Ann Thorac Surg 1995;59:1476-1480
© 1995 The Society of Thoracic Surgeons
Surgical Management of Tricuspid Malinsertion in the Rastelli Operation: Conal Flap Method
Hiroshi Niinami, MD, PhD,
Yasuharu Imai, MD,
Kazuo Sawatari, MD,
Shuichi Hoshino, MD,
Kazuaki Ishihara, MD,
Mitsuru Aoki, MD
Department of Pediatric Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women's Medical College, Tokyo, Japan
Accepted for publication February 18, 1995.
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Abstract
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From June 1986 to May 1994, 25 patients underwent the Rastelli operation for complete transposition of the great arteries with ventricular septal defect and pulmonary stenosis or atresia. Fourteen patients whose tricuspid valve chordae were normal underwent the conventional Rastelli procedure (conventional group), whereas 11 patients who had tricuspid malinsertion into the infundibular septum underwent the Rastelli operation concomitant with mobilization of the infundibular septal flap, with the tricuspid valve chordae, to the right ventricular side of the intraventricular conduit (conal flap method) (conal flap group). In relation to the mobilization of the tricuspid valve chordae, right heart function and tricuspid regurgitation were compared between the two groups. There was one early death after the conventional Rastelli procedure and no early death after the Rastelli operation with a conal flap. There was one late death in the conventional group and two late deaths in the conal flap group. The mean follow-up was 50.8 ± 5.1 months in the conventional group and 54.9 ± 7.5 months in the conal flap group (p = 0.43). Reoperation was necessary for 1 patient in the conal flap group during follow-up. At the most recent follow-up, all patients in both groups were in New York Heart Association functional class I. Tricuspid regurgitation was estimated from the echocardiograms. Mild to moderate regurgitation was noted in 6 patients in the conventional group and 8 in the conal flap group. However, postoperative right heart catheterization data did not show any significant differences. Mean right atrial pressure was 8.1 ± 0.9 mm Hg in the conventional group and 8.6 ± 1.3 mm Hg in the conal flap group (p = 0.74). Minimal pressure gradients between the left ventricles and the aortas were found in both groups (4.1 ± 1.6 mm Hg in the conventional group and 2.4 ± 1.1 mm Hg in the conal flap group [p = 0.42]). Further, the degree of tricuspid regurgitation showed a tendency toward improvement on the follow-up echocardiogram in the conal flap group. Both procedures provided satisfactory early and late results. These data suggest that the conal flap method in conjunction with the Rastelli operation can be used as safely as the conventional Rastelli procedure in terms of right heart function.
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Introduction
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The Rastelli operation is generally considered the standard surgical procedure for transposition of the great arteries (TGA) associated with ventricular septal defect (VSD) and pulmonary stenosis or pulmonary atresia [1]. However, structural abnormalities of the tricuspid valve unfavorable for the intracardiac rerouting are occasionally found in cases of TGA with VSD [2–6]. If the tricuspid valve chordae are attached to the infundibular septum, which is a potential cause of obstruction between the VSD and the aorta, the Rastelli procedure has been considered inapplicable [2, 3, 4, 7]. To accomplish the Rastelli operation in this circumstance, we [8] used to perform physiologic repair. Since 1986, we have used a technique that is basically the Rastelli operation plus mobilization of an infundibular septal pedicled flap, with the abnormally attached tricuspid valve chordae, to the right ventricular side of the intraventricular conduit (conal flap method) [6, 8, 9].
In this study, we evaluated the efficacy of the conal flap method in conjunction with the Rastelli operation compared with the conventional Rastelli operation, with special regard to tricuspid regurgitation and right heart function, by echocardiography and cardiac catheterization.
