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J Thorac Cardiovasc Surg 2008;135:331-338
© 2008 The American Association for Thoracic Surgery
Surgery for Congenital Heart Disease |
Department of Pediatric Cardiovascular Surgery, The National Cardiovascular Institute and Fu Wai Hospital Beijing, Chinese Academy of Medical Science, and Peking Union Medical College, Beijing, China
Received for publication June 5, 2007; revisions received August 22, 2007; accepted for publication September 6, 2007. * Address for reprints: Sheng-Shou Hu, MD, PhD, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Science, Department of Cardiac Surgery, Beilishi Rd 167A, Beijing 100037, China. (Email: huss{at}vip.sohu.com; liuzgfwh{at}hotmail.com).
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Abstract |
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Methods: Between March 2004 and September 2006, a total of 30 consecutive patients underwent double root translocation procedures (modified Nikaidoh n = 11, REV n = 7, Rastelli n = 12). In the Nikaidoh procedure, both aortic and pulmonary roots were translocated. A single-valved bovine jugular vein patch was used to repair the stenotic pulmonary artery in both Nikaidoh and REV procedures. The Senning procedure was added for those with atrioventricular discordance.
Results: The Nikaidoh procedure was the most time-consuming in terms of mean cardiopulmonary bypass and aortic crossclamp times. The average mechanical ventilation time was significantly shorter in the Rastelli group (63.3 ± 89 hours) than that in the Nikaidoh group (188.7 ± 159 hours, P = .016), but not different from that in the REV group (76.4 ± 112.5 hours, P = .395). Two patients in the REV group and 1 in the Rastelli group died. There were no in-hospital or late deaths in the Nikaidoh group. Postoperative echocardiography demonstrated physiologic hemodynamics in the left ventricular outflow tract and normal heart function in the Nikaidoh group. Abnormal flow pattern in the left ventricular outflow tract was noted in both REV and Rastelli groups. There were no late deaths or reoperations in any group during follow-up.
Conclusion: The modified Nikaidoh procedure is a better surgical option for transposition of the great arteries, ventricular septal defect, and pulmonary stenosis in terms of physiologic cardiac hemodynamics. Its long-term benefits need to be evaluated with a larger number of patients and longer follow-up.
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Introduction |
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Clinical data, however, have revealed the long-term results of the Rastelli procedure to be far from optimal; most importantly, the reported long-term survival is surprisingly low, with a 20-year survival of only 52%.3,4 In 1982, Lecompte and colleagues5 introduced the Lecompte procedure (REV) technique to reconstruct the pulmonary outflow tract without using prosthetic conduit as an alternative for Rastelli candidates.5 Two years later, Nikaidoh6 proposed the idea of aortic translocation and biventricular outflow tract reconstruction for the management of TGA with VSD and PS.6 For various reasons, this technique has not been widely applied.7,8 Which procedure is the best choice for surgical management of TGA, VSD, and PS in terms of the operative feasibility and long-term results? It has become apparent that the fate of the reconstructed left ventricular outflow tract (LVOT) and RVOT plays an essential role in determination of prognosis. In this sense, there is no ideal surgical procedure for these lesions so far.
With the intent to preserve the competence and growth potential of the pulmonary valve and acquire a better long-term performance of the reconstructed biventricular outflow tract, we proposed the double root translocation technique for biventricular outflow tract reconstruction. This study compares the double root translocation (modified Nikaidoh) technique with modified REV and conventional Rastelli procedures in terms of operative feasibility, postoperative hemodynamics of the LVOT and RVOT, and early-term follow-up. Here we present the experience we gained, the problems we encountered, and lessons we learned.
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Materials and Methods |
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Table 1.
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Among patients treated with a modified REV procedure, the mean age at operation was 72.4 ± 44.9 months (range 19–13.3 years), and the mean weight was 15.9 ± 6.9 kg. Four patients had DORV with subpulmonary VSD, malposition of the great arteries, and PS; the other 3 had dextro-TGA, VSD, and PS, with CTGA in 2 cases. Associated lesions were multiple VSDs in 2 cases and ASD in 5.
