf{References}

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stenosis. \emph{Circulation.} 2007;115:103-8.

2. Kawahira Y, Kadoba K, Matsuda H. Compression of the pulmonary veins
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3. Kotani Y, Sano T, Arai S, Kasahara S. Aortopexy for left pulmonary
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4. Kotani Y, Zhu J, Grosse-Wortmann L, Honjo O, Coles JG, Van Arsdell
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7. Lee SY, Kim SJ, Baek JS, Kwak JG, Lee C, Lee CH, et al. Outcomes of
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8. Shieh HF, Smithers CJ, Hamilton TE, Zurakowski D, Visner GA, Manfredi
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9. Weber TR, Keller MS, Fiore A. Aortic suspension (aortopexy) for
severe tracheomalacia in infants and children. \emph{Am J
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10. Smallhorn JF, Pauperio H, Benson L, Freedom RM, Rowe RD. Pulsed
Doppler assessment of pulmonary vein obstruction. \emph{Am Heart
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11. Ohtsuki S, Baba K, Kataoka K, Ohno N, Okamoto Y, Ishino K, et al.
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12. Jang WS, Kim WH, Choi K, Nam J, Kim JT, Lee JR, et al. Aortopexy
with preoperative computed tomography and intraoperative bronchoscopy
for patients with central airway obstruction after surgery for
congenital heart disease: postoperative computed tomography results and
clinical outcomes. \emph{Pediatr Cardiol.} 2014;35:914-21.

13. Caldarone CA, Najm HK, Kadletz M, Smallhorn JF, Freedom RM, Williams
WG, et al. Relentless pulmonary vein stenosis after repair of total
anomalous pulmonary venous drainage. \emph{Ann Thorac
Surg.}1998;66:1514-20.

14. Fukushima Y, Onitsuka T, Nakamura K, Yoshioka M, Kuwabara M, Koga Y.
A simple method for excising pulmonary venous obstruction after repair
of total anomalous pulmonary venous drainage. \emph{Jpn Circ
J.}1994;58:805-7.

15. Lacour-Gayet F, Zoghbi J, Serraf AE, Belli E, Piot D, Rey C, et al.
Surgical management of progressive pulmonary venous obstruction after
repair of total anomalous pulmonary venous connection. \emph{J Thorac
Cardiovasc Surg.} 1999;117:679-87.

16. Driscoll DJ, Hesslein PS, Mullins CE. Congenital stenosis of
individual pulmonary veins: clinical spectrum and unsuccessful treatment
by transvenous balloon dilation. \emph{Am J Cardiol.} 1982;49:1767-72.

17. Yoshii S, Matsukawa T, Nishida K, Tada Y, Sugiyama H, Yanai J.
Transesophageal echo-guided balloon dilatation for postoperative
pulmonary venous obstruction. \emph{Surg Today.} 1994;24:666-8.

18. Hyde JA, St\selectlanguage{ngerman}ümper O, Barth MJ, Wright JG, Silove ED, de Giovanni JV,
et al. Total anomalous pulmonary venous connection: outcome of surgical
correction and management of recurrent venous obstruction. \emph{Eur J
Cardiothorac Surg.} 1999;15:735-40; discussion 40-1.

19. Mendelsohn AM, Bove EL, Lupinetti FM, Crowley DC, Lloyd TR, Fedderly
RT, et al. Intraoperative and percutaneous stenting of congenital
pulmonary artery and vein stenosis. \emph{Circulation.} 1993;88:Ii210-7.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-01-A/Figure-01-A}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-01-B/Figure-01-B}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-02/Figure-02}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-03-A/Figure-03-A}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-03-B/Figure-03-B}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-04-A/Figure-04-A}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-04-B/Figure-04-B}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-05-A/Figure-05-A}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-05-B/Figure-05-B}

\end{center}
\end{figure}

\selectlanguage{english}
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\end{document}

