Rotation of the outflow tracts

Rotation of the outflow tracts Abstract The optimal treatment for transposition of the great arteries with stenosis along the pulmonary tract has always been a challenge. En bloc rotation of the truncus arteriosus has been proposed as an alternative method in this group of patients. We report a truncus turnover in a 3-month-old, 3.4 kg infant. Transposition of the great arteries, Truncus arteriosus rotation, Congenital heart disease INTRODUCTION The optimal treatment for transposition of the great arteries with stenosis along the pulmonary tract remains a challenge. The Rastelli procedure risks creating a narrow, at times, obstructive left ventricular outflow tract. The risk is greater with a larger pulmonary annulus [1]. The Bex–Nikaidoh procedure has been popularized to circumvent this problem. In this approach, only the aortic root is harvested and moved in a systemic position, and the valved conduit is used to connect the right ventricle to the pulmonary artery [2]. It has become evident that in some patients, dysplastic pulmonary valve (PV), unable to function under systemic pressure, could be used in the low-pressure subpulmonary position. Thus, a few surgeons have proposed complete en-bloc rotation of the truncus arteriosus, where the PV is recycled [3]. This procedure is more challenging in newborns and infants. Therefore, some have to undergo an initial palliation to equilibrate the systemic and pulmonary circulations. A truncus turnover in a 3-month-old infant is described, with the message that this procedure can be performed earlier, without an initial palliative procedure. PATIENTS AND METHODS A neonate was diagnosed with transposition of the great arteries, pulmonary stenosis, VSD, ASDII and Leiden Type A coronary arteries. Arterial saturation remained acceptable until the child reached the age of 3 months and a weight of 3.4 kg, when it started to drop below 75%. Echocardiography showed that the pulmonary stenosis was the result of a dysplastic PV, with a mildly hypoplastic annulus (Z-score −2) and 3 thickened leaflets with reduced mobility. On surgical inspection, the aortic valve was normal, but the PV showed thickened leaflets without commissural fusion. It was evident that this valve would not fare well under systemic pressures. The coronary arteries were harvested with a stripe of sinus wall, without disrupting the sino-tubular anatomy, and mobilized extensively. The aortic root was separated from the infundibulum in the same way as the pulmonary root is harvested during a Ross procedure (Fig. 1A). From there, the incision was directed around the PV, sideways until the common annulus with the mitral valve (Fig. 1B). The separation of these 2 structures had to be performed with great caution, as this common annulus must serve 2 annuli. To achieve this, the cut was made with a 45° angle and with the thought of leaving at least enough tissue in the mitral annulus for a subsequent suture. The en-bloc valves were rotated 180°. The aortic root was sutured to the mitral annulus. A patch of xenopericardium was used to close the VSD and was sutured on the anterior part of the aortic annulus. Finally, the pulmonary root was sutured to the infundibulum. Figure 1: View largeDownload slide En-bloc rotation of the truncus arteriosus. (A) Aortic root harvesting. (B) Incision of the pulmomitral continuity. Ao: aortic; Ant. Leaftlet: anterior leaflet; Ao v.: aortic valve; LCA: left coronary artery; MV: mitral valve; MPA: major pulmonary artery; PV: pulmonary valve; RCA: right coronary artery; SVC: superior vena cava; TV: tricuspid valve; VSD: ventricular septal defect. Figure 1: View largeDownload slide En-bloc rotation of the truncus arteriosus. (A) Aortic root harvesting. (B) Incision of the pulmomitral continuity. Ao: aortic; Ant. Leaftlet: anterior leaflet; Ao v.: aortic valve; LCA: left coronary artery; MV: mitral valve; MPA: major pulmonary artery; PV: pulmonary valve; RCA: right coronary artery; SVC: superior vena cava; TV: tricuspid valve; VSD: ventricular septal defect. The pulmonary arteries were mobilized widely and Lecompte manoeuvre was performed. The coronary arteries were implanted on the already existing holes. Weaning from cardiopulmonary bypass occurred without difficulties. The chest was electively left open and closed the next day. Transoesophageal echocardiography showed good biventricular function and good function of both the aortic and PV (with a gradient of 20 mmHg). There was a slight central mitral valve regurgitation which disappeared over the next 3 days. DISCUSSION This case shows that a complex repair of malposed great arteries—such as a Nikaidoh or double root rotation—is possible early in