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Patients and Methods
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Patient Population
From June 1986 to May 1994, 35 patients underwent surgical correction of TGA, VSD, and pulmonary stenosis or pulmonary atresia at the Heart Institute of Japan. The types of surgical procedures employed were as follows: Rastelli procedure with conal flap, 11 patients; Rastelli procedure without conal flap, 14; modified Fontan procedure, 4; Lecompte procedure with conal flap, 2; Lecompte procedure without conal flap, 3; and Nikaidoh procedure with conal flap, 1 patient. In 14 patients (40%), there was abnormal attachment of tricuspid valve chordae to the infundibular septum (Fig 1
).
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Fig 1. . Abnormal tricuspid chordal attachment (*) to the anterior aspect of the infundibular septum. (VSD = ventricular septal defect.)
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In this study, we analyzed the results for the 25 patients who underwent the Rastelli operation. There were 14 male and 11 female patients. Age at operation ranged from 5 months to 25 years (mean age, 6.6 ± 1.0 years), and body weight at operation ranged from 5.3 to 49 kg (mean weight, 17.8 ± 1.8 kg). Nineteen (76%) of the 25 patients had previously undergone one or more palliative procedures (Table 1). Associated cardiac anomalies are listed in Table 2.
Surgical Procedure
All patients were operated on using an open heart technique. Eleven patients who had tricuspid malinsertion into the infundibular septum underwent the Rastelli operation with mobilization of the infundibular septal pedicled flap, including the tricuspid valve chordae, to the right ventricular side of the internal conduit (conal flap method) (conal flap group). Their mean age was 5.7 ± 1.1 years. The 14 patients whose tricuspid valve chordae were normally inserted underwent the conventional Rastelli procedure (conventional group). Their mean age was 7.3 ± 1.6 years.
CONVENTIONAL RASTELLI OPERATION.
The basic steps of the surgical repair were similar to those originally described by Rastelli. In 8 patients (57%) in whom the size of the VSD was smaller than the diameter of the aorta, the VSD was enlarged anteriorly. An intraventricular conduit was created with a patch of two-ply glutaraldehyde-preserved equine pericardium (Xenomedica; Xenomedica AG, Luzern, Switzerland) to lead systemic blood flow from the left ventricle into the aorta. Continuity between the right ventricle and the pulmonary artery was restored with a Xenomedica tubular conduit bearing a trileaflet valve made of the same material [10]. The diameter of the extracardiac conduit ranged from 18 to 26 mm (mean diameter, 24.3 ± 0.7 mm).
RASTELLI OPERATION WITH CONAL FLAP.
The only technical difference from the usual Rastelli operation was the conal flap. A part of the infundibular septum bearing the medial papillary muscle was mobilized by two incisions, one anterior and vertical and the other subaortic, as shown in Figure 2. The septum was pulled backward as a pedicled flap. The intraventricular conduit, which was made of a Xenomedica patch, was then sutured around the defect, thereby enlarging the VSD simultaneously. The aortic cross-clamp was released to inflate the intraventricular conduit to allow determination of the appropriate place for reattachment of the mobilized portion of the infundibular septum. The pedicled flap was then reattached to the right side of the prosthetic patch (see Fig 2). Finally, as in the conventional Rastelli operation, the right ventricular-pulmonary arterial continuity was restored with a Xenomedica conduit. The diameter of the extracardiac conduit ranged from 22 to 26 mm (mean diameter, 23.0 ± 0.5 mm).
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Fig 2. . Conal flap method in patient with abnormal tricuspid chordal attachment to infundibular septum. (A) Anatomic relation between ventricular septal defect (VSD), tricuspid valve chordae, and aortic valve. (B) Mobilization of the infundibular septum, including tricuspid valve chordae, with two incisions, one anterior and vertical and the other subaortic. (C) After intracardiac rerouting, the infundibular septal flap is reattached to the right side of the prosthetic patch. (Ao = aorta; PA = pulmonary artery.)
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Follow-up Studies
All patients underwent postoperative cardiac catheterization and right and left ventriculography 1 month after the operation. Echocardiographic studies were also undertaken in all patients 1 month after operation and during the follow-up. To define the degree of postoperative tricuspid regurgitation, the following numerical ratings were used: none = 0; trivial = 1; mild = 2; moderate = 3; and severe = 4.
