Ann Thorac Surg 2008;85:352-353. doi:10.1016/j.athoracsur.2007.04.095
© 2008 The Society of Thoracic Surgeons
How To Do It
Anatomic Correction of Corrected Transposition {I,D,D} Using an Atrial Switch and Aortic Translocation
Viktor Hraska, MD*
Department of Pediatric Cardiac Surgery, German Pediatric Heart Centre, Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany
Accepted for publication April 20, 2007.
* Address correspondence to Dr Hraska, German Pediatric Heart Centre, Asklepios Clinic Sankt Augustin, Arnold Jansen Str. 29, Sankt Augustin, 53757, Germany (Email: v.hraska{at}asklepios.com).
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Abstract
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This report demonstrates the feasibility of performing an anatomic correction in corrected transposition of the great arteries {I,D,D} with inlet ventricle septal defect and subpulmonary obstruction, using aortic translocation combined with a modified Senning operation.
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Introduction
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The long-term outcome of patients with corrected transposition of the great arteries (ccTGA) after a "classical" surgical approach is unsatisfactory [1]. Anatomic correction using the morphologic left ventricle as a systemic pumping chamber is the preferred method [2]. In the presence of an important subpulmonary obstruction and ventricular septal defect (VSD), the Rastelli operation combined with an atrial switch represents the treatment of choice. An unfavorable anatomy might prevent the performance of a Rastelli operation. In these circumstances, consideration should be given either to conversion to the Fontan procedure, or in suitable patients, to aortic translocation [3].
This case report describes the technique of aortic translocation combined with a modified Senning operation for ccTGA {I,D,D} with an inlet VSD and severe subpulmonary obstruction.
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Technique
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A cyanotic, 2-year-old girl was referred to our center with a diagnosis of ccTGA {I,D,D} and severe subpulmonary obstruction. The echocardiogram revealed an inlet type of VSD with straddling of the tricuspid valve and valvular and subvalvular pulmonary stenosis. Catheterization confirmed a long segment of left ventricular outflow tract obstruction with systemic pressure in the left-sided, morphological left ventricle and low pulmonary artery (PA) resistance. Instead of a Rastelli operation combined with a modified Senning operation, aortic translocation and a modified Senning operation were considered as an optional treatment due to the inlet type of VSD, the long segment of subpulmonary narrowing, the valvular pulmonary stenosis, and the straddling of the tricuspid valve.
A standard median sternotomy was performed revealing a mesocardia. The right ventricle was on the right side, and the left ventricle, as well as the right atrium and both venae cavae were on the left side. The aorta was right-sided and slightly anterior; the PA was left-sided and was posteriorly located. The left coronary artery came from the left anterior coronary sinus. The right coronary artery arose from the right posterior coronary sinus. The cardiopulmonary bypass was commenced with bi-caval cannulation; the patient was cooled down to 25°C.
On the fibrillating heart, triggered by a fibrillator, the left-sided right atrium was opened in an oblique fashion. The interatrial septum was completely resected. A patch of autologous pericardium, pre-treated in gluteraldehyde, was used for the creation of the posterior wall of the systemic venous baffle. This patch was sutured anterior to the right-sided left pulmonary veins, which drained the right-sided lung and posterior to the base of the right-sided left appendage. A large incision was made on the entrance point of the left-sided right pulmonary veins, which drained the left-sided lung. The anterior wall of the systemic venous baffle was completed by suturing the free right atrial wall to the edge of the excised atrial septum between the mitral and tricuspid valves. The coronary sinus was left in the pulmonary venous atrium. Because of the lack of atrial tissue, the pulmonary venous atrium was supplemented by a pericardial pedicle flap. After finishing the modified Senning procedure, the left atrial vent was inserted to the left-sided appendage. The aortic cross clamp was applied and cardioplegia was administered to the aortic root. The aorta and PA were transected. The left and right coronary arteries were excised and extensively mobilized. The left coronary artery, in particular, was mobilized with all the ventricle branches, which supplied the right ventricle outflow tract. The aortic root was harvested from the right ventricle with an 8 to 10 mm cuff of muscle. The pulmonary valve was excised and the outlet septum was transected into the superior corner of the VSD. One of the primary papillary muscles with the chordal attachments of the tricuspid valve had to be detached due to straddling. The posterior half of the aortic annulus was sutured to the pulmonary valve annulus by using a continuous suture technique. The ventricular septal defect was closed with a Dacron patch (Impra Inc, Tempe, AZ) using interrupted pledgeted sutures. The remaining anterior rim of the proximal aortic root was sutured to the upper part of a Dacron patch (Impra Inc). The posterior half of the anastomosis was reinforced by another suture line using the remnant of the PA wall. The detached papillary muscle and attached chordae of the tricuspid valve were reattached to the appropriate position on the Dacron patch. The right coronary artery was implanted to the harvest site. The left coronary artery needed to be reimplanted at a different site in the aorta. The harvest site was covered by pericardium. After the Lecompte maneuver, the aortic root was anastomosed with the ascending aorta. The left coronary artery was implanted anterior and to the right of the harvest site. After 156 minutes the aortic cross clamp was released and the heart started to beat in sinus rhythm. During rewarming, a pulmonary homograft (22 mm in diameter) was placed in the right ventricle outflow tract. The bifurcation of the PA was partially closed, moving the anastomosis between the homograft and the PA to the right. After placement of a left atrial catheter and epimyocardial pacing wires, the patient was weaned from bypass on low inotropic support in sinus rhythm. The bypass time was 386 minutes. The chest was left open.
