| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
J Thorac Cardiovasc Surg 2002;123:192-193
© 2002 The American Association for Thoracic Surgery
Letters to the Editor |
Pediatric Cardiology Unit Institut Hospitalier Jacques Cartier Rue du Noyer Lambert, 91300 Massy, France
To the Editor
I read with extreme interest the article by Kreutzer and associates
1 published in the August 2000 issue of the Journal. This article relates the extensive experience of one of the world's most prestigious surgical groups with the repair of transposition of the great arteries (TGA) associated with ventricular septal defect (VSD) and pulmonary outflow tract obstruction. The conclusions of this study are that the long-term results of the Rastelli procedure are extremely disappointing. However, as stated by the authors, this procedure "continues to be the most common choice worldwide."
In 1982, my colleagues and I 2 proposed another approach to this surgical challenge, which aimed at overcoming some of the limitations of the Rastelli procedure. This technique, which we called REV (réparation à l'étage ventriculaire), is based on the resection of the infundibular septum in all cases in which it is present. This permits the construction of a tunnel from the left ventricle to the aorta that is much shorter and more direct than in the Rastelli operation and allows freedom from most of the anatomic contraindications to this procedure. 3,4 The REV technique has had very little diffusion since its publication, probably because it has been interpreted, due to the name of the author, as a Rastelli operation without a conduit, using the so-called "Lecompte maneuver" that I described for the arterial switch. This confusion, once again surfacing in Kreutzer's article, would be unimportant had it no consequence on the surgical results. Unfortunately, I believe that it may have prevented some improvements in the surgical treatment of these complex cases.
From the beginning of my experience with the REV procedure, I operated on 139 patients (mean age 3.1 years; 33 younger than 1 year; 38 between 1 and 2 years old). Many of these patients had previously been refused by other groups for the Rastelli repair. The operative mortality was 15% (21 patients). This figure is higher than in Kreutzer's series, probably because my group accepted many patients with complex types of anomalies of ventriculoarterial connection or associated lesions (atrioventricular valve anomalies, inlet VSD, multiple VSDs, restrictive VSD). However, at a median follow-up of 7.6 years (4 months to 20 years), there were 7 late deaths (1 of them from noncardiac origin) versus 17 in the Rastelli group at a slightly longer follow-up (8.5 years). The estimate of survival (Kaplan-Meier method) was 79% at 15 years. I did not find the exact number in Kreutzer's article, but the curve indicates a survival less than 70%. I observed only 2 cases of left ventricular outflow tract obstruction, both in very unusual types of ventriculoarterial connection, and no patient with "classic" TGA had this complication. Eleven patients underwent reoperation for this reason in the Rastelli group. Except in 1 patient who had a myocardial infarction at operation (and who ultimately died after heart transplantation), ventricular function was normal during the entire follow-up. In 1988 (unpublished study) my colleagues and I studied left ventricular function in 18 of our survivors, using the methods described by Graham and associates 5 for the study of 11 patients treated by the Rastelli procedure. Unlike the observations noted in the Rastelli series, ventricular function was strictly normal in all children treated by REV. This is not illogical since, morphologically, the left ventricular outflow tract of these patients looks nearly normal because of natural realignment of the aortic orifice with the left ventricular cavity. This normal appearance is probably made possible by the resection of the infundibular septum—by far the main advantage of the REV operation over the Rastelli repair. In the discussion of their article, Kreutzer and coworkers state that, in the past 10 years, VSD enlargement "is done almost routinely." However, they remain faithful to the classic resection of the anterosuperior margin of the VSD. I really believe that this technique of resection is more dangerous and less efficient than the excision of the infundibular septum: what is important is not only the diameter of the VSD but also the geometry of the left ventricle–aorta tunnel. It is not logical to leave any piece of muscle between the VSD and the aortic orifice that makes this tunnel longer and less direct, thus increasing the risk of obstruction and, in all cases, compromising left ventricular function. I agree with Kreutzer's suggestion that left ventricular dysfunction plays an important role in the disappointing results of the Rastelli operation. May I suggest that this could be due to a less than optimal repair of the left ventricular outflow tract and that it could be avoided?
The final benefit of the technique of intraventricular reconstruction in the REV procedure is that the tunnel does not bulge in the right ventricular cavity: this is probably beneficial to right ventricular function and permits the direct reimplantation of the pulmonary trunk on the infundibular incision. Before I read Kreutzer's article, I was not convinced that this technique of pulmonary outflow tract reconstruction was really an advantage over the use of a conduit in the Rastelli operation: we had to reoperate on 18 patients to enlarge the right ventricular outflow tract. However, the results are even worse when a valved conduit is used: there were 44 reoperations for conduit stenosis in the Rastelli group.
The difference in results between the two surgical approaches is best illustrated by the comparison of the probability of freedom from death or reintervention at 15 years: about 20% in the Rastelli group compared with 61% in the REV group.
Kreutzer's article illustrates the results of the perfect observance of surgical orthodoxy. In view of the long-term results, I wonder whether this observance is still justified?
12/8/117833
References
This article has been cited by other articles:
|
|
 |
|
  T. Yeh Jr, C. Ramaciotti, S. R. Leonard, L. Roy, and H. Nikaidoh The aortic translocation (Nikaidoh) procedure: Midterm results superior to the Rastelli procedure J. Thorac. Cardiovasc. Surg., February 1, 2007; 133(2): 461 - 469. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N T Wijesekera, M N Sheppard, and M J Mullen Candida endocarditis with mycotic pulmonary emboli following re-do Rastelli operation Heart, June 1, 2004; 90(6): e34 - e34. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 W. G. Williams, B. W. McCrindle, D. A. Ashburn, R. A. Jonas, C. Mavroudis, E. H. Blackstone, and the members of the Congenital Heart Surgeon's Soci Outcomes of 829 neonates with complete transposition of the great arteries 12-17 years after repair Eur. J. Cardiothorac. Surg., July 1, 2003; 24(1): 1 - 10. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Kreutzer Rastelli repair for transposition of the great arteries J. Thorac. Cardiovasc. Surg., April 1, 2003; 125(4): 974 - 974. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
