Volume 13, Issue 3 , Pages 172-180, Autumn 2008
The Aortic Translocation (Nikaidoh) Operation
Article Outline
Surgical management of d-transposition of the great arteries associated with ventricular septal defect (VSD) and left ventricular outflow tract obstruction remains a challenge. The arterial switch operation is usually not feasible because of the resulting valvar and subvalvar aortic stenosis. Atrial switch procedures (Mustard or Senning operation) with relief of the left ventricular outflow tract obstruction are of historical interest only, because of poor early and late results. The Rastelli operation has been used extensively for this combination of congenital heart defects. However, late morbidity and mortality are discouragingly high because of left ventricular dysfunction, or the development of left ventricular outflow tract obstruction because of closure of the VSD or narrowing of the interventricular tunnel.
Because of disappointment with the Rastelli operation, the senior author (HN) developed the aortic translocation operation as an alternative procedure. Results of the first two patients undergoing the aortic translocation operation were reported in 1984.1 The procedure was proposed as a technique to avoid obstruction of the right and left ventricular outflow tracts. Complete mobilization of the aortic root from the right ventricular outflow tract and subsequent translocation of the aortic root into the opened left ventricular outflow tract combine to eliminate the potential for valvar and subvalvar aortic stenosis. Reconstruction of the right ventricular outflow tract without a valved conduit greatly reduces the need for reoperation for conduit degeneration and stenosis.
Technical Considerations
Patients who have pulmonary stenosis with a normal-size pulmonary valve annulus may not require the aortic translocation operation for surgical correction. These patients may be better treated with an arterial switch procedure with pulmonary valvotomy and/or subvalvar resection. In addition, aortic translocation in a patient with a normal-size pulmonary annulus may be complicated by coronary artery distortion from excessive posterior movement of the aortic root into the left ventricular outflow tract.
If the ventricular septal defect is not large, we prefer to avoid using a patch to close the defect. During mobilization of the aortic root, a generous lip of ventricular free wall may be harvested on the anterior aspect of the root and this may be used to close the VSD.
Branch pulmonary artery stenosis can be caused by too aggressively moving the pulmonary bifurcation anteriorly on the left side of the ascending aorta. The posterior movement of the aortic root combined with the anterior traction of the pulmonary bifurcation may compress the proximal right pulmonary artery. Also, spatulating the proximal left pulmonary artery and enlarging this segment with the right ventricular outflow tract patch may decrease the incidence of proximal left pulmonary artery stenosis. As described by others,2 we have recently incorporated the Lecompte maneuver to bring the pulmonary bifurcation anterior to the ascending aorta. This maneuver is very valuable in reducing the risk of branch pulmonary artery stenosis.
Operative Technique
Figure 1.
(A) Cardiopulmonary bypass is established using bicaval cannulation. The aortic cannula is placed as cephalad as possible in the ascending aorta. (B) The aortic root is mobilized circumferentially from the right ventricular outflow tract. A wider rim of the right ventricular free wall is left attached to the anterior aspect of the aortic root. The proximal coronary arteries are mobilized off the underlying myocardium. Injury to major coronary artery branches must be avoided. Ao = aorta; LCA = left coronary artery; Lig. art. = ligamentum arteriosum; MPA = main pulmonary artery; RA = right atrium; RCA = right coronary artery; VSD = ventricular septal defect.
Figure 2.
(A) The main pulmonary artery is divided just above the pulmonary valve. The branch pulmonary arteries should be mobilized distally to the pulmonary hila. Division of the ligamentum arteriosum is also important for complete mobilization of the pulmonary arteries. (B) The proximal pulmonary root is opened longitudinally into the superior aspect of the ventricular septal defect and the pulmonary valve tissue is excised. This allows the left ventricular outflow tract to be widely opened to accommodate the aortic root. Lig. art. = ligamentum arteriosum; MPA = main pulmonary artery; MV = mitral valve; Pulm. v. = pulmonary valve; VSD = ventricular septal defect.
Figure 3.