Statistical Analysis
Data are expressed as the mean ± the standard error of the mean. A Student's t test was performed on unpaired data to detect significant differences. A p value of less than 0.05 was considered significant.
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Results
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There was one early death (7%) in the conventional group; this patient died of respiratory failure caused by a pulmonary hypertensive crisis. There were no early deaths in the conal flap group. All survivors were followed up and seen periodically at our outpatient department. The mean follow-up was 52.7 ± 4.3 months (range, 4 months to 7 years); it was 50.8 ± 5.1 months for the conventional group and 54.9 ± 7.5 months for the conal flap group. There were no significant differences in age (p = 0.65) and body weight (p = 0.67) at operation, diameter of the extracardiac conduit (p = 0.17), and mean follow-up (p = 0.65) between the two groups.
There was one late death in the conventional group (sudden death at 9 months in a patient with residual VSD and pulmonary hypertension). There were two late deaths in the conal flap group (one sudden death at 7 years in a patient with cerebral hemorrhage resulting from infective endocarditis and one unexplained sudden death at 3 months).
Reoperation during follow-up was necessary for 1 patient in the conal flap group. This patient had infective endocarditis 4 years after operation and required replacement of the extracardiac conduit. The postoperative course was uneventful. The patient died suddenly 3 years after reoperation. At the most recent follow-up, all patients in both groups were in New York Heart Association functional class I and leading normal, active lives.
All patients underwent cardiac catheterization 1 month postoperatively, and echocardiographic studies were performed during follow-up for long-term survivors. The left ventricular function was normal in all patients (Table 3). There were minimal pressure gradients between the left ventricles and the aortas: 4.1 ± 1.6 mm Hg in the conventional group and 3.5 ± 1.1 mm Hg in the conal flap group (p = 0.42).
The pressure gradient between the right ventricle and the pulmonary artery was 19.8 ± 4.2 mm Hg in the conventional group and 13.1 ± 3.0 mm Hg in the conal flap group (p = 0.20). Right heart catheterization data are shown in Table 4. A right ventriculogram showed mild tricuspid regurgitation in 2 conal flap group patients (none in the conventional group). Ventriculograms failed to show impaired right ventricular motion in any patient. Further, right atrial pressure remained low (8.1 ± 0.9 mm Hg in the conventional group and 8.6 ± 1.3 mm Hg in the conal flap group; p = 0.74). The echocardiogram revealed a slightly higher incidence of tricuspid regurgitation in the conal flap group than in the conventional group. The numerical ratings were as follows: trivial = 4, mild = 5, and moderate = 1 for 10 of 13 in the conventional group and trivial = 1, mild = 8, and moderate = 1 for 10 of 11 in the conal flap group 1 month after operation. However, the degree of regurgitation tended to decrease during the long-term follow-up (Fig 3).
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Fig 3. . Degree of postoperative tricuspid valve regurgitation by echocardiography during follow-up in the group having Rastelli operation with conal flap.
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Comment
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Patients with TGA and VSD usually undergo the Rastelli procedure if they also have pulmonary stenosis [1]. However, the anatomy, such as abnormalities of the atrioventricular valve and size of the VSD, is also an important factor to consider for this procedure [2–5]. It has been believed that the optimal anatomy for a Rastelli operation is a large subaortic VSD, which should be at least 80% of the circumference of the aortic annulus, without interposition of atrioventricular valve tissue between the VSD and the aortic orifice [2].
