Caval translocation as a surgical strategy for patients with congenital heart disease and bilateral superior vena cava

Abstract

Objective

The presence of bilateral superior vena cava (SVC) may complicate biventricular or single-ventricle pathway surgery. Translocation of an SVC to create a neoinnominate vein may simplify subsequent procedures.

Methods

Fourteen patients received an SVC translocation. The longer SVC was translocated, facilitated by complete mobilization of both SVCs, including division of azygos or hemiazygos, and bilateral mammary veins, which increased length and reduced tension on the SVC-SVC anastomosis.

Results

Translocation was achieved in 6 patients with commonly corrected defects, in 5 patients to aid in biventricular conversions, and in 3 patients in conjunction with a cavopulmonary anastomosis. At a median follow-up of 1.3 years (range, 2 weeks to 7.1 years), there were no translocation-related deaths or evidence of impaired superior systemic venous return.

Conclusions

For patients with bilateral SVCs, translocation is a valuable addition to the armamentarium of strategies and holds promise for facilitating biventricular repair. Moreover, for patients requiring cavopulmonary anastomosis, a translocation enables a single cavopulmonary connection, and future studies may prove this strategy to be optimal over the traditional bilateral cavopulmonary connection.

Graphical Abstract

Caval translocation restoring “normal” anatomy for cavopulmonary anastomoses.

Central Message.

Caval translocation is an effective strategy for managing bilateral SVCs in patients with complex congenital heart disease and restores normal anatomy.

Perspective.

For patients with bilateral SVCs with single-ventricle anatomy or SVCs draining to different atria, restoring optimal systemic venous return can be achieved by translocation of an SVC to the other to create a neoinnominate vein. This strategy simplifies the surgical approach for biventricular repair strategies and may prove optimal for Fontan candidates.

Because of an embryologic persistence of the right and left anterior cardinal veins,¹ bilateral superior vena cava (SVC) are present in 50% to 70% of patients with heterotaxy syndrome and 3% to 11% with congenital heart disease.2, 3, 4 For those with an isomeric anatomy, the left superior vena cava (LSVC) often drains to the roof of the anatomical left atrium, a mirror image of the right superior vena cava (RSVC) and right atrial confluence. For situs solitus anatomy, the LSVC drains through an intact or unroofed coronary sinus. Bilateral SVC anatomy may be observed in numerous concomitant pathologies, ranging from atrial or ventricular septal defects to double-outlet right ventricle or transposition of the great arteries.⁵ In both heterotaxy and situs solitus presentations, bilateral SVCs may complicate surgical approaches.

Although a historical challenge, with preliminary descriptions in 1967,⁶ many have proposed intra- and extracardiac strategies for bilateral SVC, the most common being intracardiac baffle, which uses patches to direct venous return from the LSVC to the tricuspid valve along with the RSVC and inferior vena cava (IVC). This approach complicates repair for those with atrioventricular septal defects or double discordance who require interatrial baffling and may prolong ischemic time. Alternatively, there are 3 main extra-cardiac strategies: (1) recreation of the innominate vein with autologous pericardium or an artificial graft,⁷ (2) transposition of the LSVC to the right atrial appendage, or (3) translocation of one SVC anterior or posterior to the ascending aorta to recreate a neoinnominate vein with native tissue.⁸ In 2021, we reported our early success with SVC translocation to aid in the “ventricular switch.“⁹ Since then, we have used this technique on each patient presenting with bilateral SVCs whose surgical repair would be amenable to translocation (Figure 1, A-D). We believe that this strategy has aided in complex reconstructions and simplified the surgical approach for less-complex concomitant defects. We report our historical experience of translocations in 14 consecutive patients.

Figure 1.

Surgical strategies for bilateral SVCs. A, LSVC Translocation in conjunction with complete tetralogy of Fallot repair. B/C, RSVC translocation anterior and posterior to the aorta as part of the ventricular switch technique. D, LSVC translocation as part of a cavopulmonary anastomosis. E, Bilateral cavopulmonary anastomosis without translocation. Red arrow indicates saturated blood, blue arrow indicates not saturated blood. SVC, Superior vena cava; LSVC, left superior vena cava; RSVC, right superior vena cava.

