EDITORIALS
Damus-Stansel-Kaye Procedure: Personal Observations Gordon K. Danielson, MD Mayo Clinic/Foundation, Rochester, Minnesota
D
r di Carlo and associates [l]have presented a comprehensive review of their experience in infants with the ingenious operation known as the DamusStansel-Kaye (DSK) procedure [2,3], among other names. The operation achieves a functional great artery switch in patients with complete transposition of the great arteries or other complex anomalies with transposition hemodynamics without the need to relocate the coronary arteries. The main pulmonary artery is transected near the bifurcation and anastomosed to the posterolateral aspect of the ascending aorta. Any ventricular septal defect is closed, and an extracardiac conduit establishes right ventricle to pulmonary artery continuity. If present, pulmonary artery narrowing from a pulmonary artery band and valvular or subvalvular pulmonary stenosis must be relieved to allow unrestricted outflow from the left ventricle to the aorta. This arrangement leaves an anatomical double-outlet right ventricle, but the aortic valve remains closed throughout the cardiac cycle because the pressure in the aorta is higher than the pressure in the right ventricle. The history of development of this concept is a fascinating one; the appearance of multiple independent letters and reports within a short period of time probably represents another example of ”an idea whose time has come.”
See also page 1148. The first reference to this concept was in a letter to Dr Dwight C. McGoon from Paul S. Damus, a West Coast resident in general surgery, dated September 30, 1972, which described and illustrated a new operation for transposition [4, 51. A manuscript was subsequently submitted to The Annals of Thoracic Surgery in December 1973, but for uncertain reasons, perhaps because there was no report of carrying out the procedure on cadaver hearts, the manuscript was not accepted [4, 61. Subsequently, in May 1975, Dr H. C. Stansel, Jr, independently proposed the operation and described experimental procedures on postmortem specimens that confirmed that, with suitable tailoring, anastomosis of the pulmonary artery to the aorta was feasible [7]. Later in the same year, also independently, Dr Michael P. Kaye from Rochester, MN, published the same concept [8], and Dr F. Alvarez from Madrid, Spain, described the operation in the Spanish literature [9]. Doctor McGoon was the first to perform the operation clinically (in 1975, but the patient did not survive) and the Address reprint requests to Dr Danielson, 200 First St, SW, Rochester, MN 55905.
0 1991 by The Society of Thoracic Surgeons
first to achieve an operative survivor (a 5-month-old infant on February 12, 1976) (McGoon DC; personal communication). The patient lived 2 years before dying of pulmonary hypertension. The first patient to survive to the present time was a 3-year-old who was operated on July 22, 1976, the first of 2 patients on whom the first hemodynamic and angiographic data related to the DSK operation were published [lo]. By 1982, the DSK procedure had been performed at our institution on 20 patients with complete transposition and on 4 patients with double-outlet right ventricle and subpulmonary ventricular septal defect [2]. We [ll]and others [12-141 have expanded the application of this concept to include patients having univentricular heart with subaortic stenosis and patients having other complex anomalies. Although the DSK concept has been employed now for 15 years, controversy still exists regarding its role in the treatment of various cardiac anomalies. The major advantage of the operation is that the coronary arteries do not need to be transferred from the aorta to the pulmonary artery. This is particularly advantageous when there are dense adhesions at the base of the heart from a previous operation, which make coronary artery transfer hazardous, or when there are coronary artery anomalies such as an intramural coronary artery, which make coronary artery transfer difficult. Additionally, the operation is advantageous when the great artery relationships preclude coronary artery transfer. The major disadvantage of the DSK procedure is the need for a right ventriculotomy and an extracardiac conduit, which becomes more of a problem in infancy, as reported by di Carlo and associates in their series [l]. Hospital mortality was high in infants in the early experience of all centers, but has declined substantially in recent years concomitant with increasing experience in repair of cardiac anomalies of all types in infants. In our opinion, the DSK operation is similar to operation for truncus arteriosus in infancy and also in older ages with respect to mortality, morbidity, and need for future conduit replacement. There are several technical pitfalls that must be avoided to have a successful result with the DSK procedure. Because the pulmonary valve becomes the new “aortic” valve, great care must be taken not to distort the pulmonary valve when the pulmonary artery is anastomosed to the ascending aorta. Even minor tension or distortion can produce serious valvular regurgitation. This is especially important when the main pulmonary artery is short or when a pulmonary artery band is present; the surgeon should be prepared to augment the main pulmonary Ann Thorac Surg 1991;52:1033-5
