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J Thorac Cardiovasc Surg 2007;133:461-469
© 2007 The American Association for Thoracic Surgery
Surgery for Congenital Heart Disease |
University of Texas, Southwestern Medical Center at Dallas, Tex.
Received for publication September 6, 2006; revisions received October 2, 2006; accepted for publication October 9, 2006. * Reprint requests: Thomas Yeh Jr, MD, PhD, The University of Texas, Southwestern Medical Center at Dallas, Children’s Medical Center Dallas, 1935 Motor Street, Suite E03-320.Z, Dallas, TX 75235 (Email: yehjr{at}aol.com).
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Abstract |
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METHODS: Nineteen patients underwent a Nikaidoh procedure at a median age of 3.3 years (0.9-9.3 years). The native aortic valve was translocated from the right to the left ventricular outflow tract by full (n = 6) or partial (n = 13) mobilization of the aortic root. Seven patients with partial mobilization had the right coronary artery reimplanted as a button. The conal septum was divided in 13 patients. The right ventricular outflow tract was reconstructed with either a homograft (n = 4) or a right ventricular outflow tract patch (n = 15). The median follow-up was 11.4 years (0.1-23 years), and the median age at follow-up was 17.4 years (1-30 years). Left ventricular outflow tract obstruction and aortic insufficiency were assessed by echocardiography.
RESULTS: One patient died of right coronary arterial ischemia. All remaining patients (95%) survived. The median survival was 13.6 years (longest, 23.0 years). Seven right ventricular outflow tract reoperations were required in 5 patients (6 with obstruction and 1 with pulmonary insufficiency). No reoperations have been performed on the left ventricular outflow tract or aortic valve. No patient had any left ventricular outflow tract obstruction or aortic insufficiency more than mild (mild in 9 patients, trivial in 3 patients, and absent in 6 patients).
CONCLUSIONS: Midterm actuarial survival was 95% after the Nikaidoh procedure. Reintervention for the right ventricular outflow tract is more common when valved conduits are used versus valveless reconstruction; however, the Nikaidoh procedure provides complete freedom from important aortic insufficiency and left ventricular outflow tract obstruction.
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Introduction |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionsReferences |
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have been notable for continuing late mortality. In particular, the development of left ventricular outflow tract (LVOT) obstruction caused by the natural tendency of VSDs to close over time, as well as the inability of the artificial material used to construct the LVOT tunnel to grow, remains a significant cause of morbidity and mortality.4,5 Kreutzer and colleagues5 suggest that left ventricular dysfunction plays an important role in the disappointing results after the Rastelli operation. The additional limitations of pulmonary homograft reconstruction of the right ventricular outflow tract (RVOT) are well known.
As a result, a search for modifications of and alternatives to the Rastelli procedure has led to a variety of options to manage the LVOT (Table 1). Dearani and colleagues4 emphasize the importance of VSD enlargement when performing the Rastelli procedure. Rubay and colleagues6 proposed the réparation á l’étage ventriculaire (REV) procedure, a modification of the Rastelli procedure that emphasizes the importance of conal resection. We proposed aortic translocation7 after a patient undergoing the Rastelli procedure died with biventricular outflow tract obstruction. We were motivated by the complete RVOT mobilization described by Kreutzer and colleagues’8 for use as a right atrial to pulmonary artery conduit in tricuspid atresia, as well as reports of the Ross procedure for LVOT replacement.9
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or valveless autologous reconstruction as described by Nikaidoh7 or Lecompte and colleagues.11 The purpose of this report is to present the midterm results of the aortic translocation (Nikaidoh) procedure. We also discuss our results along with published outcomes of the Rastelli and REV procedures.