(A) The aortic root is sutured into the left ventricular outflow tract with continuous polypropylene suture. If the VSD is not too large, the rim of myocardium along the anterior aspect of the aortic root may be sutured directly to the inferior aspect of the ventricular septal defect to close the defect. (B) However, if the VSD is large, it may be necessary to place a patch between the aortic root and the inferior margin of the defect for adequate closure. (C) Moving the aortic root directly posterior into the left ventricular outflow tract will usually not cause kinking or stretching of the coronary arteries. Pivoting the aortic root around the origin of the left coronary artery may result in stretching of the right coronary artery. The coronary artery ostia should be reimplanted in the aortic root if there is any question of kinking or stretching of the coronary arteries. RCA = right coronary artery; VSD = ventricular septal defect.
Figure 4.
The medial aspect of the distal end of the divided main pulmonary artery is sutured to the left lateral aspect of the ascending aorta with running polypropylene suture. Care should be taken to avoid pulling the pulmonary artery so far anteriorly that the right pulmonary artery becomes stretched, as this may cause stenosis of the right pulmonary artery. The proximal left pulmonary artery is incised to prevent narrowing of this branch. LPA = left pulmonary artery.
Figure 5.
A large pericardial patch is used to reconstruct the right ventricular outflow tract. The patch extends into the incision in the left pulmonary artery and is sutured in place with running polypropylene suture. Alternatively, the right ventricular outflow tract can be reconstructed using a homograft or similar valved tissue conduit.
Figure 6.
(A) Applying the Lecompte maneuver to the pulmonary artery may decrease the incidence of branch pulmonary artery stenosis. The aorta is transected well above the aortic valve and the pulmonary artery bifurcation is moved anterior to the ascending aorta. (B) The divided aorta is approximated with running polypropylene suture. VSD = ventricular septal defect.
Figure 7.
(A) The posterior aspect of the distal main pulmonary artery is sutured to the anterior wall of the ascending aorta. (B) A large pericardial patch is used to complete reconstruction of the right ventricular outflow tract. Incisions in the proximal right and left pulmonary arteries may decrease the incidence of branch pulmonary artery stenosis. (C) The ASD is closed through a right atrial incision with direct suture technique or with a patch. ASD = atrial septal defect.
Comments
To date, we have performed 21 aortic translocation operations. The experience in the first 19 patients was reported in 2007.3 One patient died after 7 days of postoperative extracorporeal membrane oxygenation support, probably from coronary artery insufficiency. All other patients (20/21, 95%) survived. Performance of the left ventricular outflow tract has been excellent. No patients have required reoperation for the left ventricular outflow tract. Recent echocardiographic data are available on 19 patients. Aortic valve insufficiency was graded mild in nine patients, trivial in three patients, and absent in seven patients. As expected, reoperation on the right ventricular outflow tract is not uncommon whether the right ventricular outflow tract (RVOT) reconstruction was done with a valved tissue conduit or a pericardial patch without a valve. Eight late operations have been performed in six patients on the right ventricular outflow tract (seven for stenosis and one for insufficiency). Of seven operations for pulmonary stenosis, six were performed in patients who had reconstruction of the right ventricular outflow tract with a homograft, suggesting relatively stable results in valveless reconstruction of the RVOT with a pericardial patch.
References
- . Aortic translocation and biventricular outflow tract reconstruction: a new surgical repair for transposition of the great arteries associated with ventricular septal defect and pulmonary stenosis. J Thorac Cardiovasc Surg. 1984;88:365–372
- . Aortic translocation with autologous tissue. Tex Heart Inst J. 2007;34:420–422
- The aortic translocation (Nikaidoh) procedure: midterm results superior to the Rastelli procedure. J Thorac Cardiovasc Surg. 2007;133:461–469
PII: S1522-2942(08)00037-8
doi:10.1053/j.optechstcvs.2008.06.002
© 2008 Elsevier Inc. All rights reserved.
Volume 13, Issue 3 , Pages 172-180, Autumn 2008