0003-4975/91/$3.50
1034
EDITORIAL DANIELSON DSK PROCEDURE
artery if there is any concern about distortion of the pulmonary valve. Another consideration is to avoid compression of the conduit between the heart and sternum. We have found it helpful to place the extracardiac conduit either to the right or left of the ascending aorta, as indicated, to minimize the length of conduit lying beneath the sternum [lo]. Durability of the pulmonary valve as the new “aortic” valve has the same limitations as in the arterial switch procedure. Late insufficiency of the neoaortic valve was reported by di Carlo and associates [l]in 1 patient, and there is 1 recent patient in our series who has required neoaortic valve replacement because of progressive valvular insufficiency (Puga FJ; personal communication). The question of whether to close the aortic valve/ subaortic area remains controversial [3]. Closure of the aortic valve is not necessary to prevent the valve from opening if cardiac hemodynamics are satisfactory. In 1 of our early patients who had severe pulmonary hypertension, episodic increases in pulmonary vascular resistance caused the aortic valve to open, resulting in severe cyanotic episodes. Reoperation was performed to close the aortic valve; this prevented cyanotic episodes but did not prevent profound low cardiac output when pulmonary vascular resistance increased. It was not until the pulmonary hypertension was controlled with vasodilators, sedation, and hyperventilation that the patient improved, and it seems likely closure of the valve might have been obviated by earlier control of the pulmonary hypertension. The principal reason given for closure of the native aortic valve is to avoid development of aortic valve insufficiency [3]. Early onset aortic insufficiency is probably related to distortion of the aorta by the anastomosis. The reason for late onset of this complication is not known, but it appears to be a definite problem: Di Carlo and associates [l]report 2 cases in their series and we have encountered 1patient in our experience who required late (9 years after repair) reoperation for aortic valve insufficiency. Suture of the aortic valve at the time of initial repair may not be an answer; 1 of the patients of di Carlo and associates required a second procedure for treatment of aortic valve insufficiency after valve suture. In my practice, the aortic valve/subaortic area is not closed at the time the DSK procedure is performed because of concern that the sutures, pledgets, or patches may promote stasis and thrombosis in the aortic root and to simplify the operation and shorten the duration of aortic crossclamping. An additional advantage of leaving the aortic valve unclosed is that, should conduit obstruction develop and not be recognized, exertional cyanosis will signal the need for conduit replacement. Further longterm evaluation of all patients undergoing this procedure should yield an improved perspective on this controversial issue. The DSK principle has been employed successfully by us [ll]and others [12-141 to relieve subaortic stenosis in various forms of univentricular heart, especially doubleinlet left ventricle with rudimentary right ventricle (outlet chamber) giving origin to the aorta. However, we have
Ann Thorac Surg 1991;52:103>5
generally abandoned the DSK approach in favor of direct resection of the subaortic stenosis either through the aorta and retracted aortic valve or through the outlet chamber [15]. In a personal series of 27 patients who underwent subaortic resection in relation to a modified Fontan procedure, there were only 3 deaths (cardiac failure, infection, and pulmonary embolism) and no instances of complete heart block, results that are notably better than our previous experience with the DSK procedure in relation to a modified Fontan procedure. Dr di Carlo and colleagues have employed a previously described modification of the DSK operation [14]in which the ventricular septal defect patch is carried to the right of the aortic valve (similar to the Rastelli principle), with the thought that the aortic sinuses would be washed out with antegrade blood flow through the aortic valve. Whether the hoped for advantages of this modification merit the increased time needed for placement of the baffle and the increased risk of residual ventricular septal defect (the incidence of residual ventricular septal defect was higher in our Rastelli series than for ventricular septal defect closure in other cardiac anomalies requiring a less extended baffle) remains to be determined by further experience. The DSK operation has been largely supplanted in the treatment of transposition of the great arteries and double-outlet right ventricle with subpulmonary ventricular septal defect by direct arterial switch procedures and in the relief of subaortic stenosis in univentricular heart anomalies by direct resection of the obstructing tissue. However, Dr di Carlo and colleagues have confirmed that the DSK operation does provide an excellent solution to certain difficult anatomical situations where other procedures are not feasible or are hazardous, and it should remain in the cardiac surgeon’s armamentarium, to be recalled when the occasion merits.
