Ann Thorac Surg 2000;69:643-645
© 2000 The Society of Thoracic Surgeons
How to Do It
Pulmonary root translocation in transposition of great arteries repair
Jose Pedro da Silva, MDa,
Jose Francisco Baumgratz, MDa,
Luciana da Fonseca, MDa
a Division of Cardiovascular Surgery, Hospital Beneficência Portuguêsa de São Paulo, São Paulo, Brazil
Address reprint requests to Dr da Silva, Rua Maestro Cardim, 769, Sala 202, 01323-001 São Paulo, Brazil
e-mail: jps{at}u-net.com.br
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Abstract
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Anterior pulmonary root translocation is used as a new approach for anatomic repair of transposition complexes with ventricular septal defect and pulmonary stenosis. It is performed to construct the right ventricle outflow tract, after patch diversion of left ventricle to aorta. Since 1994, 3 infants underwent this procedure. The preliminary results indicate some growth of the pulmonary root and suggest that this technique could diminish reoperations in this group of patients.
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Introduction
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The majority of patients with transposition of the great arteries (TGA) associated with ventricular septal defect (VSD) and pulmonary stenosis have been surgically managed by the Rastelli procedure [1]. Even though this operation accomplishes good anatomic and physiologic results in the short term, it has been associated with reoperations in the long term either related to complications of the right ventricle (RV)-pulmonary artery prosthetic conduit or to its overgrowth [2]. Aiming to overcome these problems and to assure pulmonary valve competency, we have performed pulmonary root translocation to the RV as part of the procedure we are reporting.
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Material and methods
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From April 1994 to January 1999, 3 patients underwent transposition complexes and VSD repair using translocation of the pulmonary artery root to the RV as part of a surgical technique described below. The 1 girl and the 2 boys were, respectively, 3 years, 2 months, and 3 months of age. The first and third patients had TGA with VSD and pulmonary stenosis. The second patient had Taussig-Bing anomaly with no pulmonary stenosis, but was also submitted to this operation, because of bad coronary artery anatomy for the Jatene’s switch procedure (left coronary artery arising anteriorly from the aorta, too far to be transferred to the pulmonary artery).
After a median sternotomy, a piece of the anterior pericardium was harvested and treated with glutaraldehyde solution. The pulmonary artery and its branches were dissected free from the aorta and its posterior connections, enough to be mobilized anteriorly to the right ventriculotomy.
The patient was placed in cardiopulmonary bypass by aortic and bicaval cannulation and cooled down to 22°C. The pulmonary artery root was dissected from the left ventricle (LV) with great care, so as not to damage the pulmonary valve or the coronary arteries. This hole was closed using the pretreated homologous pericardial patch. A right ventriculotomy was performed and the VSD position confirmed. Some myocardial resection was done at the conal septum to unobstruct the LV exit to the aorta in the first and second patients. A Dacron patch (DP) and 5.0 polypropylene running suture were used to close the VSD, diverting the blood flow from the LV to the aorta. The right ventricle outflow tract was constructed according to Figure 1.
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Fig 1. (A) Pulmonary root dissected out and its origin closed with a pericardial patch (PP). (B) Pulmonary root sutured to right ventriculotomy with 6-0 polydioxanone running technique. (DP = Dacron patch.) (C) Right ventricle outflow tract completed with an in situ pericardial patch.
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The first patient, who had the smallest pulmonary artery, had a 10-mm pulmonary valved conduit placed from the right ventriculotomy inferior aspect to the pulmonary artery. This was done to prevent an elevated initial transpulmonary gradient.
There was neither early nor late mortality in this small series. The early postoperative echocardiogram showed a pulmonary valve gradient of 10 mm Hg in the first patient. The echocardiogram done 5 years later in this patient showed a 41-mm Hg transpulmonary gradient, complete occlusion of the spare pulmonary conduit, and growth of the pulmonary valve annulus from 3.2 to 10.0 mm in diameter (Figs 2A, 2B). The second patient (DORV) had no initial gradient, but developed a 15-mm Hg transpulmonary gradient at 1 year, which remained unchanged 3 years later. This patient had an early pulmonary root diameter of 10 mm, which has grown to 12 and 16 mm at 1 and 3 years, respectively. The third infant, who presented with an early transpulmonary gradient of 25 mm Hg, has not had late echocardiography done yet. In all patients, the LV outflow tract (Fig 2C) appeared well, and no LV-aortic gradient was observed.