Methods

This was a single-center case series of 14 patients with bilateral SVCs who received a translocation at our center. Patients were identified using department-level records supplemented by patients found through robust key word searches of our electronic medical records from 2016 to 2025. Characteristics, imaging, operative details, and clinical outcomes were extracted from electronic medical records. The study protocol and use of data for research were approved by the Cleveland Clinic Institutional Review Board (no. 24-225; approved March 5, 2024), with a waiver of consent.

Indications for SVC Translocation

Our center uses 3 primary indications for SVC translocations in patients who present with bilateral SVCs and no substantial bridging vein: (1) when a translocation would avoid intra-atrial baffling; (2) when a translocation would simplify a biventricular conversion; and (3) when a translocation could simplify a future intervention:

• a.A translocation would avoid future left-sided LSVC dissection and the associated risk of left phrenic nerve injury.
• b.In anticipation of transplant, a translocation would reduce systemic venous reconstruction and potentially donor ischemic times.

Surgical Technique and Management

SVC translocation was performed at a median age of 16 months (range, 44 days to 32 years). Both SVCs were dissected, including division of the corresponding mammary and azygos veins, and mobilization cephalad to the tributaries. In our experience, the SVC contributing to the coronary sinus is often 1 to 2 cm longer. By choosing this SVC and dividing the cava from the sinoatrial confluence, the extravenous tissue gives ample length for a tension-free anastomosis without the need for patch materials. Planning the caval cannulation is critical to avoid stenosis. Atrial cannulation with a straight cannula passed beyond the neocavo-caval anastomosis was performed in some, and in others, intermittent caval occlusion and release facilitated the translocation. The anterior part of the translocated SVC was marked to avoid twist and shifted anterior or posterior to the aorta (Figure 1). End-to-side anastomosis was fashioned with a fine 6-0 or 7-0 PROLENE suture (Ethicon; Figure 2). Our preference was to complete anterior translocations; however, if patients presented with anatomies that did not have the space to accommodate an anterior translocation, posterior translocations were performed. In these instances, ample dissection of the aorta and pulmonary arteries was needed to create space and avoid compression (Figure E1). Postoperative anticoagulation varied considerably between patients, predominantly dependent upon the additional intracardiac interventions performed at the time of translocation. In rare instances, our cardiology/hematology colleagues requested 3 months of subcutaneous enoxaparin.

Figure 2.

Surgeon's view of (A) elaborate mobilization of RSVC, (B) division of hemiazygos vein from LSVC and visualization of a small native innominate vein, and (C) completed RSVC translocation in the superior region of the LSVC just adjacent to small native innominate vein (patient 10). RSVC, Right superior vena cava; LSVC, left superior vena cava.

Figure E1.

LSVC Translocation posterior to the aorta (patient 12). A, Elaborate LSVC mobilized with a cannula inserted directly into the LSVC. B, Cannula is used to thread LSVC posterior to the aorta before RSVC anastomosis with 7-0 PROLENE. LSVC, Left superior vena cava; RSVC, right superior vena cava.

Cannulation and Timing

Venous canulation and timing varied considerably and depended on the size of the extra SVC and ease of anastomosis. For large SVCs, we performed direct cannulation with snaring. Medium-sized cava received a plastic cannula through the end, and small SVCs were intermittently clamped and released. Bilateral superior caval cannulation was achieved directly in 5 patients, in whom care was taken to place the cannulas as high as possible to ease later mobilization. The remaining patients did not require bilateral SVC cannulation. The majority of translocations were performed while warming from hypothermia, but the translocation was also performed before other components of the intervention. Case-specific details can be found in Table E1.

Results

Demographics, previous interventions, operative characteristics, and SVC anatomy after translocation are detailed in Table 1. Table 2 details postoperative outcomes, complications, follow-up, and assessment of caval patency. In this cohort, translocation was performed to aid in a biventricular repair in 6 patients with commonly corrected defects and unroofed coronary sinuses and 5 who underwent a biventricular conversion strategy. Three received a translocation with a bidirectional cavopulmonary anastomosis (CPA). Patient-specific diagnoses are detailed in Table E1.

Table 1.