Among patients who underwent a Rastelli procedure, the mean age at operation was 101.8 ± 104.3 months (range 19 months–25.3 years), and the mean weight was 23.8 ± 16.6 kg. Six patients had dextro-TGA, VSD, and PS; among them, 1 patient had CTGA. Five patients had DORV with subpulmonary VSD, malposition of the great arteries, and PS. Double-outlet left ventricle was diagnosed in 1 case. Associated lesions were multiple VSDs in 3 patients, ASD in 2, coronary arterial anomalies in 2, mitral insufficiency in 1, and pulmonary atresia in 1. One patient underwent a preliminary modified Blalock–Taussig shunt.
There were no significant differences among the groups in terms of mean age and weight at operation. Patient group was selected by random assignment.
Operative Technique
Median sternotomy and hypothermic cardiopulmonary bypass (CPB) with modified balanced ultrafiltration technique were routinely used. Cold histidine tryptophane ketoglutarat solution crystal cardioplegia solution (Custodiol; Dr F Köhler Chemie GMBH, Alsbach, Germany) was administered every 2 hours for myocardial protection. The technical modification of Nikaidoh procedure was that both aortic and pulmonary root were completely mobilized and translocated, the double root translocation technique.8 If the aorta and pulmonary artery are in anteroposterior relation, the coronary arteries and aortic root can be harvested and translocated en bloc. Otherwise, if the great vessels are side by side, detaching just one or both coronary arteries and reimplanting them at a different site in the aortic sinus during translocation should be considered (
Figure 1, A and B). In our series, the coronary arteries were detached and reimplanted in 5 of 11 patients. During pulmonary root harvesting, injury to the conductive tissue and mitral valve apparatus must be avoided. In those patients with CTGA, great care must be taken to avoid damage to the conductive tissue. The anterior portion of pulmonary annulus must be kept intact (not harvested) to avoid injury to the His branch or left bundle branch. Only the posterior portion of the pulmonary root can be dissected and harvested. In this case, one must try to maintain the integrity of the pulmonary leaflets. The orifice of the LVOT was opened anteriorly, and the conal septum was divided completely. The LVOT was reconstructed by anastomosing the aortic root to the opened LVOT orifice posteriorly. The anterior portion of the aortic root was sutured to the upper edge of the polyester fabric (Dacron) VSD patch. The RVOT was reconstructed by anchoring the anteriorly opened pulmonary annulus to the cephalad margin of the right ventriculotomy with 5-0 polypropylene suture in a running fashion (Figure 1, C); thus the posterior wall of the neopulmonary artery was created. A single-valved bovine jugular vein patch was tailored to repair RVOT and enlarge the stenotic main pulmonary artery, taking care that the valve of the bovine jugular vein patch should be in the same plane as the native pulmonary valves for competent neopulmonary valvular function.
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as shown in
Figure 2. The Lecompte maneuver was routinely performed in our cases. A monovalve bovine jugular vein patch was used to repair the RVOT and enlarge the hypoplastic main pulmonary artery. The Rastelli procedure we applied was a conventional one, and the extracardiac conduits we used were homograft in 5 cases (3 pulmonary and 2 aortic) and bovine jugular vein graft in 7 cases.
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Follow-up
All patients discharged from the hospital were followed up to the end date of the study (September 2006). The patients were contacted by telephone or direct interview in our outpatient clinic. Echocardiographic studies were performed at 3 and 6 postoperative months and then once each year. The latest follow-up echocardiograms were available for all survivors. The performance of the heart valves and LVOT and RVOT function were assessed by echocardiography. The severity of the valvular regurgitation was graded according to guidelines published by the American Society of Echocardiography.10
Statistical Analysis
Statistical analyses were performed with SPSS version 11.5 software (SPSS Inc, Chicago, Ill). All results are expressed as mean ± SD. The significance of differences between two groups was assessed with the unpaired Student t test.