References 1. Di Carlo DC, Di Donato RM, Carotti A, Ballerini L, Marcelletti C. Evaluation of the Damus-Kaye-Stansel operation in infancy. Ann Thorac Surg 1991;52:114%53. 2. Ceithaml EL, Puga FJ, Danielson GK, McGoon DC, Ritter DG. Results of the Damus-Stansel-Kaye procedure for transposition of the great arteries and for double-outlet right ventricle with subpulmonary ventricular septal defect. Ann Thorac Surg 1984;38:433-7. 3. DeLeon SY, Idriss FS, Ilbawi MN, et al. The Damus-StanselKaye procedure. Should the aortic valve or subaortic valve region be closed? J Thorac Cardiovasc Surg 1986;91:747-53. 4. Damus PS. Correspondence. Ann Thorac Surg 1975;20: 7245. 5. Editor’s note. J Thorac Cardiovasc Surg 1982;83:316. 6. Editorial comments. Ann Thorac Surg 1975;20:725. 7. Stansel HC Jr. A new operation for d-loop transposition of the great vessels. Ann Thorac Surg 1975;19:565-7. 8. Kaye MP. Anatomic correction of transposition of great arteries. Mayo Clin Proc 1975;50:63%40. 9. Alvarez Diaz F, Hurtado Hoyo E, De Leon JP, et al. Tecnica de correcci6n anat6mica de la transposici6n completa de grandes vasos. Rev Esp Cardiol 1975;28:255-7.
Ann Thorac Surg 1991;52:1033-5
10. Danielson GK, Tabry IF, Mair DD, Fulton RE. Great-vessel switch operation without coronary relocation for transposition of great arteries. Mayo Clin Proc 1978;53:675-82. 11. Barber G, Hager DJ, Edwards WD, et al. Surgical repair of univentricular heart (double inlet left ventricle) with obstructed anterior subaortic outlet chamber. J Am Coll Cardiol 1984;4:771-8. 12. Yacoub MH, Radley-Smith R. Use of a valved conduit from the right atrium to pulmonary artery for ”correction” of single ventricle. Circulation 1976;54(Suppl 3):63-70. 13. Penkoske PA, Freedom RM, Williams WG, Trusler GA,
EDITORIAL
DANIELSON DSK PROCEDURE
1035
Rowe RD. Surgical palliation of subaortic stenosis in the univentricular heart. J Thorac Cardiovasc Surg 1984;87 767-81. 14. Lin AE, Laks H, Barber G, Chin AJ, Williams RG. Subaortic obstruction in complex congenital heart disease: management by proximal pulmonary artery to ascending aorta end to side anastomosis. J Am Coll Cardiol 1986;7617-24. 15. O’Leary PW, Driscoll DJ, Connor A, Puga FJ, Danielson GK. The univentricular heart with subaortic obstruction: results of a staged approach [Abstract]. Circulation 1990;82(Suppl 3):76.
