Surgical Treatment for Double Outlet Right Ventricle. Masakazu Nakao Consultant, Paediatric Cardiothoracic Surgery

Transcription

1 for Double Outlet Right Ventricle Masakazu Nakao Consultant, Paediatric Cardiothoracic Surgery 1

2 History Intraventricular tunnel (Kawashima) First repair of Taussig-Bing anomaly (Kirklin) Taussig-Bing anomaly (Taussig & Bing) Today s Detail understanding of anatomy (Newfeld) First surgical description of DORV(Kirklin) Intracardiac repair of Taussig-Bing anomaly (McGoon) Contemporary concept of DORV (Lev) 2

3 Indication Congestive heart failure The patients with no pulmonary stenosis Cyanosis Patients with pulmonary stenosis Streaming due to VSD location 3

4 - Overview Able to commit VSD to aorta? If not able to commit VSD to pulmonary artery, then switch? If not Fontan path Is the patient big enough for surgery of choice? 4

5 Intracardiac repair feasible Commit VSD to aorta PA band or BT shunt / RV-PA shunt PS Commit VSD to PA TOF type repair VSD closure / Intracardiac tunnel PS Fontan of VSD Rastelli, REV, Nikaidoh VSD closure & Arterial switch Kawashima DKS of VSD of VSD 5

6 Commit VSD to aorta PS Commit VSD to PA TOF type repair VSD closure / Intracardiac tunnel PS Fontan Rastelli, REV, Nikaidoh VSD closure & Arterial switch Kawashima DKS 6

7 7 Surgical Treatment TOF type

8 Commit VSD to aorta PS Commit VSD to PA TOF type repair VSD closure / Intracardiac tunnel PS Fontan Rastelli, REV, Nikaidoh VSD closure & Arterial switch Kawashima DKS 8

9 - VSD Closure / Intracardiac Tunnel c 4 1. Approach can be transatrial or transventricular 2. Conduction pathway 3. Dacron or eptfe graft 4. Possible leak easier with continuous suture 5. Can secure from epicardium 4 Adopted from Tsang VT, Stark J. Double outlet right ventricle: Surgery for congenital heart defect, third edition. Eds. Stark JF, et al. John Wiley & Sons, 2006:

10 - 1. VSD size aorta 2. Away from conduction, away from mitral valve - stay anterosperiorly 1 2 Conduction pattern Adopted from Tasng VT, Stark J. Double outlet right ventricle: Surgery for congenital heart defect, third edition. Eds. Stark JF, et al. John Wiley & Sons, 2006:

11 Commit VSD to aorta PS Commit VSD to PA TOF type repair VSD closure / Intracardiac tunnel PS Fontan Rastelli, REV, Nikaidoh VSD closure & Arterial switch Kawashima DKS 11

12 Rastelli Consists of a. Rerouting or VSD to aorta b. RV-PA conduit 1 1. Tunnel size aorta 2. Redundant patch 3. Conduit curves to left redo is inevitable Adopted from Mavroudis C, Backer CL. Transposition of the Great Arteries: Pediatric cardiac surgery, fourth edition. Eds. Mavroudis C, Backer CL, Wiley-Blackwell, 2013:

13 REV E F Consists of a. Rerouting from VSD to aorta b. Locompte maneuver c. Posterior wall reconstruction d. Anterior patch 1. Tunnel size aorta 2. Stretch of LPA 3. PR Adopted from Mavroudis C, Backer CL. Transposition of the Great Arteries: Pediatric cardiac surgery, fourth edition. Eds. Mavroudis C, Backer CL, Wiley-Blackwell, 2013:

14 Nikaidoh Consists of a. Harvesting aorta b. Creating common orifice c. Aortic translocation 1 2 d. Rerouting VSD to neo-aorta e. Reconstruction of PA 1. Harvesting aorta while keeping coronary 2. Open widely 3. PR 3 14 Adopted from Mavroudis C, Backer CL. Transposition of the Great Arteries: Pediatric cardiac surgery, fourth edition. Eds. Mavroudis C, Backer CL, Wiley-Blackwell, 2013:

15 Rastelli vs REV vs Nikaidoh Rastelli REV Nikaidoh Surgical mortality 5~30% 12~18% 0~7% Long-term mortality 20~30% at 15 years 15% at 25 years NA Technical challenge rmal Complex More complex Conduit stenosis / pulmonary stenosis AR PR Reoperation Inevitable 55% at 25 years NA 15