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Materials and Methods |
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In patients managed with the Nikaidoh procedure, 18 patients had d-TGA, VSD, and PS, and 1 patient had double outlet right ventricle, subpulmonary VSD, and PS. A conal septum was present in 13 of 19 patients. Preoperative palliation included atrial septostomies and systemic to pulmonary artery shunts. Fourteen balloon atrial septostomies were performed at a median patient age of 2 days. Two patients required no septostomy because their native atrial septal defects were sufficient. The use of septostomy could not be determined in 3 patients. Sixteen of 19 patients had systemic to pulmonary artery shunts (7 classic Blalock–Taussig, 8 modified Blalock–Taussig, and 1 central). Three patients required additional shunts.
The median age at the Nikaidoh procedure was 3.3 years (range 0.9-9.3 years, mean 4.2 ± 2.4). The mean weight and height were 16.1 ± 6.4 kg (range 9.8-35 kg) and 99 ± 15.7 cm (range 75-126 cm), respectively. The mean cardiopulmonary bypass and aortic crossclamp times were 246 ± 95 minutes and 105 ± 56 minutes, respectively. Two patients required brief circulatory arrest (14 and 8 minutes).
The technical evolution of the Nikaidoh procedure is described in Figure 1. Over time, 2 aortic root mobilization methods were used. Six patients had complete mobilization of their aortic root and both proximal coronary arteries. Thirteen patients had partial mobilization of their aortic root, leaving a pedicle of myocardium under the left main coronary artery, in theory to decrease the risk of bleeding at a point where 3 major suture lines converge (the aortic root anastomosis, VSD patch, and RVOT patch, Figure 1, Panel 6). In all patients, the stenotic pulmonary annulus was divided anteriorly. If a conal septum was present, it too was divided completely (Figure 1, Panel 1B). The LVOT was reconstructed by anastomosing the aortic root to the opened pulmonary annulus posteriorly (Figure 1, Panel 2A). In 13 patients, the anterior aortic root (Figure 1, Panel 2B) was anastomosed to the VSD patches of various types (6 polytetrafluoroethylene [Gore-Tex, WL Gore and Associates Inc, Newark, Del], 3 Dacron, 4 bovine pericardium). In 6 patients, the VSD was closed using the original right ventricular free wall under the aortic root without a patch. The RVOT was reconstructed with a pulmonary homograft by anchoring the medial wall of the distal main pulmonary artery to the ascending aorta in 4 patients (Figure 1, Panel 6) and overlaying a patch of pericardium to reconstruct the RVOT in 15 patients (Figure 1, Panel 7).
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The severity of other valvular regurgitation was graded according to guidelines published by the American Society of Echocardiography.13 A qualitative assessment of the right ventricle in comparison with the left ventricle in multiple views, in addition to measurement of the right ventricle in the short-axis view, was used to assess the presence of right ventricular dilation.14
Statistical Methods
Means are reported as mean ± standard deviation. Time-related freedoms from death and LVOT or RVOT reintervention were obtained using the Kaplan–Meier method. Time zero was either the date of birth or the date of the Nikaidoh procedure. The outcomes assessed were death, RVOT reintervention, and LVOT reintervention. Patients who had not reached a defined end point at last follow-up were censored. The survival estimates were plotted over time with 95% confidence intervals.
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Results |
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Six patients required late reoperation. One patient required mitral valve repair for endocarditis 1.6 years after the Nikaidoh procedure and is now 20.5 years old. The remaining 5 patients underwent reoperation primarily to address the RVOT. Two patients required 2 homograft replacements: 1 patient underwent reoperation 1.5 and 11.4 years after the Nikaidoh procedure and is now 17.4 years old, and 1 patient underwent reoperation 6.4 and 11.3 years after the Nikaidoh procedure (along with right atrial reduction, cryoablation, and pacemaker placement for atrial flutter) and is now 16.3 years old and in sinus rhythm. One patient required 1 homograft replacement 10.5 years after the Nikaidoh procedure (along with tricuspid annuloplasty and Maze procedure) and is now 16.5 years old. One patient required 1 homograft replacement 11.8 years after the Nikaidoh procedure and is now 22.1 years old. Finally, 1 patient required pulmonary valve placement 2.1 years after the Nikaidoh procedure (with an RVOT patch) and is now 7.7 years old.