infancy. The main advantage of this procedure in this group of patients, in comparison with ASO, is having a normal AV in a systemic position which potentially avoids reintervention on the AV. Many steps are similar to those used in other operations, such as the coronary arteries transfer in an arterial switch operation or the harvest of the semi-lunar valves in a Ross procedure. There are, however, 2 specific points that are slightly different from a Nikaidoh: the separation of the pulmonary and mitral valve and the enbloc rotation of the truncus arteriosus. This approach avoids the use of a conduit, and a long intracardiac tunnel, as the aorta sits directly above the left ventricular outflow tract, which is enlarged by the VSD patch (see Fig. 2). Figure 2: View largeDownload slide Postoperative echocardiogram. The LVOT and RVOT are wide and show laminar flow. The aorta sits above the LVOT, with an anatomic configuration and mitro-aortic continuity. LV: left ventricle; LVOT: left ventricular outflow tract; MV: mitral valve; RVOT: right ventricular outflow tract. Figure 2: View largeDownload slide Postoperative echocardiogram. The LVOT and RVOT are wide and show laminar flow. The aorta sits above the LVOT, with an anatomic configuration and mitro-aortic continuity. LV: left ventricle; LVOT: left ventricular outflow tract; MV: mitral valve; RVOT: right ventricular outflow tract. Conflict of interest: none declared. REFERENCES 1 Kreutzer C, De Vive J, Oppido G, Kreutzer J, Gauvreau K, Freed M et al.   Twenty-five-year experience with rastelli repair for transposition of the great arteries. J Thorac Cardiovasc Surg  2000; 120: 211– 23. Google Scholar CrossRef Search ADS PubMed  2 Raju V, Myers PO, Quinonez LG, Emani SM, Mayer JE, Pigula FA et al.   Aortic root translocation (Nikaidoh procedure): intermediate follow-up and impact of conduit type. J Thorac Cardiovasc Surg  2015; 149: 1349– 55. Google Scholar CrossRef Search ADS PubMed  3 Mair R, Sames-Dolzer E, Vondrys D, Lechner E, Tulzer G. En bloc rotation of the truncus arteriosus—an option for anatomic repair of transposition of the great arteries, ventricular septal defect, and left ventricular outflow tract obstruction. J Thorac Cardiovasc Surg  2006; 131: 740– 1. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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1569-9293
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Abstract

Abstract The optimal treatment for transposition of the great arteries with stenosis along the pulmonary tract has always been a challenge. En bloc rotation of the truncus arteriosus has been proposed as an alternative method in this group of patients. We report a truncus turnover in a 3-month-old, 3.4 kg infant. Transposition of the great arteries, Truncus arteriosus rotation, Congenital heart disease INTRODUCTION The optimal treatment for transposition of the great arteries with stenosis along the pulmonary tract remains a challenge. The Rastelli procedure risks creating a narrow, at times, obstructive left ventricular outflow tract. The risk is greater with a larger pulmonary annulus [1]. The Bex–Nikaidoh procedure has been popularized to circumvent this problem. In this approach, only the aortic root is harvested and moved in a systemic position, and the valved conduit is used to connect the right ventricle to the pulmonary artery [2]. It has become evident that in some patients, dysplastic pulmonary valve (PV), unable to function under systemic pressure, could be used in the low-pressure subpulmonary position. Thus, a few surgeons have proposed complete en-bloc rotation of the truncus arteriosus, where the PV is recycled [3]. This procedure is more challenging in newborns and infants. Therefore, some have to undergo an initial palliation to equilibrate the systemic and pulmonary circulations. A truncus turnover in a 3-month-old infant is described, with the message that this procedure can be performed earlier, without an initial palliative procedure. PATIENTS AND METHODS A neonate was diagnosed with transposition of the great arteries, pulmonary stenosis, VSD, ASDII and Leiden Type A coronary arteries. Arterial saturation remained acceptable until the child reached the age of 3 months and a weight of 3.4 kg, when it started to drop below 75%. Echocardiography showed that the pulmonary stenosis was the result of a dysplastic PV, with a mildly hypoplastic annulus (Z-score −2) and 3 thickened leaflets with reduced mobility. On surgical inspection, the aortic valve was normal, but the PV showed thickened leaflets without commissural fusion. It was evident that this valve would not fare well under systemic pressures. The coronary arteries were harvested with a stripe of