Advances in pediatric cardiovascular surgery: anatomic reconstruction of the left ventricular outflow tract in transposition of the great arteries with pulmonic valve abnormalities

Effects of surgical en bloc rotation of the arterial trunk on the conduction system in children with transposition of the great arteries, ventricular septal defect and pulmonary stenosis

OBJECTIVES

The standard surgical management of patients with transposition of the great arteries, ventricular septal defect, and pulmonary stenosis is the Rastelli operation. Recently, en bloc rotation of the arterial trunk, by cutting out the aortic and the pulmonary root in one block and by rotating it 180°, has been introduced as a new option for anatomical repair.

METHODS

To evaluate the effects of this surgical method on the conduction system, pre-operative, post-operative, and follow-up electrocardiograms as well as patient charts were reviewed retrospectively. A total of 16 consecutive patients with transposition of the great arteries and left outflow tract obstruction were treated with en bloc rotation.

RESULTS

During the post-operative period, there were two patients with complete atrio-ventricular block, one with junctional ectopic tachycardia, one with ventricular tachycardia, and one with supraventricular tachycardia. None of the patients had a typical right bundle branch block pattern before surgery; however, this pattern was detectable after surgery in eight out of 16 patients (50%), which persisted during the follow-up. All patients without typical right bundle branch block pattern showed a median QRS duration of 65 ms (54-112 ms) before surgery, 62 ms (54-122 ms) after surgery, and 84 ms (66-128 ms) at the last follow-up visit. This compares well with a similar Rastelli cohort, where a right bundle branch block prevalence of 77% was reported. Out of 16 patients, 12 showed non-specific ST changes and negative T-waves, which persisted during follow-up with an unknown significance for the future.

CONCLUSION

Our data suggest that en bloc rotation of the arterial trunk seems not to have more negative effects on the conduction system than the Rastelli operation.

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.

The role of Fontan's procedure and aortic translocation in the surgical management of patients with discordant atrioventricular connections, interventricular communication, and pulmonary stenosis or atresia

A variety of surgical strategies have been utilized in attempts to accomplish long-term haemodynamic stability in patients with cardiac anomalies characterized by discordant atrioventricular connections, ventricular septal defect, and severe sub-pulmonary obstruction. The majority of these patients have what is commonly referred to as congenitally corrected transposition, together with a ventricular septal defect and pulmonary stenosis or atresia, in the setting of either usual or mirror imaged arrangement of the atrial chambers and the other organs of the body. A smaller sub-group, with discordant atrioventricular connections and double outlet right ventricle, with severe sub-pulmonary obstruction or pulmonary atresia, present similar physiology, and a comparable surgical challenge.

Aortic Translocation in the Management of Transposition of the Great Arteries With Ventricular Septal Defect and Pulmonary Stenosis: Results and Follow-Up

BACKGROUND

The surgical management of patients with transposition of the great arteries, ventricular septal defect, and pulmonary stenosis remains a challenge. The Rastelli operation is the preferred surgical procedure, but its long-term results are not optimal. The objective in this retrospective study was to review our experience using aortic translocation and biventricular outflow tract reconstruction as an alternative surgical procedure for the management of these patients.

METHODS

Since January 1996, 12 patients have undergone aortic translocation and biventricular outflow tract reconstruction for the management of transposition of the great arteries, ventricular septal defect, and pulmonary stenosis at our institution. All patients had ventriculoarterial discordance; 9 had atrioventricular concordance and 3 atrioventricular discordance. Associated lesions included a straddling atrioventricular valve in 3 patients. An inlet ventricular septal defect was present in 4 patients. The median age at operation was 2 years. Eight patients had previous palliative procedures. The surgical technique used was a modification of the Nikaidoh procedure. The 3 patients with atrioventricular discordance required a Senning procedure.

RESULTS

There was one hospital death (8.3%) as a result of a massive cerebrovascular accident. The median intensive care unit and hospital stays were 15 and 18 days, respectively. At a median follow-up of 33 months, all patients are alive. Four late reoperations occurred in 3 patients, including two reoperations for conduit obstruction.

CONCLUSIONS

Aortic translocation and biventricular outflow tract reconstruction is a valuable surgical option for the surgical management of patients with transposition of the great arteries, ventricular septal defect, and pulmonary stenosis, especially in the presence of "inadequate anatomy" for a Rastelli repair.

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

The surgical management of transposition of the great arteries with a ventricular septal defect and left ventricular outflow tract obstruction still remains a significant challenge despite major advances in pediatric cardiovascular surgery. Almost four decades after its inception, the Rastelli procedure continues to be the standard surgical technique used in the management of these patients, despite less than optimal long-term results. Aortic translocation with biventricular outflow tract reconstruction is an alternative surgical technique that creates anatomically sound connections between the ventricles and their respective great arteries, which could result in better long-term outcomes. This technique is especially useful in patients with transposition of the great arteries/ventricular septal defect/left ventricular outflow tract obstruction who have an inlet or restrictive ventricular septal defect, a small right ventricle, a straddling atrioventricular valve, or an aberrant coronary artery crossing the right ventricular outflow tract.

Late outcome after arterial switch operation for complete transposition of great arteries with left ventricular outflow tract obstruction

BACKGROUND

Long-term follow-up of patients who underwent arterial switch operation for complete transposition of great arteries with anatomic left ventricular outflow tract obstruction (LVOTO) has rarely been brought into the focus.

METHODS

Of 299 patients who underwent an arterial switch operation between January 1991 and January 2001, 23 patients had anatomic LVOTO. Age ranged from 4 days to 18 years (median 90 days) and weight ranged from 2.6 to 35 kg (median 4.3 kg). Surgical management included arterial switch operation, closure of ventricular septal defect wherever indicated, and excision of LVOTO.

RESULTS

Among patients with preoperative LVOTO there were 2 early deaths and 8 patients had mild neoaortic regurgitation at the time of discharge. Follow-up ranged from 8 months to 9 years (mean 60 +/- 12 months). In 4 patients who had mild neoaortic regurgitation at discharge, the regurgitation progressed to moderate or severe degree after a follow-up of 22 to 72 months. In 1 patient mild mitral regurgitation present at the time of discharge progressed to severe mitral regurgitation. This patient subsequently underwent double valve replacement.

CONCLUSIONS

Presence of preoperative anatomical LVOTO in patients undergoing arterial switch operation predicts high incidence of postoperative neoaortic regurgitation.