CASE REPORT KOSHIYAMA ET AL TRUNCAL SWITCH FOR DORV STRADDLING MV
1431
was relatively maintained. This appears to have occurred on the basis of severely injured airways and morphologically preserved pulmonary vessels in the native lung, as shown by the pathologic examination of the excised right lung. We performed native lung PAB, and the patient was successfully weaned from ECMO. Pneumonectomy of the native lung was another option in this situation. We proceeded with PAB first because of an anxiety about postpneumonectomy syndrome, which was reported after a single-lung transplantation [4]. Another concern about native lung pneumonectomy was associated with the patient’s age. The patient was 14 years old and had the potential to grow. When the patient grows and the transplanted lobe becomes too small for her body, one of the treatment options will be contralateral single-lung transplantation from a cadaveric donor. Native lung pneumonectomy will make retransplantation difficult. In summary, the experience with the present case indicates that PAB may be a feasible procedure to rescue patients from hypoxemia resulting from ventilation–perfusion mismatch after a single LDLLT, which could be considered before contralateral pneumonectomy, especially in pediatric cases.
References
Fig 2. A photograph of the left hilum of the recipient at the second operation. The left main pulmonary artery was banded using an expanded polytetrafluoroethylene vascular graft.
successfully increased the ventilation of the left lung and improved hypoxemia. After a careful weaning process under tracheostomy, the patient was eventually weaned from the ventilator on postoperative day 42. Her recovery thereafter was uneventful. She is well and goes to school without oxygen at 12 months after the single LDLLT, treated with minimal immunosuppression consisting of 500 mg of mycophenolate mofetil and 3 mg of prednisolone. The scintigraphic examination at this point showed 73% ventilation and 69% perfusion to the transplanted lobe. Histologic examination of the native right lung revealed severely injured bronchioles and well-preserved pulmonary vessels, accounting for the severe perfusion–ventilation mismatch seen in the present case.
Comment One of the problems that will be encountered after a single LDLLT is ventilation–perfusion mismatch between the transplanted lobe and the contralateral native lung, which may result in hypoxemia. In the present case, preferential ventilation of the lobar graft on the basis of a significant discrepancy of the pulmonary compliance between the graft and the native lung caused atelectasis of the native lung, whereas blood flow to the native lung Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Starnes VA, Barr ML, Cohen RG. Lobar transplantation. Indications, technique, and outcome. J Thorac Cardiovasc Surg 1994;108:403–11. 2. Date H, Shiraishi T, Sugimoto S, et al. Outcome of livingdonor lobar lung transplantation using a single donor. J Thorac Cardiovasc Surg 2012;144:710–5. 3. Force SD, Miller DL, Pelaez A, et al. Outcomes of delayed chest closure after bilateral lung transplantation. Ann Thorac Surg 2006;81:2020–5. 4. Sakiyalak P, Vigneswaran WT. Postpneumonectomy syndrome in single lung transplantation recipient following previous pneumonectomy. Ann Thorac Surg 2003;75: 1023–5.
Successful Biventricular Repair of Double-Outlet Right Ventricle With Transposition of the Great Arteries, Pulmonary Stenosis, and Straddling Mitral Valve Hiroshi Koshiyama, MD, Mitsuru Aoki, MD, Syou Akiyama, MD, Yuki Nakamura, MD, Ikuo Hagino, MD, and Tadashi Fujiwara, MD Department of Cardiovascular Surgery, Chiba Children’s Hospital, Chiba, Japan
A 9-month-old boy with polysplenia, double-outlet right ventricle (DORV), transposition of the great arteries (TGA), a large ventricular septal defect (VSD), straddling Accepted for publication July 1, 2013. Address correspondence to Dr. Aoki, Department of Cardiovascular Surgery, Chiba Children Hospital, 579-1 Heta, Midori, Chiba 266-0007, Japan; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.07.063
FEATURE ARTICLES
Ann Thorac Surg 2014;97:1431–3
1432
CASE REPORT KOSHIYAMA ET AL TRUNCAL SWITCH FOR DORV STRADDLING MV
mitral valve, pulmonary stenosis (PS), and a normalsized pulmonary annulus underwent ventricular septation at the right side of the straddling mitral chord as well as an en bloc truncal switch procedure to minimize reduction of right ventricular (RV) volume from the intraventricular conduit. Echocardiography 5 months postoperatively showed laminar flow without obstruction through both ventricular outflow tracts, normal ventricular function, trivial aortic regurgitation, and mild pulmonary regurgitation (PR). This procedure is a good option for biventricular repair in the presence of a straddling mitral valve. (Ann Thorac Surg 2014;97:1431–3) Ó 2014 by The Society of Thoracic Surgeons
T FEATURE ARTICLES
