Asian Cardiovasc Thorac Ann 2005;13:208-210
© 2005 Asia Publishing EXchange Ltd
Early Results of Anatomic Repair in A Subgroup of Corrected Transposition
Thaworn Subtaweesin, MD,
Somchai Sriyoschati, MD
Department of Surgery, Siriraj Hospital Bangkok, Thailand
For reprint information contact: Thaworn Subtaweesin, MD Tel: 66 2 419 7998 Fax: 66 2 411 0260 Email: sitsw{at}mucc.mahidol.ac.th, Department of Surgery, Siriraj Hospital, 2 Phrannok St., Bankoknoi, Bangkok 10700, Thailand.
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ABSTRACT
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The atrial switch operation with the Rastelli procedure is becoming popular for treatment of the subgroup of corrected transposition of the great arteries with ventricular septal defect and pulmonary obstruction. This technique eliminates the problem of short- and long-term right ventricular failure, and decreases the incidence of iatrogenic atrioventricular heart block. Between April 2001 and November 2002, this technique was used in 3 patients aged 5 to 7 years. Two had a Senning operation and one had a Mustard operation. There was no operative death. The first patient needed re-operation to close the sternum. The last patient was re-explored for bleeding. All patients were in New York Heart Association functional class I at their last follow-up. The atrial switch plus Rastelli procedure is feasible in this subgroup of corrected transposition, but longer follow-up is necessary to determine whether this approach is indeed warranted.
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INTRODUCTION
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Congenital corrected transposition of the great arteries (TGA) is characterized by the presence of both atrioventricular and ventriculoarterial discordance. There are 3 segmental anatomic types described by Van Praagh1 and referred to as SLL, SLD, and IDD. Corrected TGA is commonly associated with ventricular septal defect (VSD) and pulmonary obstruction.2 The operations performed for this triad of anomalies include closure of the VSD and creation of a conduit from the morphologic left ventricle (LV) to the pulmonary artery, a Fontan operation, or the alternative approach comprised of atrial switch and a Rastelli operation.3 Our early experience of anatomic repair of this subtype of corrected TGA is described.
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PATIENTS AND METHODS
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Between April 2001 and November 2002, 3 patients with corrected TGA combined with VSD and pulmonary obstruction underwent anatomic correction at Siriraj Hospital. Two patients were 7 years of age and the other was 5-years old at the time of operation. Their weights were 19, 21, and 23 kg (Table 1
). One patient had situs inversus (IDD), and the other 2 had situs solitus (SLL). Previously, 2 patients had a modified Blalock-Taussig saturation shunt at 2-years old, due to severe hypoxia (O2 < 65%). There was pulmonary atresia in one and severe pulmonary stenosis in the other two. The first patient developed stenosis of the pulmonary continuity at the site of shunt insertion. No heart block or tricuspid valve regurgitation were found. All patients had a large perimembranous VSD (Figure 1).
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Figure 1. Angiography of patient no. 3, showing ventriculoarterial discordance. AO = ascending aorta, RV = right ventricle.
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Repair was performed through a median sternotomy. A large piece of free pericardium was harvested for the Mustard operation, and a large piece of in situ pericardium was prepared for the pulmonary venous pathway in the Senning operation. Moderate hypothermia (22°C–24°C) was used. Ascending aortic and bicaval cardiopulmonary bypass was commenced after the previously placed systemic-to-pulmonary artery shunt was taken down. Myocardial protection was achieved with antegrade cold blood cardioplegia during the atrial switch procedure and closure of the VSD. The RV outflow tract reconstruction was carried out on a beating heart. The atrial switch was performed using the original Mustard operation in one patient and the modified Senning in two (Table 1
).4 A longitudinal ventriculotomy was made in the morphologic RV, caudad to the aortic valve. A large patch of vascular graft was used to direct blood flow from the morphologic LV through the VSD into the aorta and, in effect, to close the defect. The patch was secured with interrupted pledgeted sutures placed on the morphologic RV septum to avoid the conduction pathway. Continuity between the morphologic RV and the pulmonary artery was established using a homograft (2 aortic, 1 pulmonic) conduit (20–22 mm in diameter). A tube extension of pericardium, ascending aortic homograft, or vascular graft was used to lengthen the conduit and also to avoid compression of the valve by the sternum.
