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Address reprint requests to Sheng-Shou Hu, MD, FACC, Department of Pediatric Cardiovascular Surgery, The National Cardiovascular Center and Fu Wai Hospital Beijing, Chinese Academe of Medical Science and Peking Union Medical College, 167 Beuilishi Road, Beijing, 100037 China
Surgical management of patients with ventriculoarterial discordance, ventricular septal defect (VSD), and pulmonary outflow tract obstruction (PS) remains challenging. The Rastelli procedure has been the surgical approach to such patients. However, given its poor long-term results, an alternative surgical technique is required. With the aims of preserving the competence and growth potential of both the native aortic and the pulmonary valves, as well as of achieving better long-term results, we proposed the “double-root translocation” technique for biventricular outflow tract reconstruction. Since March 2004, we have used this technique as a routine surgical management for 40 consecutive patients with transposition of great arteries (TGA), VSD, and PS, or “transposition-type” double-outlet right ventricle with PS.
Between November 2004 and June 2008, 40 consecutive patients underwent double-root translocation. The median age at operation was 3.8 years (range, 0.3-18). TGA with VSD and PS were diagnosed in 30 patients (4 with atrioventricular discordance), and double-outlet right ventricle (Taussig-Bing anomalies) with PS in 10 cases (1 with atrioventricular discordance). The mean cardiopulmonary bypass and aortic cross-clamp times were 325 ± 57 and 225 ± 43 minutes, respectively. The mean mechanical ventilation time was 142 ± 151 hours. Four patients required ECMO support; two of these four recovered. Two patients died in this series. The causes of death were left ventricular dysfunction caused by left coronary artery insufficiency, and renal failure and sepsis caused by severe hemolysis (a complication of ECMO). Postoperative echocardiography demonstrated physiologic flow in the LVOT and normal heart function in 39 cases. Five patients had a competent pulmonary valve; 22 patients had mild pulmonary insufficiency, and 13 patients had moderate pulmonary insufficiency. Only one patient demonstrated mild aortic and mitral valve insufficiency after surgery. At the most recent echocardiographic examination of this patient (19 months after surgery), the ventricular function had totally recovered and only trivial aortic and mitral insufficiency could be detected. No patient developed new aortic or mitral insufficiency, and no re-interventions have been necessary during follow-up. The double-root translocation technique is a feasible and effective procedure for patients with anomalies of ventriculoarterial connection, VSD, and PS. Attention to coronary artery manipulation is of crucial importance to the success of this procedure. Long-term benefits need to be further assessed by a larger number of patients as well as a longer follow-up study.