In TGA with VSD, posterior displacement of the infundibular septum has been reported to cause left ventricular outflow tract obstruction. In this situation, the uppermost portion of the tricuspid annulus and the highest papillary muscle of the tricuspid valve are posterior to the outlet VSD. However, if the left ventricular outflow tract obstruction is mainly valvular, supravalvular, or a combination of these and if the infundibular septum is fully developed and not displaced, the VSD must be of the perimembranous trabecular type. Moreover, the uppermost portion of the tricuspid annulus and the highest papillary muscle and chordae are anterosuperior to the VSD [5]. The rate of occurrence of tricuspid chordal attachment to the infundibular septum in TGA is reported to be 14% to 56% [2–4, 6, 8], which means that the optimal anatomy is not common. We, in fact, encountered this anomaly in 14 (40%) of 35 patients in this series. In such cases, physiologic repair used to be advised [2–4, 7]. However, the disadvantages of physiologic repair, such as supraventricular arrhythmia, systemic-side atrioventricular valve insufficiency, and right ventricular failure, are well documented [11–15]. In our previous series [8], we performed physiologic repair with VSD closure and pulmonary valvotomy with or without fibromyotomy in 5 patients, but a higher morbidity compared with the anatomic repair group was observed postoperatively.
Since 1986, we have used the conal flap method concomitantly with the Rastelli operation, a technique originally described by Lecompte and co-workers [7] (see Fig 1
). The advantage of this method is that it not only avoids tricuspid insufficiency by preserving the valvular apparatus but also permits a wide left ventricular-aortic connection. In terms of VSD size, the minimum acceptable circumference was considered to be at least 80% of the circumference of the aortic annulus [2]. In this study, more than half of the patients (57%) in the conventional group required VSD enlargement. Using the conal flap method, VSD enlargement can be done simultaneously, and this does not interfere with left ventricular function.
Of technical importance for this method is the choice of the optimal site of reattachment of the mobilized infundibular septal flap with the tricuspid chordae. To minimize the tricuspid insufficiency, the aortic cross-clamp should be released prior to the reattachment, as it is difficult to obtain a suitable position for the reattachment of the conal flap when the intracardiac conduit is collapsed.
To estimate the effectiveness of this method, it is very important to assess right heart function and tricuspid regurgitation. In regard to the mobilized pedicled infundibular septum, mild tricuspid regurgitation was seen by echocardiography in 73% in the early postoperative period. However, this tendency was also observed after the conventional Rastelli procedure (36%). From this fact, we assume that the tricuspid regurgitation might be due, to some extent, to the use of the tricuspid valve annulus for closure of the VSD. Despite the existence of tricuspid regurgitation after the conal flap method, the right atrial pressure remained normal (8.6 ± 1.3 mm Hg). Moreover, an encouraging finding is the tendency for the tricuspid insufficiency to lessen during the follow-up probably with the reduction in right ventricular pressure.
In the conal flap group, 1 patient needed reoperation. In this patient, we replaced the extracardiac conduit and were able to observe the conal flap 4 years after reimplantation on the intracardiac conduit. The tricuspid chorda of the flap looked healthy and was not elongated, but the muscle of the flap looked shrunken and pale. As the patient underwent reoperation because of infective endocarditis, it might have caused the muscle atrophy.
In our series, we used equine pericardium for both the intracardiac conduit and the extracardiac conduit instead of other artificial materials such as Dacron or Gore-Tex. We selected that material because it is flexible and soft, which makes it easy to place sutures and to control bleeding, and it does not bend the heart [10].
In conclusion, the Rastelli-type operation was feasible, even in the presence of tricuspid valve chordal attachment to the infundibular septum, when it was used with the conal flap. Wide left ventricular-aortic communication and satisfactory decompression of the right ventricle could be obtained without interfering with tricuspid valve function. The early and late results confirmed that this maneuver does not compromise tricuspid competence and can be performed as safely as the conventional Rastelli procedure.
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Footnotes
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Address reprint requests to Dr Niinami, Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women's Medical College, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162, Japan.
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References
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- Byrum CJ, Bove EL, Sondheimer HM, Kavey R-EW, Blackman MS. Hemodynamic and electrophysiologic results of the Senning procedure for transposition of the great arteries. Am J Cardiol 1986;58:138–42.[Medline]
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Abstract
Introduction