sinus wall, without disrupting the sino-tubular anatomy, and mobilized extensively. The aortic root was separated from the infundibulum in the same way as the pulmonary root is harvested during a Ross procedure (Fig. 1A). From there, the incision was directed around the PV, sideways until the common annulus with the mitral valve (Fig. 1B). The separation of these 2 structures had to be performed with great caution, as this common annulus must serve 2 annuli. To achieve this, the cut was made with a 45° angle and with the thought of leaving at least enough tissue in the mitral annulus for a subsequent suture. The en-bloc valves were rotated 180°. The aortic root was sutured to the mitral annulus. A patch of xenopericardium was used to close the VSD and was sutured on the anterior part of the aortic annulus. Finally, the pulmonary root was sutured to the infundibulum. Figure 1: View largeDownload slide En-bloc rotation of the truncus arteriosus. (A) Aortic root harvesting. (B) Incision of the pulmomitral continuity. Ao: aortic; Ant. Leaftlet: anterior leaflet; Ao v.: aortic valve; LCA: left coronary artery; MV: mitral valve; MPA: major pulmonary artery; PV: pulmonary valve; RCA: right coronary artery; SVC: superior vena cava; TV: tricuspid valve; VSD: ventricular septal defect. Figure 1: View largeDownload slide En-bloc rotation of the truncus arteriosus. (A) Aortic root harvesting. (B) Incision of the pulmomitral continuity. Ao: aortic; Ant. Leaftlet: anterior leaflet; Ao v.: aortic valve; LCA: left coronary artery; MV: mitral valve; MPA: major pulmonary artery; PV: pulmonary valve; RCA: right coronary artery; SVC: superior vena cava; TV: tricuspid valve; VSD: ventricular septal defect. The pulmonary arteries were mobilized widely and Lecompte manoeuvre was performed. The coronary arteries were implanted on the already existing holes. Weaning from cardiopulmonary bypass occurred without difficulties. The chest was electively left open and closed the next day. Transoesophageal echocardiography showed good biventricular function and good function of both the aortic and PV (with a gradient of 20 mmHg). There was a slight central mitral valve regurgitation which disappeared over the next 3 days. DISCUSSION This case shows that a complex repair of malposed great arteries—such as a Nikaidoh or double root rotation—is possible early in infancy. The main advantage of this procedure in this group of patients, in comparison with ASO, is having a normal AV in a systemic position which potentially avoids reintervention on the AV. Many steps are similar to those used in other operations, such as the coronary arteries transfer in an arterial switch operation or the harvest of the semi-lunar valves in a Ross procedure. There are, however, 2 specific points that are slightly different from a Nikaidoh: the separation of the pulmonary and mitral valve and the enbloc rotation of the truncus arteriosus. This approach avoids the use of a conduit, and a long intracardiac tunnel, as the aorta sits directly above the left ventricular outflow tract, which is enlarged by the VSD patch (see Fig. 2). Figure 2: View largeDownload slide Postoperative echocardiogram. The LVOT and RVOT are wide and show laminar flow. The aorta sits above the LVOT, with an anatomic configuration and mitro-aortic continuity. LV: left ventricle; LVOT: left ventricular outflow tract; MV: mitral valve; RVOT: right ventricular outflow tract. Figure 2: View largeDownload slide Postoperative echocardiogram. The LVOT and RVOT are wide and show laminar flow. The aorta sits above the LVOT, with an anatomic configuration and mitro-aortic continuity. LV: left ventricle; LVOT: left ventricular outflow tract; MV: mitral valve; RVOT: right ventricular outflow tract. Conflict of interest: none declared. REFERENCES 1 Kreutzer C, De Vive J, Oppido G, Kreutzer J, Gauvreau K, Freed M et al.   Twenty-five-year experience with rastelli repair for transposition of the great arteries. J Thorac Cardiovasc Surg  2000; 120: 211– 23. Google Scholar CrossRef Search ADS PubMed  2 Raju V, Myers PO, Quinonez LG, Emani SM, Mayer JE, Pigula FA et al.   Aortic root translocation (Nikaidoh procedure): intermediate follow-up and impact of conduit type. J Thorac Cardiovasc Surg  2015; 149: 1349– 55. Google Scholar CrossRef Search ADS PubMed  3 Mair R, Sames-Dolzer E, Vondrys D, Lechner E, Tulzer G. En bloc rotation of the truncus arteriosus—an option for anatomic repair of transposition of the great arteries, ventricular septal defect, and left ventricular outflow tract obstruction. J Thorac Cardiovasc Surg  2006; 131: 740– 1. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Mar 24, 2018

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