Dysrhythmias
Atrial flutter developed acutely in 2 patients and 7 years postoperatively in 1 patient. Only 1 of these patients had right coronary ischemia requiring coronary transfer. Two patients underwent Maze procedures. All 18 survivors were in sinus rhythm at the time of their last follow-up. One patient had moderate tricuspid regurgitation; the remainder were trivial or mild. No patient with a history of atrial flutter had significant tricuspid regurgitation. Pulmonary insufficiency was present in 15 of 16 patients, although 2 cases of atrial flutter had no regurgitation. Right ventricular dilation was present in 12 of 16 patients; 1 patient with atrial flutter had no dilation. One of these patients required a pacemaker placement for short-lived sick sinus syndrome with junctional bradycardia after the Maze procedure. The incidence of atrial flutter in this cohort seems higher than we would have predicted.
Right Ventricular Outflow Tract Performance
Immediate RVOT performance varied by repair method. Four homografts functioned well immediately, but as expected, 2 of 4 homografts eventually required 1 or more replacements. In contrast when the RVOT was reconstructed with a patch, 53% of patients (8/15) required intraoperative revision, but 80% of these patients (12/15) have not required further RVOT reintervention to date. Twenty percent of patients (3/15) have undergone reoperation primarily for pulmonary insufficiency. One patient required homograft insertion for pulmonary insufficiency, a second homograft and the Maze procedure for atrial flutter, and a pacemaker placement for sick sinus syndrome. This patient is now in sinus rhythm and has good ventricular function. A second patient required a homograft and left pulmonary arterioplasty with residual VSD closure and a second homograft with a takedown of the Glenn shunt. A third patient underwent pulmonary valve insertion and pulmonary arterioplasty for mixed PS and insufficiency.
Actuarial freedom from RVOT intervention (Figure 2, B) shows that of 18 survivors, 5 have required RVOT reintervention, for a 64% freedom of reintervention at 15 years. Echocardiography in 17 patients showed that right ventricular dilation, RVOT obstruction or regurgitation, and tricuspid regurgitation were identical to findings commonly seen in patients undergoing RVOT surgery. Seventy-three percent of patients had RVOT regurgitation (moderate or severe in 60%, mild in 13%, and none in 27%). The systolic gradient across the RVOT was less than 30 mm Hg in 80% of the patients.
Coronary Arteries
Coronary artery performance also varied by subgroup. Six patients with full aortic root mobilization required no coronary arterial transfer. In contrast, of the 13 patients with partial aortic root mobilization, 7 required right coronary arterial transfer. Four operations were performed primarily, and the outcome was good. Three operations were performed when right coronary arterial insufficiency became evident after cardiopulmonary bypass. Two of these patients who underwent delayed transfer required ECMO. The left main coronary artery was not transferred in any patient. The 1 patient who died (after a period of ECMO support) had not undergone coronary arterial transfer and probably died of unrecognized right coronary artery insufficiency.
Left Ventricular Outflow Tract Performance
No patient required reoperation on the LVOT (Figure 2, B). Seventeen of 18 survivors were restudied with echocardiography. The LVOT was unobstructed with generally well-preserved systolic function (mean shortening fraction was 34% ± 5.7%). No patient had more than mild aortic insufficiency, ranging from none in 6 patients, to trace in 3 patients, and to mild in 8 patients. The material used to close the VSD exerted no effect on LVOT performance. The aortic annulus was dilated in the majority of patients (63%), but there were no signs of aortic valve distortion or significant regurgitation.
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Discussion |
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(W. G. Williams, personal communication, 2006), REV,3,11,15-19 and Nikaidoh20,21 procedures.
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report from Boston. Dearani and colleagues’4 series from the Mayo Clinic is included, although actuarial analysis excluded operative deaths. Of 231 Rastelli procedures, 71 patients died and 160 early survivors were analyzed. Had operative deaths been included, the Rastelli survival would have been further diminished. Unpublished Rastelli outcomes were also provided by W. G. Williams from Toronto (personal communication, 2006). The similarities in late mortality from 3 experienced centers argues that the Rastelli procedure may not be the ideal approach for d-TGA, VSD, and PS.