Characteristics of patients with bilateral SVC

No.	Demographics	Previous interventions	Bridging vein	Accompanying interventions	Translocated SVC	Relation to aorta	Destination of venous return
Translocation in commonly corrected defects
1	23-y male	×	×	Pulmonary valvotomy and ASD closure	LSVC	Anterior	Right atrium
2	6-mo female	×	×	Atrioventricular septal defect repair	LSVC	Anterior	Right atrium
3	5-mo female	✔×1	×	VSD and ASD closure, removal of MPA band	LSVC	Anterior	Right atrium
4	44-d female	×	×	ToF repair	LSVC	Anterior	Right atrium
5	1.5-y female	×	✔	Left atrioventricular valve and ASD repair	LSVC	Anterior	Right atrium
6	13-y male	✔×2	✔	Pulmonary valve repair, intracardiac right partially anomalous pulmonary venous rerouting, and VSD repair	LSVC	Posterior	Right atrium
Translocation in biventricular conversions
7	6-y female	✔×8	×	Atrial switch	RSVC	Anterior	Left atrium
8	32-y male	×	×	Biventricular conversion	RSVC	Posterior	Left atrium
9	3-y female	✔×1	×	Congenitally corrected transposition physiologic repair	LSVC	Posterior	Right atrium
10	17-mo female	✔×2	×	Ventricular switch	RSVC	Anterior	Left atrium
11	11-mo female	✔×1	×	Biventricular repair	LSVC	Anterior	Right atrium
Translocation with cavopulmonary anastomosis
12	1-y male	✔×2	×	Ventricular switch (1.5-ventricle repair)	LSVC	Anterior	RPA
13	4-mo female	✔×1	×	CPA	LSVC	Anterior	RPA
14	6-mo female	✔×1	×	CPA	LSVC	Anterior	RPA

SVC, Superior vena cava; ASD, atrial septal defect; LSVC, left superior vena cava; VSD, ventricular septal defect; MPA, main pulmonary artery; ToF, tetralogy of Fallot; RSVC, right superior vena cava; RPA, right pulmonary artery; CPA, cavopulmonary anastomosis; ✔, present.

Table 2.

Outcomes after translocation

No.	Chylothorax	Stenosis of cava or pulmonary arteries	Collaterals			Intervention	Follow-up, y		Hospital mortality	Assessment of SVC translocation (echo)
			Azygos	Arterio pulmonary	Pulmonary AVM		Age	Time
Translocation in commonly corrected defects
1	×	×	×	×	×	×	30	7	×	Mild narrowing through LSVC without impingement of flow.
2	✔	×	×	×	×	(1) ECMO (2) biventricular assist device	1	7 mo	Multisystem organ failure	SVC was not visualized in 15 postoperative echocardiograms
3	×	×	×	×	×	×	4	4	×	Laminar flow through LSVC
4	×	×	×	×	×	×	3	3	×	LSVC appeared dilated without obstruction, (LSVC was larger in diameter than RSVC)
5	×	×	×	×	×	×	3	2	×	No obvious obstruction, robust flow in RSVC (mean gradient ∼2 mm Hg)
6	×	×	×	×	×	×	13	1 mo	×	Low velocity phasic flow, LSVC (mean gradient 0.26 mm Hg), RSVC (mean gradient 1.6 mm Hg).
Translocation in biventricular conversions
7	×	×	×	×	×	×	9	3	×	Mild turbulence at translocation anastomosis. No gradient with laminar flow in LSVC
8	×	×	×	×	×	×	33	2	×	Mild narrowing of the retro aortic portion of RSVC between aorta and pulmonary artery.
9	×	×	×	×	×	×	8	5	×	No echocardiogram or catheterization evidence of translocation stenosis.
10	×	×	×	×	×	×	18 mo	3 wk	×	No evidence of translocation stenosis.
11	×	×	×	×	×	×	11 mo	3 wk	×	Unobstructed phasic flow across translocation
Translocation at the time of cavopulmonary anastomosis
12	×	×	×	×	×	×	2	1	Multisystem organ failure	Patent translocation with pulsatile Glenn.
13	✔	×	✔	×	×	Azygos collateral coiling	1	6 mo	Persistent chylothorax	Catheterization: RSVC widely patent, LSVC unobstructed
14	✔	×	×	×	×	×	6 mo	2 wk	×	Low-velocity unobstructed phasic flow

AVM, Arteriovenous malformation; SVC, superior vena cava; LSVC, left superior vena cava; ECMO, extracorporeal membrane oxygenation; RSVC, right superior vena cava; ✔, present.