Damus-Stansel-Kaye Procedure: Personal Observations Gordon K. Danielson, MD Mayo Clinic/Foundation, Rochester, Minnesota
D
r di Carlo and associates [l]have presented a comprehensive review of their experience in infants with the ingenious operation known as the DamusStansel-Kaye (DSK) procedure [2,3], among other names. The operation achieves a functional great artery switch in patients with complete transposition of the great arteries or other complex anomalies with transposition hemodynamics without the need to relocate the coronary arteries. The main pulmonary artery is transected near the bifurcation and anastomosed to the posterolateral aspect of the ascending aorta. Any ventricular septal defect is closed, and an extracardiac conduit establishes right ventricle to pulmonary artery continuity. If present, pulmonary artery narrowing from a pulmonary artery band and valvular or subvalvular pulmonary stenosis must be relieved to allow unrestricted outflow from the left ventricle to the aorta. This arrangement leaves an anatomical double-outlet right ventricle, but the aortic valve remains closed throughout the cardiac cycle because the pressure in the aorta is higher than the pressure in the right ventricle. The history of development of this concept is a fascinating one; the appearance of multiple independent letters and reports within a short period of time probably represents another example of ”an idea whose time has come.”
See also page 1148. The first reference to this concept was in a letter to Dr Dwight C. McGoon from Paul S. Damus, a West Coast resident in general surgery, dated September 30, 1972, which described and illustrated a new operation for transposition [4, 51. A manuscript was subsequently submitted to The Annals of Thoracic Surgery in December 1973, but for uncertain reasons, perhaps because there was no report of carrying out the procedure on cadaver hearts, the manuscript was not accepted [4, 61. Subsequently, in May 1975, Dr H. C. Stansel, Jr, independently proposed the operation and described experimental procedures on postmortem specimens that confirmed that, with suitable tailoring, anastomosis of the pulmonary artery to the aorta was feasible [7]. Later in the same year, also independently, Dr Michael P. Kaye from Rochester, MN, published the same concept [8], and Dr F. Alvarez from Madrid, Spain, described the operation in the Spanish literature [9]. Doctor McGoon was the first to perform the operation clinically (in 1975, but the patient did not survive) and the Address reprint requests to Dr Danielson, 200 First St, SW, Rochester, MN 55905.
0 1991 by The Society of Thoracic Surgeons
first to achieve an operative survivor (a 5-month-old infant on February 12, 1976) (McGoon DC; personal communication). The patient lived 2 years before dying of pulmonary hypertension. The first patient to survive to the present time was a 3-year-old who was operated on July 22, 1976, the first of 2 patients on whom the first hemodynamic and angiographic data related to the DSK operation were published [lo]. By 1982, the DSK procedure had been performed at our institution on 20 patients with complete transposition and on 4 patients with double-outlet right ventricle and subpulmonary ventricular septal defect [2]. We [ll]and others [12-141 have expanded the application of this concept to include patients having univentricular heart with subaortic stenosis and patients having other complex anomalies. Although the DSK concept has been employed now for 15 years, controversy still exists regarding its role in the treatment of various cardiac anomalies. The major advantage of the operation is that the coronary arteries do not need to be transferred from the aorta to the pulmonary artery. This is particularly advantageous when there are dense adhesions at the base of the heart from a previous operation, which make coronary artery transfer hazardous, or when there are coronary artery anomalies such as an intramural coronary artery, which make coronary artery transfer difficult. Additionally, the operation is advantageous when the great artery relationships preclude coronary artery transfer. The major disadvantage of the DSK procedure is the need for a right ventriculotomy and an extracardiac conduit, which becomes more of a problem in infancy, as reported by di Carlo and associates in their series [l]. Hospital mortality was high in infants in the early experience of all centers, but has declined substantially in recent years concomitant with increasing experience in repair of cardiac anomalies of all types in infants. In our opinion, the DSK operation is similar to operation for truncus arteriosus in infancy and also in older ages with respect to mortality, morbidity, and need for future conduit replacement. There are several technical pitfalls that must be avoided to have a successful result with the DSK procedure. Because the pulmonary valve becomes the new “aortic” valve, great care must be taken not to distort the pulmonary valve when the pulmonary artery is anastomosed to the ascending aorta. Even minor tension or distortion can produce serious valvular regurgitation. This is especially important when the main pulmonary artery is short or when a pulmonary artery band is present; the surgeon should be prepared to augment the main pulmonary Ann Thorac Surg 1991;52:1033-5