Réparation á l’étage ventriculaire procedure
Midterm results for similar periods of follow-up after the REV procedure have not been formally published; however, in a letter to the editor, Lecompte3 reported an operative mortality of 15% (21/139 patients) and an actuarial survival of 79% (7 late deaths, 1 noncardiac death) at 15 years. The causes of ongoing mortality were not delineated; however, this longitudinal mortality is concerning. Others have published excellent operative mortalities with the REV procedure as well, but reported follow-up remains brief.
Nikaidoh procedure
No investigator has reported late deaths or LVOT reintervention after the Nikaidoh procedure.7,20 In our series we have had 1 operative death and no late deaths. Morell and colleagues20 report 1 of 12 operative deaths and no late deaths. Although the Nikaidoh procedure has been criticized for its technical danger,22 midterm follow-up indicates that the Nikaidoh procedure is proving to be the safest option over the life of a patient. Although we agree it is a more technically challenging procedure, aortic translocation seems warranted in view of its superior long-term outcomes. We believe that morbidity can be minimized by lessons we have learned.
Right Ventricular Outflow Tract Considerations
Of patients receiving homograft reconstruction of the RVOT, half are undergoing the expected, repeated operations for RVOT obstruction and homograft replacement.
Patched reconstructions of the RVOT required intraoperative revision in 53% of the patients. We believe that the difficulty is in forcing a flat pericardial patch to assume a complex configuration that must curve not only around the long axis of the aorta but also from front to back to reach from the anterior ventriculotomy to the posterior main pulmonary artery. In addition, posterior movement of the ascending aorta and the forward movement of the pulmonary confluence can compromise the right pulmonary artery. In longer follow-up, however, the patches have remained relatively free of reintervention. The Lecompte maneuver has been reported by Morell and colleagues20 with excellent results. Although we have no experience with this option, care must be exercised to avoid disturbing the aortic sinotubular junction when transecting the aorta.
In midterm follow-up, the design of the Nikaidoh procedure does nothing to improve on outcomes using valved pulmonary conduits (conduit stenosis, insufficiency, and high reoperation rate) or on those using valveless RVOT reconstruction methods. With respect to valveless methods as ours, the REV as described by Rubay and colleagues,6 or the tube autograft described by Metras and Kreitmann,16 all demonstrate a low incidence of reintervention in the midterm; however, it seems likely that pulmonary valve implantations will ultimately be necessary, much the same as they are in other cases of free pulmonary insufficiency. The issue of whether valved conduits with their early reoperations, or valveless techniques with free pulmonary insufficiency but a lower incidence of early reoperation, will provide better longitudinal outcomes has yet to be answered. We believe that valveless options are outperforming valved conduits in the midterm.
Coronaries
In aortic translocation, we now transfer coronaries selectively when tension is apparent and preferably before weaning cardiopulmonary bypass. Coronary artery tension is directly related to the diameter of the pulmonary annulus; that diameter is the distance the aortic root must be moved (Figure 1, Panel 4A).7
In our original description, the aortic root was completely mobilized (Figure 1, Panels 1 and 4B). Later, to minimize a theoretic risk of bleeding at confluent suture lines, we began partially mobilizing the aortic root and preserving a pedicle of myocardium under the left main coronary artery (Figure 1, Panels 3, 4C, 5, and 6). In this review, we discovered that the only cases that required coronary artery transfer were a subset of patients in whom aortic roots were partially mobilized. Partial mobilization necessitates rotation of the aortic root around the left main coronary artery, preserving its alignment at the expense of right coronary arterial tension (Figure 1, Panel 4C). Fully mobilized roots can shift directly posteriorly without rotation and, we suspect, with less distortion (Figure 1, Panel 4B). No patient with full mobilization required coronary arterial transfer. We believe we may have avoided right coronary artery kinking by continuing to use full aortic root mobilization, which is our currently preferred technique. We continue to transfer any coronary artery that manifests evidence of tension or when right ventricular function seems abnormal after weaning from cardiopulmonary bypass.