The postoperative course was uneventful. The chest was closed on postoperative day 2; the patient was extubated on postoperative day 4 and discharged from the intensive care unit on postoperative day 6. At the last follow-up, 6 months after surgery, the echocardiogram showed no tricuspid or mitral regurgitation. There was a trace of aortic regurgitation but no obstruction in the ventricular outflows and no reoccurrence of a VSD. The homograft showed first degree insufficiency and both ventricles functioned excellently. The patient was in sinus rhythm, receiving diuretics and beta-blockers.
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Comment
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The limited experience with aortic translocation is confined particularly to the management of physiologically uncorrected transposition of the great arteries with a VSD and pulmonary stenosis. The presence of an inlet or restrictive VSD, or both, the association with straddling of the atrioventricular valves, or the presence of borderline right ventricular volume are all considered contraindications for a Rastelli operation. Aortic translocation with biventricular outflow tract reconstruction might be a valuable surgical option if the anatomy is inadequate for a Rastelli operation [4].
To date, it is believed that there is only one report in the literature in which 3 patients underwent aortic translocation combined with a modified Senning operation as a part of anatomic correction (ie, ccTGA {S,L,L}) [4]. As was demonstrated by this case report, aortic translocation combined with a modified Senning procedure can also be used in ccTGA {I,D,D}.
Aortic translocation results in better aligned outflow tracts. The divided outlet septum offers excellent visualization of the attachment of the atrioventricular valve, as well as the VSD borders. Enlargement of the left ventricular outflow tract with the patch is easily performed, despite straddling of the atrioventricular valve. The translocated aorta is directly committed to the left ventricle. There is no intraventricular baffle with its inherent propensity to postoperative left ventricular outflow tract obstruction, as typically seen in the Rastelli operation.
The anatomy of the right ventricle outflow tract is favorable for placement of an oversized pulmonary conduit and orthotopical placement minimizes the risk of sternal compression. This may result in improved longevity of the conduit.
In contrast to the {S,L,L} anatomy of the ccTGA{I,D,D}, the atrioventricular conduction bundle arises from the posterior node to follow the conventional path along the posteroinferior margin of the VSD. There is no risk of damaging the conduction system during the division of the outlet septum [5].
Aortic translocation in ccTGA with a complex left ventricular outflow tract obstruction is a challenging procedure that should be considered only if the anatomy is inadequate for an intraventricular baffle. The long-term benefits of this approach in ccTGA must be established by careful follow-up of these patients.
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References
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- Hraska V, Duncan BW, Mayer Jr JE, Freed M, del Nido PJ, Jonas RA. Long-term outcome of surgically treated patients with corrected transposition of the great arteries J Thorac Cardiovasc Surg 2005;129:182-191.[Abstract/Free Full Text]
- Duncan BW, Mee RBB, Mesia CI, et al. Results of the double switch operation for congenitally corrected transposition of the great arteries Eur J Cardiothorac Surg 2003;24:11-20.[Abstract/Free Full Text]
- Jacobs ML, Pelletier G, Wearden PD, Morell VO. 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 Cardiol Young 2006;16(Suppl 3):97-102.[Medline]
- Morell VO, Jacobs JP, Quintessenza JA. Aortic translocation in the management of transposition of the great arteries with ventricular septal defect and pulmonary stenosis: results and follow-up Ann Thorac Surg 2005;79:2089-2092discussion 2092-3.[Abstract/Free Full Text]
- Wilkinson JJ, Smith A, Lincoln Ch, Anderson RH. Conducting tissues in congenitally corrected transposition with situs inversus Br Heart J 1978;40:41-48.[Abstract/Free Full Text]
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Abstract
Introduction
