The role of aortic translocation in the management of complex transposition of the great arteries

Optimizing Surgical Selection for Transposition With Left Ventricular Outflow Tract Obstruction

BACKGROUND

Studies that have assessed the Rastelli and Nikaidoh operations for transposition of the great arteries (TGA) with obstructed left ventricular outflow tract obstruction (LVOTO) have not fully evaluated the anatomic drivers that may contribute to surgical selection. We present our procedural selection process for optimizing outcomes of complex TGA in the modern era.

METHODS

This is a single-center, retrospective study that included pediatric patients who underwent either a Nikaidoh or Rastelli operation for the treatment of TGA-LVOTO, congenitally corrected TGA-LVOTO, or double-outlet right ventricle TGA type-LVOTO from June 2004 to June 2021.

RESULTS

There were 34 patients stratified by Nikaidoh (n = 16) or Rastelli (n = 18) operation. The incidence of all postoperative complications and mortality was low, and the incidence of complications between the groups was similar. Patients were more likely to have undergone a Nikaidoh than a Rastelli if they had a pulmonary annulus >5 mm (87.5% vs 11.1%), anteriorly/posteriorly oriented great vessels (88% vs 8%), remote (80% vs 11%) or restrictive (75% vs 6%) ventricular septal defect, and right ventricular hypoplasia (50% vs 0%; all, P < .05). The resulting rates of reoperation were similar between the groups (44.0% vs 37.5%; P = .24) and largely composed of conduit replacements in the Rastelli patients and valvular repairs or replacements in the Nikaidoh group. Rates of catheter-based interventions were also similar.

CONCLUSIONS

These findings suggest that for the optimal treatment of conotruncal anomalies with discordant ventriculoarterial connections, procedural selection should be based on pathoanatomic criteria that can ensure patients undergo the operation most suited to their anatomy.

Utilization and Outcomes of the Nikaidoh, Rastelli, and REV Procedures: An analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database

BACKGROUND

Aortic Root Translocation (Nikaidoh), Rastelli, and Réparation à l'Etage Ventriculaire (REV) are repair options for transposition of the great arteries (TGA) with VSD and left ventricular outflow tract obstruction (VSD-LVOTO) or double outlet right ventricle (DORV) TGA type (DORV-TGA).

METHODS

This retrospective study using the Society of Thoracic Surgeons Congenital Heart Surgery Database evaluates surgical procedure utilization and outcomes of patients undergoing repair of TGA-VSD-LVOTO and DORV-TGA with a Nikaidoh, Rastelli, or REV procedure.

RESULTS

293 patients underwent repair at 82 centers (January 2010-June 2019). Most patients underwent a Rastelli (n=165, 56.3%) or a Nikaidoh (n=119, 40.6%) operation; only 3.1% (n=9) underwent a REV. High-volume centers performed the majority of the repairs. Fewer Nikaidoh than Rastelli patients had prior cardiac operations (n=57; 48.7% vs n=102; 63.0%, p=0.004). Nikaidohs had longer median cardiopulmonary bypass (227 minutes [interquartile range (IQR) 167-299] vs 175 minutes [IQR 133-225], p<0.001) and median aortic cross clamp times (131 minutes [IQR 91-175] vs 105 minutes [IQR 82-141], p=0.0015). Operative mortality was 3.1% (95% confidence interval (95% CI) 1.0-7.0%; n=5) for Rastelli, 4.4% (95% CI 1.4-9.9%; n=5) for Nikaidoh, and 11.1% (95% CI 0.3-48.3%, n=1) for REV. The rates of cardiac arrest, unplanned reoperation, mechanical circulatory support, prolonged ventilation, and permanent pacemaker placement were higher in the Nikaidoh population but with 95% CIs overlapping those of the other procedures.

CONCLUSIONS

Rastelli and Nikaidoh procedures are the prevalent repair strategies for patients with DORV-TGA and TGA-VSD-LVOTO. Most are performed at high volume institutions and early outcomes are similar.

Nikaidoh operation for transposition of the great arteries with a ventricular septal defect and pulmonary stenosis

The optimal surgical management of patients with transposition of the great arteries with a ventricular septal defect and pulmonary stenosis remains challenging. When compared to other surgical options, the Nikaidoh procedure results in a 'more normal' anatomic result, with better alignment of the right and left ventricular outflow tracts. Also, the pulmonary outflow is less likely to be compressed by the sternum, a major issue associated with the Rastelli repair. This technique is especially useful in the presence of an inlet or restrictive ventricular septal defect, a hypoplastic right ventricle, a straddling atrioventricular valve and/or anomalous coronary anatomy interfering with a distal right ventricular outflow tract incision.

Relief of right ventricle to pulmonary artery conduit compression by chest wall resection

Many congenital heart defects require reconstruction of the right ventricular outflow tract utilizing a right ventricle to pulmonary artery conduit. One of the challenges with these conduits is the development of conduit stenosis. This phenomenon is quite common and typically results from a combination of progressive calcification, fibrosis, and/or the relative size mismatch that occurs with patient growth. However, extrinsic compression is much less common and a much more difficult problem to address. Chest wall resection and reconstruction is an option for alleviating external conduit compression that provides good results.

The aortic translocation (Nikaidoh) procedure: Midterm results superior to the Rastelli procedure

OBJECTIVE

Midterm follow-up is analyzed after the aortic translocation (Nikaidoh) procedure, an alternative to the Rastelli procedure for ventriculoarterial discordance, ventricular septal defect, and pulmonary stenosis.

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.

[Progress in pediatric cardiology and congenital heart defects]

We present a review of progress reported in the fields of pediatric cardiology and congenital heart disease between July 2004 and July 2005. The review covers diagnosis, medical treatment, interventional cardiology, and surgery. Among advances in diagnosis, we highlight new diagnostic imaging methods such as three-dimensional echocardiography, magnetic resonance imaging, CT angiography, and tissue Doppler imaging. In the area of fetal cardiology, we focus on advances in fetal interventions, such as percutaneous aortic valvuloplasty, percutaneous pulmonary valvuloplasty, and intact or restrictive atrial balloon septostomy. In interventional cardiology, we highlight advances in the application of percutaneous techniques to adult congenital heart disease to help solve problems resulting from previous surgery, and we review new devices for enabling the percutaneous closure of muscular and membranous ventricular septal defects. In cardiac surgery, a number of developments in valved conduits and in aortic translocation in patients with complex transposition of the great arteries are of particular interest.