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J Thorac Cardiovasc Surg 2007;133:1090-1092
© 2007 The American Association for Thoracic Surgery

Brief Communication

Pulmonary and aortic root translocation in the management of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction

Sheng-shou Hu, MD, PhD*, Shou-jun Li, MD, PhD, Xin Wang, MD, PhD, Li-qing Wang, MD, PhD, Hui Xiong, MD, PhD, Li-huan Li, MD, Fu-xia Yan, MD, Xu Wang, MD, PhD

Department of Cardiovascular Surgery, Cardiovascular Institute and Fu-Wai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.

Received for publication February 18, 2006; revisions received April 7, 2006; accepted for publication April 11, 2006.

* Address for reprints: Sheng-shou Hu, MD, PhD, Department of Cardiovascular Surgery, Cardiovascular Institute and Fu-Wai Hospital, Beijing 100037, P. R. China. (Email: huss{at}163bj.com; xinwang_2002{at}hotmail.com).


Figure 1
Dr Hu


The Nikaidoh procedure, as an alternative to the Rastelli operation for dealing with transposition of the great arteries (TGA) with ventricular septal defect (VSD) and pulmonary stenosis (PS), could obtain a superior anatomic result.1,2Go However, the extracardiac conduit is unable to grow and is inevitably calcified; thereafter, the patients required reoperation. We report our experience with a novel modification in which the native pulmonary valve was preserved to address these problems.

Clinical Summary

Since December 2004, 4 boys underwent surgical repair of TGA with VSD and PS at our heart center. The patients’ demographic characteristics and clinical findings are presented in Table 1. All the patients had follow-up.


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  		TABLE 1 The patients’ demographic characteristics and clinical findings
 
Definitive repair was carried out during moderate hypothermia with cardiopulmonary bypass. The ascending aorta and the pulmonary trunk were transected above the sinotublar conjunction. The coronary arteries were mobilized and detached. The aortic root and pulmonary root, including the semilunar valves, were excised beneath the annular level from the ventricles (Figure 1, A). In patients 2 and 4, who had atrioventricular discordance, the anterior part of the pulmonary annuli was untouched, and only the posterior part of the pulmonary root was dissected to avoid injury of the conduction tissue (Figure 1, C). The subvalvular stenosis was relieved by resecting the conal septum. A Dacron patch and 5/0 Prolene running sutures (Ethicon, Inc, Somerville, NJ) were used to close the VSD. Subsequently, the detached aortic root was translocated posteriorly to the original pulmonary trunk position, and coronary arteries were reimplanted. After the Lecompte maneuver was performed, the aortic continuity was reestablished. The detached pulmonary root was then translocated anteriorly to the right ventricular outflow tract (RVOT). The pulmonary root was incised along its anterior wall, and a monocusp bovine jugular vein patch was used to enlarge the RVOT (Figure 1, B). Also, in the second and fourth patients, with atrioventricular discordance, an atrial switch operation (Senning procedure) was performed.


Figure 1
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  		Figure 1. Diagram of the modification of the Nikaidoh procedure. A, The ascending aorta and the pulmonary trunk were transected. The coronary arteries were detached. The aortic and pulmonary roots were dissected out. B, The ventricular septal defect (VSD) was closed, and the aortic root was translocated to the left ventricular outflow tract (LVOT). The anteriorly translocated pulmonary root was enlarged. C, In a patient with atrioventricular discordance, the anterior part of the pulmonary annuli was untouched, and only the posterior part of the pulmonary root was dissected. RVOT, Right ventricular outflow tract.

 
All patients survived the operation and were discharged from the hospital. There were no major complications in this series. The third patient was supported with extracorporeal membrane oxygenation because of a poor heart function on the third postoperative day; extracorporeal membrane oxygenation was weaned smoothly on the seventh postoperative day. All the patients had normal heart rhythm at discharge.

At a median follow-up of 5.5 months, all 4 patients were alive. Echocardiography demonstrated that all the patients had normal ventricular function. The median left ventricular ejection fraction value was 73% (range, 63%-85%). No residual aortic stenosis or insufficiency was found in any patient. Patients 2 and 4 had mild pulmonary insufficiency. Patient 4 had a 1.2-mm residual VSD. All the patients had normal heart rhythm during the follow-up period.

Discussion

In 1984, the Nikaidoh procedure was introduced to correct TGA with VSD and PS.1Go It involves aortic translocation and biventricular outflow tract reconstruction. The Nikaidoh procedure results in more normally aligned right and left ventricular outflow tracts, which theoretically should result in better intracardiac flow dynamics and should, in turn, result in improved outcomes over the longer term. However, growth incapability of the RVOT and pulmonary insufficiency are still main complications that require reoperation.

In comparison with the original technique of the Nikaidoh procedure, our method described herein has the following advantages. First, the pulmonary root with the preserved valve was dissected out and relocated to the normal anatomic position to the reconstructed RVOT, and the translocation of the native pulmonary root would probably have growth potential and best preserve valve function. Thus this modification might minimize the pulmonary insufficiency and allow growth of the pulmonary root. However, this modification could be used only in those whose pulmonary roots have no more than moderate stenosis; otherwise, the severely hypoplastic pulmonary artery and annuli are unlikely to grow. Second, in our modified procedure, similar to that used by others,3Go the coronary arteries are reimplanted. Two patients had difficult coronary artery anatomy (coronary patterns of patients 1 and 2, respectively; Table 1), and there were no adverse results related to the coronary insufficiency. Therefore we believe that by using this modified technique, aortic translocation could be performed in almost all the patients with difficult coronary patterns.

In summary, the modification of the Nikaidoh procedure that preserves the native pulmonary valve might minimize the postoperative pulmonary insufficiency. The procedure might also allow growth of the pulmonary root and therefore decrease the need for reoperation. However, the long-term results warrant further follow-up studies.

References

  1. Nikaidoh H. Aortic translocation and biventricular outflow tract reconstruction. J Thorac Cardiovasc Surg 1984;88:365-372.[Abstract]
  2. Nikaidoh H, Leonard SR. Aortic translocation and biventricular outflow tract reconstruction for d-transposition associated with ventricular septal defect and pulmonary stenosis: a follow-up. Presented at: Third World Congress of Pediatric Cardiology and Cardiac Surgery; May 28, 2001; Toronto, Canada.
  3. Morell OV, Jacobs PJ, Quintessenza AJ. Aortic translocation in the management of transposition of the great arteries with ventricular septal defect and pulmonary stenosis: Results and follow-up. Ann Thorac Surg 2005;79:2089-2093.[Abstract/Free Full Text]



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