Is There an Ideal Age or Weight for the Warden Procedure in Patients With Partial Anomalous Pulmonary Venous Return?

Abstract

The Warden procedure is a common surgical approach for repairing partial anomalous pulmonary venous return (PAPVR). However, it may be complicated by cavoatrial anastomosis obstruction. This study evaluates outcomes of the Warden procedure and identifies optimal age and weight thresholds to minimize reintervention risk. A retrospective cohort analysis was conducted on 136 patients undergoing the Warden procedure for PAPVR at Bambino Gesù Children's Hospital (1996-2024). Reintervention was defined as any catheterization or surgical procedure involving the superior vena cava (SVC). Receiver operating characteristic curves were utilized to assess the influence of age and weight on reintervention risk. Patients had a median age of 8.2 years (interquartile range, 4.1-12.1 years). No deaths were reported. Two early reoperations were required: one for intracardiac patch dehiscence and another for significant SVC-right atrium appendage anastomosis obstruction. Six patients (4.4%) required transcatheter intervention with a bare metal stent for SVC-right atrium anastomosis obstruction 2.3 years (interquartile range,1.7-3.0 years) after the indexed procedure. Receiver operating characteristic analysis identified an age cutoff of 4.4 years (area under the curve, 0.898) and a weight cutoff of 17.1 kg (area under the curve, 0.894) as significant predictors of reintervention, with younger age (P = .004) and lower weight (P = .015) correlated with higher risk. Mean follow-up in the cohort was 6.5 ± 6.6 years. While the Warden procedure is effective for PAPVR repair, patients younger than 4.4 years or weighing less than 17.1 kg are at increased risk for SVC reintervention. Delaying repair until these thresholds are reached is recommended unless clinical indications necessitate earlier intervention.