he Rastelli procedure [1] has become the standard for biventricular repair of transposition of the great arteries (TGA), ventricular septal defect (VSD), and pulmonary stenosis (PS). However, in the presence of a double-outlet right ventricle (DORV) and straddling mitral valve, univentricular repair is usually performed because of the significant right ventricular (RV) volume reduction from intraventricular rerouting that can be caused by the Rastelli procedure [2]. We report a case of successful biventricular repair of DORV with TGA, straddling mitral valve, PS, pulmonary regurgitation (PR), and a normal-sized pulmonary annulus with an en bloc truncal switch procedure. A full-term male neonate (3.1 kg) presenting with cyanosis was referred to our hospital immediately after birth. A diagnosis of polysplenia, DORV, TGA, subpulmonary VSD, straddling mitral valve, mild PS, mild PR, restrictive patent foramen ovale, and an azygos connection was made by echocardiography and computed tomography (Fig 1A). Balloon atrial septectomy was performed but was inadequate because of the azygos connection. Catheterization at the age of 30 days showed mild PS with a pressure gradient of 10 mm Hg and a normal pulmonary annular diameter (7.4 mm). Primary arterial switch was
Fig 1. (A) Preoperative 3-dimensional computed tomographic scan in sagittal plane showing straddling mitral valve papillary muscle in right ventricle (RV). Rastelli procedure would cause significant right ventricular volume reduction. Dotted lines indicate intraventricular rerouting plane in cases of Rastelli procedure (white) and truncal switch procedure (red). (B) Postoperative 3-dimensional computed tomographic scan in sagittal plane showing laminar flow through both the left ventricular outflow tract (LVOT) and right ventricular outflow tract (RVOT), without obstruction, and minimal RV volume reduction. Red dotted line indicates intraventricular rerouting patch. (Ao ¼ aorta; PA ¼ pulmonary artery; VS ¼ ventricular septum.)
Ann Thorac Surg 2014;97:1431–3
not considered a good option because of the PS and PR. Over the course of the patient’s hospitalization, his cyanosis and bradycardia progressed because of sinus node dysfunction. Therefore, the patient underwent atrial septectomy and dual-chamber pacemaker implantation through a median sternotomy at the age of 2 months. Intraoperative exploration showed a large perimembranous VSD extending anteriorly and inferiorly, as well as both right anterior aorta and left posterior pulmonary trunk arising from the right ventricle. The anterior papillary muscle of the mitral valve inserted into the RV anterior free wall beyond the thin anterior margin of the VSD. The pulmonary valve was thickened with commissural fusion. Coronary anatomy was Yacoub type A with an RV branch from the left main coronary artery. The Rastelli procedure did not seem a good option; creation of an intracardiac left ventricle–to-aorta route would cause a significant reduction in RV volume because of the straddling mitral valve and distant aorta (Fig 1A). Echocardiography at the age of 4 months showed a pulmonary valve with a pressure gradient of 36 mm Hg, mild PR, and a normal pulmonary annulus (9.9 mm), which was considered sufficient for a pulmonary valve but not for an aortic valve. Therefore, at 9 months of age and a body weight of 7.6 kg, an en bloc truncal switch procedure was performed under hypothermic cardiopulmonary bypass and antegrade cold cardioplegic arrest. The ascending aorta and pulmonary trunk were transected. Coronary buttons were detached and the proximal portions were mobilized as in the arterial switch operation. The RV branch from the left main coronary artery was divided. The aortic and pulmonary valves were then enucleated en bloc, together with the conus septum. The truncal block was rotated 180 degrees and carefully positioned to align with the coronary artery orifices and was then reimplanted in the LV outflow tract (LVOT). The coronary arteries were also reimplanted in the reverse corresponding aortic defects. A Lecompte maneuver was performed, and the ascending aorta was reconstructed with an end-to-end anastomosis. Intraventricular rerouting from the large perimembranous VSD to the translocated aortic valve was performed with a cut-open expanded polytetrafluoroethylene
(ePTFE) graft. The straddling mitral papillary muscle was incorporated in the left side of the rerouting patch without translocation by suturing the patch onto the RV free wall over the thin anterior margin of the VSD and around the right side of the straddling papillary muscle. The large ASD was closed using an ePTFE patch. After the aortic clamp was released, pulmonary valve commissurotomy and leaflet shaving were performed, and the pulmonary trunk was reconstructed using an end-to-end anastomosis. The gap between the RV outflow hole and the translocated pulmonary valve was supplemented with a cut-open ePTFE graft. The patient was weaned from cardiopulmonary bypass and the chest was closed primarily. Total pump time was 375 minutes and cross-clamp time was 255 minutes. His postoperative course was uneventful. Postoperative echocardiography and computed tomography showed laminar flow through both the LVOT and right ventricular outflow tract (RVOT) without obstruction. The patient has been followed for 20 months and is doing well. Echocardiography and catheterization at 10 months after operation showed normal ventricular function, trivial aortic regurgitation, mild PR, mild mitral regurgitation, no LVOT or RVOT obstruction, and normal RV pressure.
