Expanding the Limits of Posterior Aortic Translocation

2018-09-11T17:46:53Z (GMT) by Viktor Hraska Michael Madrzak
<p>Currently the posterior translocation of the aorta, the Nikaidoh procedure, is utilized in:</p><ol><li>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),</li><li>corrected TGA (ccTGA) with VSD and complex LVOTO [4,5], and</li><li>double outlet right ventricle (DORV) - TGA type with complete atrioventricular septal defect (CAVC) and pulmonary stenosis [6] (video 2).</li></ol><p>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.</p><p><strong>Video 1</strong></p><p>The patient was 8 weeks old at the time of operation.</p><p><em>Diagnosis</em></p><ol><li>TGA {1AD,Cx; 2R}</li><li>inlet type of VSD</li><li>valvar and subvalvar pulmonary stenosis</li><li>atrial septal defect</li></ol><p><em>History</em></p><ol><li>At 10 days old, the patient underwent a balloon atrioseptectomy.</li><li>At 8 weeks old, semielective surgery was performed due to progressive cyanosis.</li></ol><p><em>Procedure</em></p><ol><li>Posterior translocation of the aorta.</li><li>Direct connection of the pulmonary artery with the right ventriculotomy and patch enlargement of the right ventricular outflow tract.</li><li>Direct closure of the atrial septal defect.</li></ol><div><p><strong>Video 2</strong></p><p>The patient was 9 years old at the time of the operation.</p><p><em>Diagnosis</em></p><ol><li>complete AV canal defect Rastelli A</li><li>double outlet right ventricle with subvalvar and valvar pulmonary stenosis</li><li>monoatrium with left isomerism</li><li>bilateral superior venae cavae with no bridging vein, and a left superior vena cava draining into an unroofed coronary sinus</li><li>S/P modified Blalock–Taussig shunt</li></ol><p><em>History</em></p><ol><li>At 5 years old, the patient underwent a Blalock–Taussig shunt due to progressive cyanosis.</li><li>At 9 years old, semielective surgery was performed due to progressive cyanosis and failure to thrive.</li></ol><p><em>Procedure</em></p><ol><li>Posterior translocation of the aorta and a two-patch repair of the complete AV canal defect.</li><li>Right ventricle to pulmonary artery conduit.</li><li>Septation of the common atrium with pericardial patch, and redirection of the left superior vena cava into right atrium.</li></ol><p><strong>Operative Steps</strong></p><p>Technical points include the following:</p><ol><li>Extensive mobilization of the proximal coronary arteries to permit safe exposure of the aortic root and subsequent coronary transfer without tension.</li><li>Harvest of the aortic root with a generous cuff of RV muscle (8 - 10 mm).</li><li>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.</li><li>Transection of the pulmonary trunk and retention of a remnant of pulmonary valve tissue for later suture line reinforcement.</li><li>Incision of the outlet septum through the superior border of the VSD.</li><li>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.</li><li>LeCompte maneuver and the reconstruction of the ascending aorta.</li><li>Closure of the VSD with an appropriately trimmed patch, preserving geometry of the aortic root.</li><li>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.</li><li>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.</li></ol><p>Learn more: https://www.ctsnet.org/article/expanding-limits-posterior-aortic-translocation</p></div>

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