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1 Technique of Aortic Translocation for the Management of Transposition of the Great Arteries with a Ventricular Septal Defect and Pulmonary Stenosis Victor O. Morell, MD, and Peter D. Wearden, MD, PhD In 1980, Bex and associates 1 first introduced the initial concept of aortic translocation for the surgical management of transposition of the great arteries (TGA). They proposed moving the aortic root together with the coronary arteries to the pulmonary position as a way to provide a true anatomic correction for simple TGA. In 1984, Nikaidoh 2 described and popularized the concept of aortic translocation for the management of patients with TGA, a ventricular septal defect (VSD), and pulmonary stenosis (PS). When evaluating patients with TGA, VSD, and PS, it is important to delineate the anatomy of the left ventricular outflow tract, including the size of the pulmonary valve annulus, and the morphology of both the pulmonary valve and the left ventricular outflow tract. Left ventricular outflow obstruction is frequently secondary to posterior deviation of the outlet septum, which is not usually amenable to resection. Occasionally, there are patients with resectable lesions in the left ventricular outflow tract; they should be managed with an arterial switch operation and left ventricular outflow tract resection, rather than translocation. It is also important to Division of Pediatric Cardiothoracic Surgery of the Heart, Lung and Esophageal Surgical Institute, University of Pittsburgh Medical School, Children s Hospital of Pittsburgh, Pittsburgh, Pennsylvania. Address reprint requests to Victor O. Morell, MD, Chief, Division of Cardiothoracic Surgery, Children s Hospital of Pittsburgh, Room 2820, 3705 Fifth Avenue, Pittsburgh, PA document the presence of a straddling atrioventricular valve, which has been associated with TGA, VSD, and PS. The coronary anatomy should be documented, because there are some coronary patterns that can interfere with the repair. The epicardial course of a major coronary artery could preclude the safe harvesting of the aortic root from the right ventricle because of its proximity to the plane of resection (for example, a right coronary artery originating from the left main). There are also some coronary patterns that can hinder the ability to safely move the aorta posteriorly into the pulmonary annulus (for example, a posterior intramural coronary artery course). Such coronary anatomy may not be amenable to coronary reimplantation in conjunction with aortic translocation. Our preferred age for complete repair is 6 months. However, some neonates and small infants will develop significant cyanosis ( 70%) requiring an initial systemic to pulmonary artery shunt. Our approach is to perform the shunt via a median sternotomy incision. At the time of surgery, we document the coronary anatomy and occasionally place marking sutures near the coronaries to facilitate their visualization at the time of reoperation. Also, keeping in mind that a segment of pericardium will be needed for the right ventricle to pulmonary artery connection, we avoid making a midline pericardial incision to preserve most of the anterior pericardium in continuity. The approximation of the pericardial edges facilitates future sternal reentry /08/$-see front matter 2008 Elsevier Inc. All rights reserved. doi: /j.optechstcvs

2 182 V.O. Morell and P.D. Wearden Operative Technique Figure 1 Once on cardiopulmonary bypass, the proximal segments of both coronary arteries are mobilized to allow for the posterior movement of the aortic root during the posterior translocation.

3 Technique of aortic translocation 183 Figure 2 With a beating heart, the aortic root is harvested from the right ventricle. Initially, an anterior ventriculotomy is made to visualize the aortic valve; we then proceed with the lateral and posterior transection of the subaortic conus. The mobilization of the proximal coronary arteries makes it possible to safely separate the lateral aspects of the aortic root form the right ventricle without inadvertent coronary injury. Figure 3 After harvesting the aortic root, the main pulmonary artery is transected proximally, at the level of the pulmonary valve. The branch pulmonary arteries need to be extensively mobilized in preparation for the Lecompte maneuver.

4 184 V.O. Morell and P.D. Wearden Figure 4 The outlet septum is transected down to the level of the ventricular septal defect, opening the narrowed distal left ventricular outflow tract. Once the aorta has been harvested from the right ventricle and the outlet septum is divided, the exposure provides for excellent visualization of the ventricular septal defect and the atrioventricular valves. It also allows for a more precise closure of the VSD in patients with a straddling atrioventricular valve. Figure 5 (A) The anastomosis between the proximal aortic root and the opened pulmonary annulus is performed with a running suture to the level of the transected outlet septum. Beware of posteriorly looping coronary arteries, which can be susceptible to injury or distortion when performing the posterior suture line. (B) The residual interventricular defect is closed with a prosthetic patch; the superior aspect of the patch is sutured to the unsupported anterior segment of the aortic root. Occasionally, it is possible to close the VSD by approximating the right ventricular muscle attached to the aortic root to the crest of the VSD, without a patch. The advantages of performing the procedure with a beating heart include the benefits of a short cross-clamp time and the ability to detect the presence of coronary ischemia, which could develop after the translocation of the aorta.

5 Technique of aortic translocation 185 Figure 6 (A) After aortic cross-clamping, the mid-ascending aorta is transected and a segment of aorta is excised to prevent posterior compression of the pulmonary arteries by a bowing ascending aorta after the Lecompte maneuver. (B) The pulmonary arteries are moved anterior to the aorta. (C) Aortic continuity is reestablished. The aortic crossclamp is removed and the patient is rewarmed.