Comment
CASE REPORT BOBYLEV ET AL AORTA–RIGHT VENTRICULAR TUNNEL
1433
2. Hazekamp M, Portela F, Bartelings M. The optimal procedure for the great arteries and left ventricular outflow tract obstruction. An anatomical study. Eur J Cardiothorac Surg 2007;31:879–87. 3. Kreutzer C, De Vive J, Oppido G, et al. Twenty-five-year experience with Rastelli repair for transposition of the great arteries. J Thorac Cardiovasc Surg 2000;120:211–23. 4. Fang M, Wang H, Zhu H, et al. Half rotation of the truncus arteriosus plus arterial switch for transposition of the great arteries with ventricular septal defect and pulmonary outflow tract obstruction. Eur J Cardiothorac Surg 2011;40:579–83. 5. Nikaidoh H. Aortic translocation and biventricular outflow tract reconstruction. A new surgical repair for transposition of the great arteries associated with ventricular septal defect and pulmonary stenosis. J Thorac Cardiovasc Surg 1984;88: 365–72. 6. Yeh T, Ramaciotti C, Leonard SR, Roy L, Nikaidoh H. The aortic translocation (Nikaidoh) procedure: midterm results superior to the Rastelli procedure. J Thorac Cardiovasc Surg 2007;133:461–9. 7. Yamagishi M, Shuntoh K, Matsushita T, et al. Half-turned truncal switch operation for complete transposition of the great arteries with ventricular septal defect and pulmonary stenosis. J Thorac Cardiovasc Surg 2003;125:966–8. 8. Mair R, Sames-Dolzer E, Vondrys D, Lechner E, Tulzer G. En bloc rotation of the truncus arteriosus—an option for anatomic repair of transposition of the great arteries, ventricular septal defect, and left ventricular outflow tract obstruction. J Thorac Cardiovasc Surg 2006;131:740–1.
Surgical Repair of Aortoventricular Tunnel Connected to the Apex of the Right Ventricle in a Neonate
The Rastelli procedure [1] has been widely applied to biventricular repair of TGA with VSD and PS or DORV with TGA and PS. However, its long-term results have not been satisfactory because of LVOT obstruction, conduit obstruction, arrhythmias, and a surprisingly low long-term survival [3]. Moreover, the Rastelli procedure is contraindicated in the presence of a straddling mitral valve, for which univentricular repair is usually performed [2, 4]. In addition, a distant aorta resulting from DORV results in a long intracardiac tunnel. In these cases, aortic translocation procedures [5] are good alternative techniques for biventricular repair because of a relatively small RV volume reduction. A high incidence of serious complications such as coronary insufficiency and late RVOT obstruction [6] were reported for the original aortic translocation procedure by Nikaidoh [5]. To solve these problems, half-turned truncal switch and en bloc truncal switch procedures have recently been reported, with good early results [4, 7, 8]. Our patient had mild pulmonary valvular and subvalvular stenosis with a normalsized annulus. It was possible to use the pulmonary valve for the RVOT with commissurotomy and leaflet shaving, thereby preserving valvular function and growth potential. We believe the en bloc truncal switch procedure is the best option to accomplish biventricular repair in cases of DORV with TGA, straddling mitral valve, and mild PS with a normal-sized pulmonary annulus.
ortoventricular tunnel is a rare congenital malformation, which can lead to heart failure in neonates. This extracardiac channel may connect the ascending aorta above the sinotubular junction to the cavity of the left or right ventricle. Only 17 of cases of aorta–right ventricular tunnel (ARVT) have been reported in the
References
Accepted for publication June 10, 2013.
