Twenty-five years' experience of modified Lecompte procedure for the anomalies of ventriculoarterial connection with ventricular septal defect and pulmonary stenosis

Long-term results after the réparation à l'étage ventriculaire procedure for transposition of the great arteries and double-outlet right ventricle with pulmonary stenosis

OBJECTIVES

The purpose of this study is to describe the long-term results of the 'réparation à l'étage ventriculaire' (REV) technique for double-outlet right ventricle and transposition of the great arteries (TGA) with pulmonary stenosis (PS).

METHODS

Between 1980 and 2021, 157 patients underwent a REV procedure (median age and weight: 20.8 months and 7.7 kg). The most frequent anatomical presentation was the association between TGA, ventricular septal defect and PS (n = 116, 73.9%).

RESULTS

Sixty-seven patients (42.7%) underwent a Rashkind procedure, and 67 patients (42.7%) a prior surgical palliation (including 62 systemic-to-pulmonary artery shunts). Resection of the conal septum and/or ventricular septal defect enlargement was performed in 109 patients (69.4%). Thirteen patients (8.3%) died, including 4 during the first postoperative month and 2 after heart transplant. Overall survival at 40 years was 89.3%. Thirty-seven patients (23.6%) required 68 reinterventions on the right ventricular outflow tract (RVOT), including 49 reoperations, with a median delay of 9 years after the REV (8 months to 27 years). Twenty patients (12.7%) underwent RVOT valvulation (16 surgical and 4 interventional). Freedom from RVOT reintervention and reoperation at 40 years were 60.3% and 62.6%, respectively. Four patients (2.5%) required reoperation for left ventricular outflow tract obstruction, with a median delay of 4.8 years.

CONCLUSIONS

The REV procedure is a good alternative for TGA and double-outlet right ventricle with PS patients. Only a quarter of the patients required redo surgery on the RVOT. Reoperations for left ventricular outflow tract obstruction are scarce.

Transposition of the Great Arteries, Ventricular Septal Defect, and Pulmonary Stenosis: Modified REV versus Rastelli

The objective of this study was to evaluate and compare the results of the modified réparation à l'ètage ventriculaire (REV) and the Rastelli operation for the treatment of transposition of the great arteries (TGA), ventricular septal defect (VSD), and pulmonary stenosis (PS). Records of 38 patients who underwent the modified REV (n = 16) or the Rastelli operation (n = 22) for the treatment of TGA, VSD, and PS between 2010 and 2019 were reviewed. The median age was 2.2 years (range 0.6-8.0 years) and the median weight was 11.3 kg (range 6.4-22.0 kg). No in-hospital death occurred and there were 4 early reoperations (two in each group). Overall survival at 10 years was 97.4% (100% in Modified REV group and 95.5% in Rastelli group, P = 0.39). Freedom from left ventricular outflow tract (LVOT) reoperation was 100% in both groups. Freedom from right ventricular outflow tract (RVOT) reoperation was 100% in Modified REV group and 75.4% in Rastelli group (P = 0.073). Event-free survival was 100% in Modified REV group and 72.0% in Rastelli group (P = 0.048). The most recent echocardiography showed that LVOT peak gradient was less than 10 mmHg in all patients. In Modified REV group, 30.8% of patients (4/13) had either RVOT obstruction (RVOT peak gradient more than 40 mmHg) or moderate or severe pulmonary insufficiency, while conduit stenosis (peak gradient more than 40 mmHg) was found in 25.0% of patients (3/12) in Rastelli group. The modified REV and the Rastelli operation provide satisfactory early results, as well as long-term survival and LVOT performance. However, the modified REV has better RVOT performance.

Outcome of modified réparation à l'ètage ventriculaire (REV) based on anatomical characteristics for the anomalous ventriculoarterial connection with ventricular septal defect and left ventricular outflow tract obstruction

OBJECTIVES

The present study evaluated the results of the modified réparation à l'étage ventriculaire (REV) based on the individual anatomical and pathological findings of the patients with an anomalous ventriculo-arterial connection with ventricular septal defect (VSD) and left ventricular outflow tract obstruction.

METHODS

We reviewed a series of 24 patients who underwent modified REV between 2005 and 2019. Surgical indications included ventricles and atrioventricular valves suitable for biventricular repair, severe left ventricular outflow tract obstruction (peak gradient >30 mmHg), unrestrictive subaortic VSD and coronary arteries not suitable for reimplantation.

RESULTS

The mean follow-up time was 7.0 ± 4.2 years (range 0.5-14.1 years). Kaplan-Meier analyses showed that overall survival was 100% and freedom from any reoperation was 93.3% ± 6.4%. Longitudinal analyses of the available postoperative echocardiographic data showed that the left ventricular outflow tract peak gradient was less than 10 mmHg in all patients (15/15) and the left ventricular ejection fraction was more than 50% in 93.3% of patients (14/15). The right ventricular outflow tract peak gradient was less than 40 mmHg in 73.3% of patients (11/15).

CONCLUSIONS

The REV remains an option for selected patients despite the increasing use in recent years of the Nikaidoh procedure and its modifications. The surgical strategy needs to be determined by the specific anatomical and pathological findings of the patient. The modified REV had excellent long-term survival and freedom from reoperation for the treatment of anomalous ventriculo-arterial connection with VSD and left ventricular outflow tract obstruction. The long-term performance of the reconstructed left ventricular outflow tract and right ventricular outflow tract is satisfactory.

Long-Term Follow-Up of the Conal Flap Method for Tricuspid Malinsertion in Transposition of the Great Arteries With Ventricular Septal Defect and Pulmonary Stenosis

BACKGROUND

Rastelli and réparation à l'étage ventriculaire (REV) procedures have been applied for biventricular repair of transposition of great arteries with ventricular septal defects and pulmonary stenosis (TGA III). In some patients with TGA III, whose tricuspid valve (TV) chordae tendineae are attached to the infundibular septum, abnormal TV chorda insertion may cause intracardiac rerouting obstruction. For such cases, we performed a conal flap" (CF) procedure involving mobilization of the infundibular septum including TV chordae as a pedicled flap. This study evaluated the long-term outcomes of this CF method.

METHODS

Between October 1985 and December 1999, 17 consecutive patients with TGA III underwent a Rastelli-type or an REV-type procedure using CF. Median age at operation was 4.8 years (range, 1.5 to 14.0 years).

RESULTS

The mean follow-up period was 17.8 ± 7.2 years. One hospital death and one late death occurred. The freedom from death rates were 94.1%, 94.1%, and 85.6% at 5, 10, and 15 years, respectively. The freedom from death or reoperation rates were 94.1%, 55.8%, and 46.5% at 5, 10, and 15 years, respectively. No reoperations were performed for the left ventricular outflow tract (LVOT) or TV. The average LVOT maximum flow velocity was 1.26 ± 0.50 m/s. TV regurgitation was greater than mild in 3 patients (20%) and trivial to mild in 12 patients (80%). Thirteen patients were in New York Heart Association (NYHA) functional class I, and 2 patients were in NYHA functional class II.

CONCLUSIONS

The long-term outcomes, including the daily life activities, LVOT pressure gradients, and TV regurgitation grades, were excellent in patients who underwent Rastelli-type and REV-type procedures using CF for TGA III.