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Fig 2. (A) Early echocardiogram showing patent pulmonary artery (PA) and conduit. (B) Five-year study showing closed conduit and larger pulmonary root. (C) Unobstructed left ventricle outflow tract. (Ao = aorta; LV = left ventricle; VOT = right ventricle outflow tract; P = patch; PA = pulmonary artery; T = conduit.)
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Comment
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The problems related to the Rastelli operation have been of concern to surgeons. Lecompte has designed an operation in which a valveless pulmonary artery is brought directly to the right ventricle, by transection of the aorta [3]. He used an anterior monocusp patch to complete the right ventricle outflow tract reconstruction.
In our operation, by dissecting out the pulmonary root, we elongate the pulmonary artery trunk. This maneuver, associated with some dissection of the pulmonary branches, allowed the pulmonary root to be implanted in the right ventricle outflow tract without tension. Therefore, this technique obviates the need for aortic transection, necessary in Lecompte’s single stage repair procedure. Furthermore, our technique renders no pulmonary regurgitation, which optimizes the postoperative hemodynamics, theoretically providing a better outcome for the patient.
There are reports on pulmonary root translocation for double-outlet left ventricle repair [4–6]. Our technique differs from those because it has been applied to a different group of patients, and also because its use has been extended to patients with severe pulmonary stenosis by association of a RV-pulmonary artery conduit. The translocation of this small pulmonary root was performed because it was noticed that there was some expansion after the dissection from its original position and we anticipated some growth of this structure, which, eventually, would prevent conduit replacement reoperations. Indeed, there was some pulmonary root growth at the 5-year follow-up echocardiogram in the first patient (Fig 2). At that time, when this girl was 8 years old, she presented with a transpulmonary gradient of only 41 mm Hg and no symptoms.
The patch used to reconstruct the RV outflow tract can restrict the growth of the pulmonary root anterior aspect. Trying to minimize this inconvenience, we used in the last patient an in situ autologous pericardium patch. This pedicled patch has some growth potential [7].
In conclusion, these preliminary results indicate some growth of the pulmonary root, which may decrease or eliminate the need for reoperations and suggest that this technique can be an alternative to repair transposition complexes with VSD and pulmonary stenosis and, in some special cases, without pulmonary stenosis.
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References
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Rastelli G.C., Wallace R.B., Ongley P.A. Complete repair of transposition of the great arteries with pulmonary stenosis. Circulation 1969;39:83-95.[Abstract/Free Full Text]
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Marcelletti C., Mair D.D., McGoon D.C., et al. The Rastelli operation for transposition of the great arteries. J Thorac Cardiovasc Surg 1976;72:427-434.[Abstract]
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Lecompte Y., Neveux J.Y., Leca F., et al. Reconstruction of the pulmonary outflow tract without prosthetic conduit. J Thorac Cardiovasc Surg 1982;84:727-733.[Abstract]
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Chiavarelli M., Boucek M.M., Bailey L.L. Arterial correction of double outlet left ventricle by pulmonary artery translocation. Ann Thorac Surg 1992;53:1098-1100.[Abstract]
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DeLeon S.Y., Ow E.P., Chiemmongkoltip P., et al. Alternatives in biventricular repair of double-outlet left ventricle. Ann Thorac Surg 1995;60:213-216.[Abstract/Free Full Text]
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McElhinney D.B., Reddy M., Hanley F.L. Pulmonary root translocation for biventricular repair of double-outlet left ventricle with absent subpulmonic conus. J Thorac Cardiovasc Surg 1997;114:501-503.[Free Full Text]
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Hvass U., Khoury W., Subayi J.B., et al. The autologous pericardial tube-flap. A new technique for restoring the continuity between the right ventricle and the pulmonary artery. Presse Med 1987;16:2069-2071.
Accepted for publication October 1, 1999.
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Abstract
Introduction