Morell and colleagues20 routinely transfer both coronaries in aortic translocation. This may eliminate some of the coronary arterial insufficiency we have noted; however, even in midterm follow-up of the arterial switch, abnormalities in coronary arterial flow have been reported.23,24 Coronary ostial stenosis remains a concern, and for this and the reasons discussed next, we have not routinely transferred coronaries.
Left Ventricular Outflow Tract Considerations
After the Rastelli procedure, Kreutzer and colleagues5 reported an 84% freedom from LVOT reintervention at 15 years. In contrast, Dearani and colleagues4 note a 99% freedom from LVOT reintervention in survivors and attributes this to their low threshold for anterosuperior VSD enlargement and conal septal resection, but the actuarial survival in the series is 59% at 20 years, despite excluding a significant operative mortality. No comment is made on the presence of LVOT obstruction in the patients who died.4 The REV procedure seems to have a low incidence of LVOT obstruction (Metras and Kreitmann16 report 1 case of LVOT obstruction in 19 cases, and Lecompte3,17 reports 2 cases of LVOT obstruction in 111 survivors of the REV operation), but the operative and actuarial mortalities have been higher than those we observed with the Nikaidoh procedure.3 In addition to stable actuarial survival in midterm follow-up, the striking finding after aortic translocation has been the freedom from LVOT reintervention, with no patient having more than mild aortic insufficiency in midterm follow-up. Transection of the conal septum completely relieves any LVOT obstruction, which is an integral part of the procedure.
Morell and colleagues20 identified 3 cases of moderate aortic insufficiency in 11 patients who underwent operations at 6 months, 10 months, and 2 years. In a personal communication (2006), Morell relayed that the development of insufficiency was delayed in onset. del Nido21 also reported a case of moderate aortic insufficiency in an abstract. Although the aortic valves in our cohort are generally functioning well, we are circumspect about the potential for aortic insufficiency. In considering this issue, there are several technical differences between our approaches. We selectively reimplant only right coronaries, have not had to implant left coronaries, do not divide the ascending aorta, do not perform a Lecompte maneuver, and operate on slightly older patients. Morell harvests a free autograft (transecting the aorta and detaching the coronaries as buttons), reimplants the autograft by rotating 180 degrees, attempts to reimplant into the existing coronary ostia, performs a LeCompte maneuver, and reconstructs the RVOT with a direct right ventricle to pulmonary arterial connection. He has also decreased the lower age limit to 5 months. del Nido’s21 aortic root autograft technique also includes an extensive alteration of the native aortic root. These maneuvers may be more likely to disturb the aortic sinotubular junction or geometry of the aortic annulus. Finally, the plasticity of the younger aortic valve may make it more prone to distortion in younger patients. Although these theories are conjecture, the importance of preserving aortic valve function will be critical because freedom from LVOT reintervention seems to be the major strength of the Nikaidoh procedure.
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Conclusions |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionsReferences |
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RVOT performance after the Nikaidoh procedure is similar to other procedures using valved conduits or valveless methods and does not explain the improved survival in the management of d-TGA, VSD, and PS.
LVOT performance has been excellent, and in midterm follow-up, we see no evidence of LVOT obstruction or important aortic insufficiency after the Nikaidoh procedure. We speculate that this may translate into better left ventricle performance and thus better actuarial survival.
Ongoing referrals and excellent midterm follow-up were provided by several cardiologists involved in the ongoing care of these challenging patients. To these physicians, Ted Carlson, MD, David Fixler, MD, Ernest Kiel, MD, Pennock Laird Sr, MD, Edgar Newfeld, MD, John Pliska, MD, Deborah A. Schutte, MD, Thomas Weigel, MD, Damaris Wright, MD, we are deeply grateful. The authors are indebted to Osman Al Radi, MD, for his assistance in statistical analysis.
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