Translocation in Commonly Corrected Defects

For the 6 patients with bilateral SVCs and commonly corrected defects and unroofed coronary sinuses, the median age was 1 year (range, 44 days to 22 years). Two patients (patients 5 and 6) had bridging veins that were too small to accommodate ligation of the LSVC. Five patients had their translocation anterior to the aorta (Figure 1, A and B) and 1 posterior (Figure 1, C). There was 1 in-hospital mortality, independent of the translocation. This patient (patient 2) experienced a cardiac arrest on postoperative day 1, requiring venoarterial extracorporeal membrane oxygenation, and ultimately developed a chylous effusion with a patent neoinnominate vein. They developed multisystem organ failure, required a biventricular assist device, and died. No other patients developed a chylothorax. There were no azygos, or pulmonary arteriovenous collaterals. These patients had a median follow-up of 2.5 years (range, 1 month to 7 years). To date, there is no echocardiographic or catheterization evidence of occlusion or hemodynamically significant stenosis in any of the translocations. In clinical follow-up, there have been no symptoms of headache, facial edema, or symptoms of thoracic outlet obstruction.

Translocation in Biventricular Conversion

For the 5 patients with bilateral SVCs who required complex biventricular conversion, the median age was 3 years (range, 11 months to 32 years). No patients had bridging veins. Three had an RSVC translocation, whereas 2 had the LSVC translocated. In 3 patient, the translocation was anterior, and in 2, posterior to the aorta. None developed azygos, arteriopulmonary, or pulmonary arteriovenous collaterals. One patient with a retroaortic translocation showed mild compression as the cava passed directly posterior to the aorta yet without a gradient of impingement of flow. At a median follow-up of 2 years (range, 3 weeks to 5 years), there has been no other echocardiographic or catheterization evidence of occlusion or hemodynamically significant stenosis in any of the translocations. Clinical follow-up has not revealed symptoms of headache, facial edema, or thoracic outlet obstruction.

Translocation With CPA

Three patients with complex heterotaxy required an SVC translocation at the time of CPA (Figure 1, D, Figure 3, Table 2). None had bridging veins, and no patients had a dilated neoaorta. There were 2 in-hospital mortalities independent of the translocation. The first (patient 12) had a ventricular switch with translocation, resulting in a 1.5-ventricle repair. Ultimately, he developed severe left atrioventricular valve regurgitation, precipitating multisystem organ failure. The second (patient 13) had a central diaphragmatic hernia defect, which, despite repair, precipitated multiple hepatopleural lymphatic collaterals and a high-output chylothorax. For this patient, the hemiazygos vein could also not be identified at the time of translocation. She had a pulsatile Glenn resulting in a venovenous collateral to the subdiaphragmatic IVC, which was resolved with coiling. The final CPA translocation (patient 14) is progressing at 2 weeks after translocation. On postoperative day 1, a small cloudy output was noted from her chest tube, yet she tolerated her diet, and the tube was removed on day 4. She was discharged on day 5. In these patients, beyond the complexities that coincided with bilateral SVC anatomy, none showed clinical evidence associated with translocation stenosis. Angiogram studies also demonstrated equal arborization of systemic venous return to both lungs.

Figure 3.

Completed SVC translocations at the time of cavopulmonary anastomosis. A, Patient 13. B, Patient 14. SVC, Superior vena cava.

Discussion

We describe a simple yet intuitive approach for redirecting systemic venous return for patients with bilateral SVCs. By recreating a neoinnominate vein, bilateral systemic venous return flows singularly to the systemic atrium or CPA. With translocation, surgical repair will not require intra-atrial rerouting or an extracardiac graft that will not grow with a child. Technically, translocating SVCs is adaptable to most unique anatomies.

Simplification of the Surgical Approach

As previously described by our team,9, 10, 11 caval translocation with biventricular conversion or 1.5-ventricle repair simplifies the surgical approach. Indeed, many in the present cohort required intra-atrial diversion as part of an atrial/ventricular switch strategy or correction of anomalous pulmonary venous return. In such instances, the atria would not have accommodated additional intra-atrial baffles without risk of obstruction. Moreover, for patients requiring a 1.5-ventricle repair, a translocation simplifies the anatomy and creates a free pulmonary artery to receive a ventricle to pulmonary conduit, thereby avoiding a pulsatile bilateral cavopulmonary anastomosis (BCPA) when a band is interposed between.¹⁰

Follow-up

In previous accounts, there is limited follow-up for the patency of an SVC translocation. Yilmaz and Atalay¹² reported caval translocation in a 9-year-old girl with tetralogy of Fallot and bilateral SVCs. They reported outcomes after 2.4 years, noting the lack of long-term follow-up. We report an adult translocation with excellent patency at 7 years after translocation, and 5 of our 14 have follow-up over 3 years. There was no clinical or echocardiographic evidence of obstruction or hemodynamically significant stenosis.