16 Commit VSD to aorta PS Commit VSD to PA TOF type repair VSD closure / Intracardiac tunnel PS Fontan Rastelli, REV, Nikaidoh VSD closure & Arterial switch Kawashima DKS 16

17 - VSD Closure & Arterial Switch 3 1. The location varies- conduction pathway is a key 2. Chordae can be re-implanted 3. Tunnel / VSD size PA size 2 1 Adopted from Tsang VT, Stark J. Double outlet right ventricle: Surgery for congenital heart defect, third edition. Eds. Stark JF, et al. John Wiley & Sons, 2006:

18 1. Unusual coronary pattern is common 2. Side-by-side great arteries stretch LPA - Lecompte maneuver vs classic switch - keep ex-aorta long Adopted from Tsang VT, Stark J. Double outlet right ventricle: Surgery for congenital heart defect, third edition. Eds. Stark JF, et al. John Wiley & Sons, 2006:

19 Commit VSD to aorta PS Commit VSD to PA TOF type repair VSD closure / Intracardiac tunnel PS Fontan Rastelli, REV, Nikaidoh VSD closure & Arterial switch Kawashima DKS 19

20 - Kawashima Resect infundibulum 2. Tricuspid chordae can be detached and re-implanted - not easy 3. Need enough space between tricuspid and pulmonary valve Adopted from Tasng VT, Stark J. Double outlet right ventricle: Surgery for congenital heart defect, third edition. Eds. Stark JF, et al. John Wiley & Sons, 2006: Adopted from Walters III HL, Mavroudis C. Double-outlet ventricles: Pediatric cardiac surgery, fourth edition. Eds. Mavroudis C, Backer CL, Wiley-Blackwell, 2013:

21 Commit VSD to aorta PS Commit VSD to PA TOF type repair VSD closure / Intracardiac tunnel PS Fontan Rastelli, REV, Nikaidoh VSD closure & Arterial switch Kawashima DKS 21

22 - Fontan & DKS / Enlarged VSD tends to become smaller Adopted from Tasng VT, Stark J. Double outlet right ventricle: Surgery for congenital heart defect, third edition. Eds. Stark JF, et al. John Wiley & Sons, 2006: Adopted from Masuda M, et al. Modified Damus-Kaye- Stansel procedure using aortic flap technique for systemic ventricular outflow tract obstruction in functionally univentricular heart. Eur J Cardiothorac Surg 2006;29:

23 Short-Term Mortality 1970s 50%, 1980s 20%, 1990s - <6% Those with high pulmonary flow carries higher risk Heterogeneous group of patients 23

24 Long-Term Mortality Due to intra-tunnel stenosis at levels Bradley TJ, et al. Determinants of repair type, reintervention, and mortality in 393 children with double-outlet right ventricle. J Thorac Cardiovasc Surg 2007;134(4):

25 Short-Term Morbidities Residual leak Haemolysis due to a large patch Heart block LAD injury during enlargement Subaortic stenosis Aortic regurgitation Pulmonary regurgitation Tricuspid regurgitation 25

26 Long-Term Morbidities Common morbidities for all types Subaortic stenosis Pulmonary regurgitation Aortic reguritation Leak from long intracardiac tunnel 26

27 Conclusion DORV has wide spectrum of anomalies Surgical techniques include VSD closure to Nikaidoh operation High probability of reoperation in the future 27

28 Further Reading 1. Artrip JH, et al. Biventricular repair in double outlet right ventricle: surgical results based on the STS-EACTS International menclature classification Eur J Cardiothorac Surg;2006:29: Bradley TJ, et al. Determinants of repair type, reintervention, and mortality in 393 children with double-outlet right ventricle. J Thorac Cardiovasc Surg 2007;134(4): Hu S, et al. Strategy for biventricular outflow tract reconstruction: Rastelli, REV, or Nikaidoh procedure? J Thorc Cardiovasc Surg 2008;135(2): Lacour-Gayet F. Biventricular repair of double outlet right ventricle with noncommitted ventricular septal defect. Pediatric Cardiac Surgery Annual of the Seminars in Thoracic and Cardiovascular Surgery 2002(5):

29 29