Ann Thorac Surg 2007;84:284-286
© 2007 The Society of Thoracic Surgeons
Case Reports
Intermediate Results After a Modified Yasui Procedure With the Lecompte Maneuver
Hideki Uemura, MD, FRCSa,
Iki Adachi, MDb,
Koji Kagisaki, MDb,
Fumiaki Shikata, MDb,
Toshikatsu Yagihara, MDb,*
a Department of Cardiothoracic Surgery, Royal Brompton Hospital, London, United Kingdom
b Department of Cardiovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan
Accepted for publication February 21, 2007.
* Address correspondence to Dr Yagihara, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan (Email: yagihara{at}hsp.ncvc.go.jp).
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Abstract
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Three patients with ventricular septal defect, obstructed aortic arch, and valvular aortic stenosis underwent a modification of the Yasui procedure (the Norwood type aortic reconstruction, intraventricular rerouting from the left ventricle to the dual arterial valves, and reconstruction of the right ventricular outflow tract by the Lecompte maneuver). With a follow-up of up to 60 months, the outcome is excellent without progressive lesions or reoperation.
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Introduction
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This study was carried out to determine results in the intermediate term after a modification of the Yasui procedure without use of prosthetic materials [1]. This study was carried out under the institutional policy.
Since 2000, 3 neonates having valvular aortic stenosis in conjunction with ventricular septal defect (VSD) and either interruption of the aortic arch or coarctation of the aortic arch underwent one-stage repair by using the Yasui procedure.
The ascending aorta was transected and the pulmonary arteries were brought forward (in front of the aortic root). Reconstruction of the aortic arch, as well as the Damus-Kaye-Stansel type anastomosis between the aortic root and the pulmonary trunk, were carried out by directly attaching autologous tissues together (Fig 1). Perfusion to the brachiocephalic artery was maintained throughout these maneuvers. Through a 15-mm longitudinal incision onto the right ventricle below the pulmonary valve, a patch of expanded polytetrafluoroethylene was placed to baffle the interventricular communication to the pulmonary valve orifice. Subsequently, the translocated pulmonary arteries were directly anastomosed to the ventriculotomy, and a fresh autologous pericardial patch was anteriorly attached. Perioperative measurements were summarized in Table 1.
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Fig 1. Schema of the operative procedure. (a) The ductal tissues were entirely removed and the aortic arch was reconstructed by direct anastomosis (the upper column in patient 1 or the lower column in patients 2 and 3). (b) After placing dual outflow tracts for the left ventricle, the pulmonary arteries anteriorly relocated were directly anastomosed to the right ventricular incision, and a fresh autologous pericardial patch was placed. (ePTFE = expanded polytetrafluoroethylene; VSD = ventricular septal defect.)
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Postoperative catheterization (1 year after surgery) illustrated no obstruction across the systemic and pulmonary tracts with reasonable ventricular measurements (Table 1). Consecutive echocardiograms have demonstrated neither progressive obstructions nor regurgitation across the aortic or pulmonary valve placed for systemic circulation. All 3 patients are currently doing well.
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Comment
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Obstruction at the aortic valve in patients with VSD and the obstructed aortic arch challenges the surgeon [2]. To establish biventricular repair in this setting, the Yasui procedure [3] and its modification [1] are among the surgical choices. In particular, the latter modification uses no artificial materials and is expected to reduce potential risk of early reintervention. The prostheses used in the original Yasui procedure, either a conduit for the right ventricular outflow tract or a tube for the aortic arch, would warrant reoperation in the intermediate term.
Not only the materials used for repair, but also potential left ventricular outflow tract (LVOT) obstructions could require reinterventions after conventional closure of VSD and standard reconstruction of the aortic arch [4]. In our previous experience between 1990 and 2000, 38 patients with VSD and an obstructed aortic arch (interruption of the aortic arch, 16 patients; coarctation of the aortic arch, 22 patients) survived such "usual" one-stage repair. Of these, 8 patients (interruption of the aortic arch, 3 patients; coarctation of the aortic arch, 5 patients) had significant valvular aortic stenosis, including 4 patients with abnormal leaflets; the narrowest internal diameter of the channel was smaller than 70% of the anticipated normal aortic valve diameter. Eventually, extensive reoperations were needed for progressive LVOT obstruction in 5 patients (interruption of the aortic arch, 3 patients; coarctation of the aortic arch, 2 patients). Duration between initial repair and reoperation was 3 months or less in 3 patients, 17 months in 1 patient, and 37 months in 1 patient.
Although concomitant myectomy or other options have been reported as effective in those patients with subaortic stenosis [5], these maneuvers are not always applicable when obstruction is present at the valvular level. Indeed, of the previously mentioned 8 patients, 3 had no outlet septum, and no subaortic stenosis was present. Obvious organic change in the valvular leaflets was another factor that could not be treated with subvalvular maneuvers.
Intraventricular baffling was readily achieved for a doubly-committed VSD, and possibly for perimembranous outlet VSD. This would not have been the case had patients possessed perimembranous VSD with inlet extension. A baffle would have been long and tortuous. The pulmonary ventricle would have become small. In this respect, our opinion is different from that in the previous article [1]. No residual interventricular communication was found; this complication was known as one cause of early reoperation after the so-called REV (Réparation à l’Etage Ventriculaire) procedure [6].
One obvious downside of this procedure is regurgitation across the right ventricular outflow tract. This factor probably reflects prolonged duration of inotropic support and intensive care stay, although hemodynamics remained relatively reasonable immediately after surgery. In the longer term, pulmonary valve replacement could be needed as an adolescent or at an adult stage. Another issue is its extensiveness. Cardiopulmonary bypass time and cardiac arrest time were longer than the classical one-stage repair [7]. Nonetheless, beyond the immediate postoperative period, results after the modified Yasui procedure in our small series were encouraging.
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Acknowledgments
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We thank Dr Masaki Hamamoto for his contribution in operative schemas.
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References
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- Yamagishi M, Fujiwara K, Yamada Y, Shuntoh S, Kitamura N. A new surgical technique for one-stage repair of interrupted aortic arch with valvular aortic stenosis J Thorac Cardiovasc Surg 2001;122:392-393.[Free Full Text]
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- Yasui H, Kado H, Nakano E, et al. Primary repair of interrupted aortic arch and severe aortic stenosis in neonates J Thorac Cardiovascr Surg 1987;93:539-545.[Abstract]
- Schreiber C, Eicken A, Vogt M, et al. Repair of interrupted aortic arch: results after more than 20 years Ann Thorac Surg 2000;70:1896-1900.[Abstract/Free Full Text]
- Luciani GB, Ackerman RJ, Chang AC, Wells WJ, Starnes VA. One-stage repair of interrupted aortic arch, ventricular septal defect, and subaortic obstruction in the neonate: a novel approach J Thorac Cardiovasc Surg 1996;111:348-358.[Abstract/Free Full Text]
- Lecompte Y. Réparation à l’Etage Ventriculaire—the REV procedure: technique and results Cardiol Young 1991;1:63-70.
- Uemura H, Yagihara T, Kawahira Y, Yoshikawa Y, Kitamura S. Continuous systemic perfusion improves outcome in one stage repair of obstructed aortic arch and associated cardiac malformation Eur J Cardio-thorac Surg 2001;20:603-608.[Abstract/Free Full Text]
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Abstract
Introduction
