Expanding the Limits of Posterior Aortic Translocation

2018-09-11T17:46:53Z (GMT) by Viktor Hraska Michael Madrzak

Currently the posterior translocation of the aorta, the Nikaidoh procedure, is utilized in:

  1. complete transposition of the great arteries (d-TGA) with ventricular septal defect (VSD) and left ventricular outflow tract obstruction (LVOTO) [1,2,3] (video 1),
  2. corrected TGA (ccTGA) with VSD and complex LVOTO [4,5], and
  3. double outlet right ventricle (DORV) - TGA type with complete atrioventricular septal defect (CAVC) and pulmonary stenosis [6] (video 2).

A Nikaidoh procedure is considered if the anatomy is inadequate for an intraventricular baffle as part of a Rastelli operation in d-TGA, ccTGA, and DORV with CAVC [7]. Typically, a Nikaidoh procedure is a valuable option in the presence of an inlet and/or restrictive VSD, straddling of the atrioventricular (AV) valves and/or CAVC, and borderline right ventricular (RV) volume.

Video 1

The patient was 8 weeks old at the time of operation.

Diagnosis

  1. TGA {1AD,Cx; 2R}
  2. inlet type of VSD
  3. valvar and subvalvar pulmonary stenosis
  4. atrial septal defect

History

  1. At 10 days old, the patient underwent a balloon atrioseptectomy.
  2. At 8 weeks old, semielective surgery was performed due to progressive cyanosis.

Procedure

  1. Posterior translocation of the aorta.
  2. Direct connection of the pulmonary artery with the right ventriculotomy and patch enlargement of the right ventricular outflow tract.
  3. Direct closure of the atrial septal defect.

Video 2

The patient was 9 years old at the time of the operation.

Diagnosis

  1. complete AV canal defect Rastelli A
  2. double outlet right ventricle with subvalvar and valvar pulmonary stenosis
  3. monoatrium with left isomerism
  4. bilateral superior venae cavae with no bridging vein, and a left superior vena cava draining into an unroofed coronary sinus
  5. S/P modified Blalock–Taussig shunt

History

  1. At 5 years old, the patient underwent a Blalock–Taussig shunt due to progressive cyanosis.
  2. At 9 years old, semielective surgery was performed due to progressive cyanosis and failure to thrive.

Procedure

  1. Posterior translocation of the aorta and a two-patch repair of the complete AV canal defect.
  2. Right ventricle to pulmonary artery conduit.
  3. Septation of the common atrium with pericardial patch, and redirection of the left superior vena cava into right atrium.

Operative Steps

Technical points include the following:

  1. Extensive mobilization of the proximal coronary arteries to permit safe exposure of the aortic root and subsequent coronary transfer without tension.
  2. Harvest of the aortic root with a generous cuff of RV muscle (8 - 10 mm).
  3. Transection of the ascending aorta and excision of a short segment of aorta. This allows for a more posterior position of the reconstructed aorta in order to accomodate the LeCompte maneuver.
  4. Transection of the pulmonary trunk and retention of a remnant of pulmonary valve tissue for later suture line reinforcement.
  5. Incision of the outlet septum through the superior border of the VSD.
  6. Aortic translocation: seating the aortic root in the LVOT with a continuous suture of approximately three-quarters of the root circumference; reinforcement of a portion of this suture line with a second suture line incorporating the native pulmonary annulus and the pulmonary artery wall.
  7. LeCompte maneuver and the reconstruction of the ascending aorta.
  8. Closure of the VSD with an appropriately trimmed patch, preserving geometry of the aortic root.
  9. Reduction of the lateral aspects of the right ventriculotomy with pledgeted sutures and reconstruction, either by direct right ventricle to pulmonary artery anastomosis or by an orthotopically placed pulmonary homograft.
  10. Modifications to this technique include individual coronary transfer during translocation in order to avoid the possibility of coronary ischemia when the position of the great vessels is not optimal.

Learn more: https://www.ctsnet.org/article/expanding-limits-posterior-aortic-translocation

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