0003-4975/91/$3.50
1034
EDITORIAL DANIELSON DSK PROCEDURE
artery if there is any concern about distortion of the pulmonary valve. Another consideration is to avoid compression of the conduit between the heart and sternum. We have found it helpful to place the extracardiac conduit either to the right or left of the ascending aorta, as indicated, to minimize the length of conduit lying beneath the sternum [lo]. Durability of the pulmonary valve as the new “aortic” valve has the same limitations as in the arterial switch procedure. Late insufficiency of the neoaortic valve was reported by di Carlo and associates [l]in 1 patient, and there is 1 recent patient in our series who has required neoaortic valve replacement because of progressive valvular insufficiency (Puga FJ; personal communication). The question of whether to close the aortic valve/ subaortic area remains controversial [3]. Closure of the aortic valve is not necessary to prevent the valve from opening if cardiac hemodynamics are satisfactory. In 1 of our early patients who had severe pulmonary hypertension, episodic increases in pulmonary vascular resistance caused the aortic valve to open, resulting in severe cyanotic episodes. Reoperation was performed to close the aortic valve; this prevented cyanotic episodes but did not prevent profound low cardiac output when pulmonary vascular resistance increased. It was not until the pulmonary hypertension was controlled with vasodilators, sedation, and hyperventilation that the patient improved, and it seems likely closure of the valve might have been obviated by earlier control of the pulmonary hypertension. The principal reason given for closure of the native aortic valve is to avoid development of aortic valve insufficiency [3]. Early onset aortic insufficiency is probably related to distortion of the aorta by the anastomosis. The reason for late onset of this complication is not known, but it appears to be a definite problem: Di Carlo and associates [l]report 2 cases in their series and we have encountered 1patient in our experience who required late (9 years after repair) reoperation for aortic valve insufficiency. Suture of the aortic valve at the time of initial repair may not be an answer; 1 of the patients of di Carlo and associates required a second procedure for treatment of aortic valve insufficiency after valve suture. In my practice, the aortic valve/subaortic area is not closed at the time the DSK procedure is performed because of concern that the sutures, pledgets, or patches may promote stasis and thrombosis in the aortic root and to simplify the operation and shorten the duration of aortic crossclamping. An additional advantage of leaving the aortic valve unclosed is that, should conduit obstruction develop and not be recognized, exertional cyanosis will signal the need for conduit replacement. Further longterm evaluation of all patients undergoing this procedure should yield an improved perspective on this controversial issue. The DSK principle has been employed successfully by us [ll]and others [12-141 to relieve subaortic stenosis in various forms of univentricular heart, especially doubleinlet left ventricle with rudimentary right ventricle (outlet chamber) giving origin to the aorta. However, we have
Ann Thorac Surg 1991;52:103>5
generally abandoned the DSK approach in favor of direct resection of the subaortic stenosis either through the aorta and retracted aortic valve or through the outlet chamber [15]. In a personal series of 27 patients who underwent subaortic resection in relation to a modified Fontan procedure, there were only 3 deaths (cardiac failure, infection, and pulmonary embolism) and no instances of complete heart block, results that are notably better than our previous experience with the DSK procedure in relation to a modified Fontan procedure. Dr di Carlo and colleagues have employed a previously described modification of the DSK operation [14]in which the ventricular septal defect patch is carried to the right of the aortic valve (similar to the Rastelli principle), with the thought that the aortic sinuses would be washed out with antegrade blood flow through the aortic valve. Whether the hoped for advantages of this modification merit the increased time needed for placement of the baffle and the increased risk of residual ventricular septal defect (the incidence of residual ventricular septal defect was higher in our Rastelli series than for ventricular septal defect closure in other cardiac anomalies requiring a less extended baffle) remains to be determined by further experience. The DSK operation has been largely supplanted in the treatment of transposition of the great arteries and double-outlet right ventricle with subpulmonary ventricular septal defect by direct arterial switch procedures and in the relief of subaortic stenosis in univentricular heart anomalies by direct resection of the obstructing tissue. However, Dr di Carlo and colleagues have confirmed that the DSK operation does provide an excellent solution to certain difficult anatomical situations where other procedures are not feasible or are hazardous, and it should remain in the cardiac surgeon’s armamentarium, to be recalled when the occasion merits.