6 186 V.O. Morell and P.D. Wearden Figure 7 (A) The anterior wall of the main pulmonary artery is opened longitudinally to allow for patch augmentation, as it tends to be hypoplastic. (B) The proximal pulmonary artery is then sutured to the right ventricular outflow tract; the posterior suture line is usually at the same level as the suture line between the aortic root and the VSD patch. (C) A glutaraldehyde-treated autologous pericardial patch is used to complete the right ventricle to pulmonary artery connection, thereby augmenting the main pulmonary artery. Via a median sternotomy incision, the patient is placed on cardiopulmonary bypass with bicaval cannulation. A left ventricular vent is placed through the right superior pulmonary vein and a cardioplegia catheter is inserted in the distal ascending aorta. The patient is cooled to 32 C. Conclusions Since 1996, 21 patients have undergone aortic translocation at Children s Hospital of Pittsburgh and The Congenital Heart Institute of Florida. The cardiac lesions in these patients included transposition of the great arteries (D-TGA) with VSD and PS (16), corrected transposition of the great arteries (L-TGA) with VSD and PS (3), and double outlet right ventricle with a subpulmonary VSD and PS (2). There was one (4.7%) early death; one patient required cardiac transplantation because of severe postoperative left ventricular dysfunction (a patient with a posterior looping coronary artery). At a median follow-up of 71 months there were three late deaths, two of which were potentially preventable (one patient died from an unrecognized pericardial effusion and one from cardiac injury during sternal reentry). It is important to note that many, if not all of these patients, will eventually require reintervention. The absence of a pulmonary valve results in chronic pulmonary insufficiency, which can lead to right ventricular dilation and/or dysfunction requiring a pulmonary valve placement. We modified our initial technique 3 of using a pulmonary homograft to reestablish RV to PA continuity to the technique currently described based on the fact that there are published data 4 suggesting that a direct RV to PA connection results in a lower incidence of reoperations when compared with the use of homografts in the pulmonary position. One of the major advantages of this repair is the creation of a widely opened left ventricular outflow tract; we are not aware of any patient that has developed left ventricular outflow tract obstruction after an aortic translocation procedure. One patient in our series required reoperation for severe aortic insufficiency. At Children s Hospital of Pittsburgh the aortic translocation procedure is the preferred surgical technique for the management of patients with TGA with a VSD and PS. Although the overall published experience 1-3,5-16 with this technique is limited, the early and midterm results are encouraging, suggesting improved outcomes when compared with the Rastelli repair. Acknowledgment We thank Dr. Angelo Rutty for the illustrations.

7 Technique of aortic translocation 187 References 1. Bex JP, Lecompte Y, Baillot F, et al: Anatomic correction of transposition of the great arteries. Ann Thorac Surg 29:86-88, Nikaidoh H: Aortic translocation and biventricular outflow tract reconstruction: a new surgical repair for transposition of the great arteries associated with a ventricular septal defect and pulmonary stenosis. J Thorac Cardiovasc Surg 88: , Morell VO, Jacobs JP, Quintessenza JA: The role of aortic translocation in the management of complex transposition of the great arteries. Semin Thorac Surg Pediatr Card Surg Annu 7:80-84, Kreutzer C, De Vine J, Oppido G, et al: Twenty-five-year experience with Rastelli repair for transposition of the great arteries. J Thorac Cardiovasc Surg 120: , Morell VO, Jacobs JP, Quintessenza JA: Surgical management of transposition with ventricular septal defect and obstruction to the left ventricular outflow tract. Cardiol Young 15: , 2005 (suppl 1) 6. Morell VO, Jacobs JP, Quintessenza JA: Aortic translocation and biventricular outflow tract reconstruction in the management of complex transposition of the great arteries with ventricular septal defect and pulmonary stenosis: results and follow-up. Ann Thorac Surg 79: , Morell VO: Aortic translocation for TGA with VSD and PS. Cardiothoracic Surgery Network, Expert Techniques, Congenital Cardiac, November, Available at cogenital/expert_tech-5.html. Accessed August 7, Morell VO, Wearden PD: Aortic translocation for the management of transposition of the great arteries with a ventricular septal defect. Pulmonary stenosis and hypoplasia of the right ventricle. Eur J Cardiothorac Surg 31: , Yeh T, Ramaciotti C, Leonard SR, et al: The aortic translocation (Nikaidoh) procedure: midterm results superior to the Rastelli procedure. J Thorac Cardiovasc Surg 133: , Sayin OA, Ugurlucan M, Saltik L, et al: Modified Nikaidoh procedure for transposition of great arteries. Ventricular septal defect and left ventricular outflow tract obstruction. Thorac Cardiovasc Surg 54: , Bautista-Hernandez V, Marx GR, Bacha EA, et al: Aortic root translocation plus arterial switch for transposition of the great arteries with left ventricular outflow tract obstruction. J Am Coll Cardiol 49: , Hu S, Li S, Wang X, et al: Pulmonary and aortic translocation in the management of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction. J Thorac Cardiovasc Surg 133: , Hazekamp M, Portela F, Bartelings M: The optimal procedure for transposition of the great arteries and left ventricular outflow tract obstruction. An anatomical study. Eur J Cardiothorac Surg 31: , Yamagishi M, Shuntoh K, Matsushita T, et al: Half-turned truncal switch operation for complete transposition of the great arteries with ventricular septal defect and pulmonary stenosis. J Thorac Cardiovasc Surg 125: , Kandeel M, Kumar N, Prabhakar G, et al: Aortic translocation for D- TGA associated with LVOTO and VSD. Ann Thorac Surg 59: , Hass GS: Advances in pediatric cardiovascular surgery: anatomic reconstruction of the left ventricular outflow tract in transposition of the great arteries with pulmonic valve abnormalities. Curr Opin Pediatr 12: , 2000

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