Translocation in Patients on a Single-Ventricle Pathway

For patients on a single-ventricle pathway, there is robust evidence that bilateral SVCs may increase the risk of morbidity, especially for patients with complex heterotaxy.^13,14 Iyer and colleagues,¹⁴ in a cohort of 39 with bilateral SVC, reported central pulmonary artery stenosis/thrombosis in 23%. Ono and colleagues,¹⁵ through robust computational fluid dynamics studies on 40 patients with bilateral bidirectional Glenns and Fontan completion, found that opposing pulmonary arterial contributions were an independent risk factor for survival. Finally, Brown and colleagues,¹⁶ in an assessment of 21 patients with interrupted IVCs, found that bilateral SVCs were a significant risk factor for pulmonary arteriovenous malformations. With this previous evidence, we retrospectively reviewed our experience with patients with bilateral SVCs who received BCPAs to assess whether these patients would have benefited from a translocation technique (Figure E1, Table 3).

Table 3.

Potential comparison group: bilateral cavopulmonary anastomoses

No.	Demographics	Previous interventions	Bridging vein	Accompanying interventions	Translocated SVC	Relation to aorta	Destination of venous return
15	5-mo male	✔×1	×	BCPA	RPA	LPA	None
16	8-mo female	×	×	BCPA	RPA	LPA	None
17	8.5-mo female	✔×1	×	BCPA, Damus-Kaye-Stansel	RPA	LPA	None
18	4-mo male	×	×	BCPA, MPA band	RPA	LPA	Right ventricular outflow tract
19	3.5-mo male	✔×3	×	BCPA	RPA	LPA-MPA junction	Blalock-Tausig-Thomas shunt
20	4-mo male	✔×1	×	Ductal ligation, BCPA	RPA	LPA-MPA junction	Central shunt
21	6-mo male	✔×1	×	BCPA-Kawashima	RPA	LPA	Hemiazygos

No.	Chylothorax	Stenosis of cava anastomosis	Collaterals			Intervention	Follow-Up		Status	Central pulmonary artery stenosis	Time: Glenn to stenosis, y	Assessment of central pulmonary stenosis and other considerations
			Azygos	Arteriopulmonary	Pulmonary AVM		Age, y	Time, y
15	×	✔	×	×	×	(1) Balloon dilation of cava anastomoses (2) Fontan	30	25	Alive	✔	4.5	Central narrowing identified and corrected at Fontan. Planned for heart liver transplant
16	✔	×	✔	✔	×	Coiling	12	11	Alive	✔	7.5	Narrowing of right pulmonary artery medial to cavopulmonary anastomoses, gradient ∼10 mm Hg.
17	✔	×	×	×	×	Fontan	10	9	Alive	✔	3	At Fontan narrowing medial to right Glenn required division across inferior border of pulmonary artery.
18	✔	×	×	×	×	Fontan	7	7	Alive	✔	4	Catheterization: no washout of contrast within main pulmonary artery; resolved at Fontan.
19	×	×	×	✔	×	3× coiling	9	5	Dead	×	−	No stenosis.
20	×	×	×	✔×3	×	3× coiling	3	3	Alive	×	−	No stenosis.
21	✔	×	×	×	✔	(1) Attempted angioplasty (2) Early Fontan	4	4	Alive	✔	11 m	Pulmonary arteriovenous malformation from MPA stenosis obstructing hepatic factor.

SVC, Superior vena cava; BCPA, bilateral cavopulmonary anastomosis; RPA, right pulmonary artery; LPA, left pulmonary artery; MPA, main pulmonary artery; ✔, present.