References 1. Di Carlo DC, Di Donato RM, Carotti A, Ballerini L, Marcelletti C. Evaluation of the Damus-Kaye-Stansel operation in infancy. Ann Thorac Surg 1991;52:114%53. 2. Ceithaml EL, Puga FJ, Danielson GK, McGoon DC, Ritter DG. Results of the Damus-Stansel-Kaye procedure for transposition of the great arteries and for double-outlet right ventricle with subpulmonary ventricular septal defect. Ann Thorac Surg 1984;38:433-7. 3. DeLeon SY, Idriss FS, Ilbawi MN, et al. The Damus-StanselKaye procedure. Should the aortic valve or subaortic valve region be closed? J Thorac Cardiovasc Surg 1986;91:747-53. 4. Damus PS. Correspondence. Ann Thorac Surg 1975;20: 7245. 5. Editor’s note. J Thorac Cardiovasc Surg 1982;83:316. 6. Editorial comments. Ann Thorac Surg 1975;20:725. 7. Stansel HC Jr. A new operation for d-loop transposition of the great vessels. Ann Thorac Surg 1975;19:565-7. 8. Kaye MP. Anatomic correction of transposition of great arteries. Mayo Clin Proc 1975;50:63%40. 9. Alvarez Diaz F, Hurtado Hoyo E, De Leon JP, et al. Tecnica de correcci6n anat6mica de la transposici6n completa de grandes vasos. Rev Esp Cardiol 1975;28:255-7.
Ann Thorac Surg 1991;52:1033-5
10. Danielson GK, Tabry IF, Mair DD, Fulton RE. Great-vessel switch operation without coronary relocation for transposition of great arteries. Mayo Clin Proc 1978;53:675-82. 11. Barber G, Hager DJ, Edwards WD, et al. Surgical repair of univentricular heart (double inlet left ventricle) with obstructed anterior subaortic outlet chamber. J Am Coll Cardiol 1984;4:771-8. 12. Yacoub MH, Radley-Smith R. Use of a valved conduit from the right atrium to pulmonary artery for ”correction” of single ventricle. Circulation 1976;54(Suppl 3):63-70. 13. Penkoske PA, Freedom RM, Williams WG, Trusler GA,
EDITORIAL
DANIELSON DSK PROCEDURE
1035
Rowe RD. Surgical palliation of subaortic stenosis in the univentricular heart. J Thorac Cardiovasc Surg 1984;87 767-81. 14. Lin AE, Laks H, Barber G, Chin AJ, Williams RG. Subaortic obstruction in complex congenital heart disease: management by proximal pulmonary artery to ascending aorta end to side anastomosis. J Am Coll Cardiol 1986;7617-24. 15. O’Leary PW, Driscoll DJ, Connor A, Puga FJ, Danielson GK. The univentricular heart with subaortic obstruction: results of a staged approach [Abstract]. Circulation 1990;82(Suppl 3):76.