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RESULTS
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There was no operative death. The first case needed delayed closure of the sternum due to marked tissue edema after a very long period of bypass. The last case needed re-exploration due to bleeding from the atriotomy incision. The durations of cardiopulmonary bypass, aortic crossclamping, intensive care stay, and hospital stay are shown in Table 2. All patients were on small doses of dobutamine and nitroglycerine infusion while in the intensive care unit. They were all discharged in normal sinus rhythm with good hemodynamics. Follow-up echocardiography was carried out in all patients at 12 to 22 months postoperatively. It revealed a good result in all patients, except for anatomical compression of the homograft extension tube by the sternum in 2, without significant hemodynamic obstruction (Figure 2). At the last follow-up, all patients were asymptomatic (New York Heart Association functional class I).
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Figure 2. Echocardiography in patient no 1. at the last follow-up, showing anatomical compression of the homograft extension tube by the sternum.
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DISCUSSION
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Long-term results with the morphologic RV as the systemic ventricle in patients with corrected transposition has been the subject of considerable controversy.5–7 Systemic RV failure, usually associated with tricuspid regurgitation after atrial switch repair in complete TGA, is experienced with increasing frequency.8–9 Thus, anatomic repair of corrected TGA has become popular in the past decade.10–13 In our institution, we applied this anatomic repair concept in the subgroup of corrected TGA patients with VSD and pulmonary obstruction. The surgical approach to this triad of anomalies used in this report provides an attractive alternative to the classic repair. It corrects the lesion both anatomically and physiologically. Its main advantage is the use of the morphologic LV as the systemic ventricle by directing blood flow through the VSD into the aorta. In addition, ventriculotomy in the morphologic RV provides excellent exposure of the RV side of the septum and allows closure of the VSD with minimal chance of injury to the conduction pathway. The ventriculotomy can then be used for insertion of the RV-to-pulmonary artery valved conduit.
The drawbacks of this approach include the potential problem of systemic and pulmonary venous obstruction caused by the atrial switch operation, as well as atrial arrhythmia.9 In our series, no patient thus far has developed these problems. This was also emphasized by Sharma and colleagues14 who showed no rhythm disturbance on follow-up (mean, 44 months) in patients who underwent a Senning plus Rastelli operation. Conduit problems may also be encountered, so the timing of repair should be postponed until the patient is over 5 years of age, at which time, the retrosternal space is adequate to accommodate a large RV-to-pulmonary artery conduit, without distortion of the conduit or compression by the sternum. Because of the excellent short-term results in our patients, and good intermediate to long-term follow-up in many series, we recommend this approach as the procedure of choice in this subgroup of patients with corrected TGA.10,12–16 However, longer follow-up is necessary to determine whether this approach is indeed warranted.
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REFERENCES
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- Ilbawi MN, DeLeon SY, Backer CL, Duffy CE, Muster AJ, Zales VR, et al. An alternative approach to the surgical management of physiologically corrected transposition with ventricular septal defect and pulmonary stenosis or atresia. J Thorac Cardiovasc Surg 1990;100:410–5.[Abstract]
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- McGrath LB, Kirklin JW, Blackstone EH, Pacifico AD, Kirklin JK, Bargeron LM. Death and other events after cardiac repair in discordant atrioventricular connection. J Thorac Cardiovasc Surg 1985;90:711–28.[Abstract]
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- Turina MI, Siebenmann R, von Segesser L, Schonbeck M, Senning A. Late functional deterioration after atrial correction for transposition of the great arteries. Circulation 1989;80(3 Pt 1):I162–7.
- Ilbawi MN, Ocampo CB, Allen BS, Barth MJ, Roberson DA, Chiemmongkoltip P, et al. Intermediate results of the anatomic repair for congenitally corrected transposition. Ann Thorac Surg 2002;73:594–600.[Abstract/Free Full Text]
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- Imamura M, Drummond-Webb JJ, Murphy DJ Jr, Prieto LR, Latson LA, Flamm SD, et al. Results of the double switch operation in the current era. Ann Thorac Surg 2000;70:100–5.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