We additionally reviewed 7 patients who were found through similar key word searches and department-level records with a major surgical intervention completed from 2011 to 2020. We were surprised to find that 5 showed evidence of stenosis or hypoplasia of the medial branch or central pulmonary artery (patients 15-18, and 21, Figure 4, A-D). This was identified before, during, or several years after the Fontan. For most, central pulmonary stenosis was subclinical or corrected at the time of Fontan; however, 1 patient developed significant early central pulmonary artery stenosis (patient 21). This patient had an interrupted IVC with a Kawashima-Glenn placed at the time of BCPA. This central stenosis had impaired hepatic factor perfusion to the left lung, resulting in pulmonary arteriovenous malformations (Figure 4, E-G). This complication was unamenable to angioplasty, and the patient required an early Fontan at 1.5 years old. Of these 7 patients reviewed, only 2 did not develop central stenosis. They had the left cavopulmonary anastomosis placed centrally at the bifurcation of the main pulmonary artery and received additional contributions to the pulmonary circuit from retained systemic to pulmonary shunts. Additional complications can be found in Table 3, and these results suggest that central pulmonary stenosis may be more pervasive in patients with BCPA than previous reports. Our center believes that SVC translocation restores “normal” anatomy and mitigates such risks. Future studies with larger samples are necessary to leverage this comparison group with patients who receive translocations.

Figure 4.

Catheterization after bilateral cavopulmonary anastomosis. A-B, patient 17, mild narrowing in medial right pulmonary artery without obstructed flow. C-D, patient 18, moderate narrowing of medial right pulmonary artery. E-F, Patient 21, occlusion of central left pulmonary artery. Ground glass opacities left lower lung (F) consistent with bubble study (G) for arteriovenous malformations.

Concerning additional surgical techniques, Toronto has advocated for the V-anastomosis approach at the time of BCPA. Honjo and colleagues^15,17 reported improved rates of reintervention, death, and transplant. Indeed, the 2 patients without evidence of central PA hypoplasia/stenosis had their LSVC placed centrally at the MPA-left pulmonary artery bifurcation (Table 3). Yet, this technique is limited. To make the RSVC V-anastomosis, it must pass very proximal to the ascending aorta. This may increase the risk of compression from proximal neoaorta dilation.¹⁸ By performing a translocation, the SVC crosses the aorta at the level of the arch, where dilation is less pronounced,¹⁸ and would be at a lower risk of compression by a neoaorta. In addition, by performing a translocation, we can ensure that superior and inferior venous return converge on the same pulmonary artery at the time of Fontan. A result associated with improved outcomes in computational fluid dynamics studies.¹⁵ Although many have previously used the V-anastomosis, we believe that a translocation is superior. Future investigations are necessary to understand these differences.

Translocation in Anticipation of Transplant

In the present era, up to 50% of patients with single-ventricle will require a transplant by 40 years of age.¹⁹ For recipients of bilateral SVC, restoring satisfactory caval anatomy has many technical challenges. For heterotaxy recipients, Duong and colleagues²⁰ found that the adjusted ischemic time was 19 minutes longer than situs solitus recipients. They attributed this to the complex venous reconstruction required. Aronowitz and colleagues²¹ found that 19% of bilateral SVC transplants required reinterventions for SVC obstructions. Although only 1 BCPA in an adult is planned for transplant, a proactive SVC translocation has the potential to reduce ischemic times and will be paramount to improving outcomes in those ultimately requiring a donor heart.

Limitations and Future Directions

A major challenge in this series is the heterogeneity and small sample size, as in any single-center series that strives to restore aspects of biventricular circulation. Therefore, a rigorous comparison of those with and without translocation was not feasible. In addition, follow-up assessment of our patients’ anatomy is routinely performed by echocardiography, which is limited. For those who received catheterization studies, the translocation patency and function were excellent, but this was not feasible in all who underwent long-term follow-up. Moreover, central stenosis typically occurs in a small and isolated region of pulmonary arteries, making a quantitative assessment challenging. Finally, long-term follow-up with catheterization studies will aid in understanding caval dimensions and accommodation to flow over time.

Conclusions

The present study is an account of our surgical experience deploying caval translocation in patients with bilateral SVCs. We report the largest, most heterogeneous cohort to date, highlighting technical considerations that will certainly aid our colleagues in broad implementation. Through this account, we described 3 major merits: (1) translocation simplifies biventricular repairs; (2) translocation may abrogate the risk of central pulmonary artery stenosis and reduce pulmonary artery distortion at the time of CPA; and (3) a translocation will improve recipient anatomy in anticipation of complex patients who may ultimately require transplant. Finally, as our understanding of ventricular recruitment strategies improves and are broadly implemented, caval translocation may become fundamental.