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Results |
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Table 2).
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More patients in the Nikaidoh group than in the REV and Rastelli groups required prolonged mechanical ventilation support. The causes of prolonged mechanical ventilation support were low cardiac output syndrome, lung infection, stress ulcer, and renal dysfunction.
Postoperative Echocardiography
Echocardiography was performed for all patients before discharge, at 3 to 6 postoperative months, and then once each year. Postoperative echocardiography showed completely normal anatomy of the reconstructed LVOT after double root translocation in all cases, whereas a bending-shaped LVOT was noted in both REV (1 case of TGA) and Rastelli (6 cases of TGA) groups. Turbulence was also observed in the LVOT tunnel in 3 patients with TGA 18 months after the Rastelli operation. Interestingly, among those patients who had DORV, PS, and subaortic VSD, there were no apparent unfavorable shaped LVOTs or unphysiologic flow patterns in the LVOT tunnel in either the modified REV or Rastelli group. In the Nikaidoh group, 2 patients showed totally normal cardiac hemodynamics: competent aortic and pulmonary valves, physiologic flow pattern in the reconstructed LVOT and RVOT, and good ventricular function. One patient had mild aortic regurgitation, 3 patients had mild pulmonary insufficiency, and 6 had mild to medium pulmonary insufficiency. Five patients in the REV group had mild to medium (n = 3) or medium (n = 2) pulmonary insufficiency, whereas in the Rastelli group 3 patients showed a mild to medium pulmonary insufficiency and 2 showed severe pulmonary insufficiency.
Follow-up
The mean follow-ups were 7 months (range 2–26 months) in the Nikaidoh group, 6 months (range 2–11 months) in the REV group, and 18 months (range 6–30 months) in the Rastelli group. There were no late deaths, nor was reoperation required in any case.
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Discussion |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionsReferences |
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Clinical data, however, reveals at least three major limitations of the Rastelli technique. (1) It is not feasible for small children or those with unfavorable intracardiac anatomy. (2) Subsequent reoperation (to change the obstructed conduit) is inevitable. (3) Most importantly, the long-term survival is surprisingly low. Deterioration of the hemodynamic performance of LVOT or RVOT with time may account for these problems.3,4,11 To overcome the disadvantages inherent in the Rastelli technique, the REV and Nikaidoh procedures were introduced successively.5,6 Although the problem-causing valved conduit for RVOT reconstruction can be avoided in both procedures, the competency of pulmonary valve is sacrificed at the same time. We proposed a new method for biventricular outflow tract reconstruction—the double root translocation technique—as a modification of the Nikaidoh procedure.8 We also applied pulmonary root translocation to modify the REV procedure, similar to descriptions in the literature,10 with the aims of keeping the competence and growth potential of the native pulmonary valve and acquiring a better long-term hemodynamic performance of the reconstructed RVOT.