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Conflict of Interest Statement

The authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Supplementary Data

Audio

Audio 1

This is an audio recording of the presentation of the associated abstract and discussion. The abstract presentation ends at 7:03 and the discussion begins at 7:05.

Video 1

Video of the presentation in the AATS annual meeting with audio. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00373-6/fulltext.

Appendix E1

Table E1.

Patient demographics and technical considerations as to cannulation and timing of translocation for each patient

No.	Demographic	Underlying diagnosis	Presence of bridging vein	Cannulation strategy		Timing of translocation (with relation to intracardiac components)	SVC translocated	Relation to aorta
				RSVC	LSVC
Translocation in commonly corrected defects
1	23-y male	Absent coronary sinus, ASD, bicuspid pulmonic valve with stenosis		Directly cannulated	Directly cannulated	After	LSVC	Anterior
2	6-mo female	Translational AVSD, LSVC draining to left atrium, common atrium		Directly cannulated	Directly cannulated	After	LSVC	Anterior
3	5-mo female	Shones complex, aortic coarctation, VSD, ASD, PAPVR to RSVC LSVC to unroofed coronary sinus		Directly cannulated	Directly cannulated	After	LSVC	Anterior and superior
4	44-d female	VACTERL syndrome TOF, ASD, anomalous hepatic venous return		Not canulated, instead a vent was placed through the right atrium	Through coronary sinus	After	LSVC	Anterior
5	1.5-y female	ASD, mitral stenosis/regurgitation		Cannulated through right atrium	Not cannulated (right atrium)	After	LSVC	Anterior
6	13-y male	ToF with pulmonary atresia, right PAPVR, unroofed coronary sinus		Directly cannulated	Not cannulated	After correction of PAPVR and Before VSD	LSVC	Posterior
Translocation in biventricular conversions
7	6-y female	Dextrocardia, L-TGA, ASD, subpulmonary VSD (DORV), bicuspid aortic valve, juxtaposed atrial appendages, Interrupted aortic arch		After dissection from right atrium	Through coronary sinus	After	RSVC	Anterior
8	32-y male	Heterotaxy, complete AVSD, D-TGA, pulmonary stenosis, TAPVR, separate hepatic veins		Directly cannulated	Directly cannulated	After	RSVC	Posterior
9	3-y female	Heterotaxy, dextrocardia, L-TGA, balanced A/V canal, right aortic arch		Directly cannulated	Directly cannulated	After	LSVC	Posterior
10	17-m female	Heterotaxy, dextrocardia, atrial and visceral situs inversus, TGA with AV/VA discordance, right aortic arch, ASD, DORV with pulmonary atresia.		Clamped, not cannulated	Directly through left sided right atrium	After	RSVC	Anterior
11	11-mo female	Heterotaxy, polysplenia, left atrial isomerism, multiple VSDs, DORV, dysplastic pulmonary valve, PAPVC to the right atrium, large aortopulmonary window.		Right atrium	Through coronary sinus	After	LSVC	Anterior
Translocation with cavopulmonary shunt
12	1-y male	Heterotaxy, DORV, TAPVR, common AV valve		Directly cannulated	Not cannulated and instead translocated early in procedure	Before	LSVC	Anterior
13	4-mo female	Pentalogy of Cantrell, ectopia cordis, DORV, mitral hypoplasia, LV hypoplasia		Right atrium	Right atrium	Before	LSVC	Anterior
14	6-mo female	DORV, LV hypoplasia, severe pulmonary stenosis, mitral stenosis, restrictive ASD		Right atrium	Not cannulated	After	LSVC	Anterior

RSVC, Right superior vena cava; LSVC, left superior vena cava; SVC, superior vena cava; ASD, atrial septal defect; VSD, ventricular septal defect; PAPVR, partially anomalous venous return; TOF, tetralogy of Fallot; TGA, transposition of the great arteries; DORV, double-outlet right ventricle; AVSD, atrioventricular septal defect; TAPVR, total anomalous pulmonary venous return; AV, atrioventricular; VA, ventriculoarterial; LV, left ventricle.