Technical Concerns
The most important issue of aortic root translocation is coronary artery manipulation. To avoid any kink or distortion imposing on the coronary arteries, complete mobilization of aortic root and coronary arteries is necessary. There must be no tension on or kinking of the coronary arteries after the aortic root is translocated. There should be no hesitation to detach the coronary artery (one or both sides) if the great vessels are in a side-by-side relationship. Otherwise, we agree with Nikaidoh's view12; that is, try to translocate the aortic root and coronary arteries en bloc to avoid coronary ostial stenosis caused by coronary reanastomosis. The aortic root should be relocated to the LVOT without any distortion to keep the aortic annulus in a natural geometry. We had a case of postoperative aortic insufficiency (mild in degree) caused by aortic root distortion. In this case there was tension on the right coronary artery during aortic root reattachment. We had to reroute the suture line to transfer the tension from coronary artery to aortic root to eliminate the tension imposing on right coronary artery, as a result of which the aortic annular was distorted. Another important issue concerning pulmonary root translocation is avoidance of damage to coronary arteries and the conductive tissue, especially in patients with CTGA. Great care must be taken to keep the excision away from the regions occupied by the His bundle and its primary branches.13 Usually, we did not resect the right anterior segment of the pulmonary annulus in these cases. There were no cases of complete atrioventricular block in our series, and we have performed 20 modified Nikaidoh procedures and 14 modified REV procedures to date. We routinely perform the Lecompte maneuver during pulmonary root translocation, because the neopulmonary root always lies anterior to the neoaortic root. In addition, if the ascending aorta is too long after being posteriorly translocated, a tubular segment of aorta can be resected if it is anteriorly compressing the pulmonary artery. The aortic autograft tissue can also be used to repair the hypoplastic pulmonary artery.14
We recommend using a homograft valved pulmonary patch to repair the RVOT and stenotic main pulmonary artery. Because of the limited availability of the homograft, however, we routinely use a single-valved bovine jugular vein patch. According to unpublished observations at our institution, this kind of single-valved bovine jugular vein patch has been doing well as a material for RVOT reconstruction 5 years after repair of tetralogy of Fallot. Its durability needs to be investigated with long-term follow-up.
Hemodynamics of LVOT and RVOT
For patients with TGA, VSD, and LVOT obstruction, the hemodynamic performance of the reconstructed LVOT and RVOT in the Nikaidoh group was more physiologically normal than that of the REV or Rastelli group. There was no abnormal flow pattern observed in the LVOT or RVOT after the modified Nikaidoh procedure. Turbulent blood flow in the LVOT was noticed, however, in both the REV and Rastelli groups. Through translocation of aortic and pulmonary roots, the left ventricle and aorta are aligned anatomically, as shown in the postoperative echocardiogram in
Figures 3 and 4. The case of the right ventricle and main pulmonary artery is just the same. In contrast, the LVOT reconstructed with the Rastelli technique is a long and bending tunnel (see Figure 5), especially in cases of unfavorable intracardiac anatomy. Likewise, the LVOT after REV procedure does not show normal geometry, even though the conal septum has been widely resected, which makes the left ventricle–aorta connection straighter (see Figure 6). Postoperative echocardiography in our series demonstrated this (
Figures 5 and 6). For patients who had DORV, PS, and subaortic VSD, however, no abnormal flow patterns were detected by echocardiography in the LVOT in both the REV and Rastelli groups, suggesting that the intracardiac tunnel in this subset anatomy is more favorable and less likely to have LVOT obstruction develop late.
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Patient Selection
The double root translocation technique should be applied in patients with anomalies of ventriculoarterial connection associated with VSD and PS, including complex TGA with VSD and PS and DORV with malposition of great arteries and PS. This technique can also be applied for patients who have contraindications for the Rastelli procedure because of unfavorable intracardiac anatomy, such as small right ventricle, inlet VSD, straddling tricuspid valve, or anomalous coronary anatomy. The modified REV technique is a good alternative treatment for patients with DORV, PS, and subaortic VSD. The Rastelli operation is better used for adult patients or large children with DORV, PS, subaortic VSD, and a large right ventricular cavity. In our institution, the modified REV technique is gaining in prevalence, whereas the Rastelli procedure is only used for patients with pulmonary atresia.
We suggest the modified Nikaidoh procedure for patients with anatomic contraindications to the Rastelli procedure, such as small right ventricle or remote VSD. For those with a large subpulmonary defect (absent conal septum), it is not feasible to resect both aortic and pulmonary roots, because the aortic and pulmonary annuli join together closely; in such cases, the modified REV procedure is a better alternative. Because it is an aggressive and delicate procedure, the optimal timing of double root translocation procedure is 6 months to 1 year of age. In contrast, the modified REV procedure is less aggressive and can be used in small infants.
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Conclusions |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionsReferences |
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Footnotes |
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References |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionsReferences |
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