1. Rastelli GC, Wallace RB, Ongley PA. Complete repair of transposition of the great arteries with pulmonary stenosis. A review and report of a case corrected by using a new surgical technique. Circulation 1969;39:83–95.
Address correspondence to Dr Bobylev, Division of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, CarlNeuberg-Str. 1, 30625 Hannover, Germany; e-mail: bobylev.dmitry@ mh-hannover.de.
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Dmitry Bobylev, MD, Masamichi Ono, MD, PhD, Anneke Neumann, MD, Harald Bertram, MD, and Alexander Horke, MD Divisions of Cardiothoracic, Transplantation, and Vascular Surgery and Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
We describe a neonate in whom early symptoms of heart failure developed because of a rare aorta–right ventricular tunnel connected to the apex of the right ventricle. Successful immediate surgical repair was carried out with closure of both ends of the tunnel. (Ann Thorac Surg 2014;97:1433–6) Ó 2014 by The Society of Thoracic Surgeons
A
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.06.121
FEATURE ARTICLES
Ann Thorac Surg 2014;97:1433–6
1431
was relatively maintained. This appears to have occurred on the basis of severely injured airways and morphologically preserved pulmonary vessels in the native lung, as shown by the pathologic examination of the excised right lung. We performed native lung PAB, and the patient was successfully weaned from ECMO. Pneumonectomy of the native lung was another option in this situation. We proceeded with PAB first because of an anxiety about postpneumonectomy syndrome, which was reported after a single-lung transplantation [4]. Another concern about native lung pneumonectomy was associated with the patient’s age. The patient was 14 years old and had the potential to grow. When the patient grows and the transplanted lobe becomes too small for her body, one of the treatment options will be contralateral single-lung transplantation from a cadaveric donor. Native lung pneumonectomy will make retransplantation difficult. In summary, the experience with the present case indicates that PAB may be a feasible procedure to rescue patients from hypoxemia resulting from ventilation–perfusion mismatch after a single LDLLT, which could be considered before contralateral pneumonectomy, especially in pediatric cases.
References
Fig 2. A photograph of the left hilum of the recipient at the second operation. The left main pulmonary artery was banded using an expanded polytetrafluoroethylene vascular graft.
successfully increased the ventilation of the left lung and improved hypoxemia. After a careful weaning process under tracheostomy, the patient was eventually weaned from the ventilator on postoperative day 42. Her recovery thereafter was uneventful. She is well and goes to school without oxygen at 12 months after the single LDLLT, treated with minimal immunosuppression consisting of 500 mg of mycophenolate mofetil and 3 mg of prednisolone. The scintigraphic examination at this point showed 73% ventilation and 69% perfusion to the transplanted lobe. Histologic examination of the native right lung revealed severely injured bronchioles and well-preserved pulmonary vessels, accounting for the severe perfusion–ventilation mismatch seen in the present case.
Comment One of the problems that will be encountered after a single LDLLT is ventilation–perfusion mismatch between the transplanted lobe and the contralateral native lung, which may result in hypoxemia. In the present case, preferential ventilation of the lobar graft on the basis of a significant discrepancy of the pulmonary compliance between the graft and the native lung caused atelectasis of the native lung, whereas blood flow to the native lung Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Starnes VA, Barr ML, Cohen RG. Lobar transplantation. Indications, technique, and outcome. J Thorac Cardiovasc Surg 1994;108:403–11. 2. Date H, Shiraishi T, Sugimoto S, et al. Outcome of livingdonor lobar lung transplantation using a single donor. J Thorac Cardiovasc Surg 2012;144:710–5. 3. Force SD, Miller DL, Pelaez A, et al. Outcomes of delayed chest closure after bilateral lung transplantation. Ann Thorac Surg 2006;81:2020–5. 4. Sakiyalak P, Vigneswaran WT. Postpneumonectomy syndrome in single lung transplantation recipient following previous pneumonectomy. Ann Thorac Surg 2003;75: 1023–5.
Successful Biventricular Repair of Double-Outlet Right Ventricle With Transposition of the Great Arteries, Pulmonary Stenosis, and Straddling Mitral Valve Hiroshi Koshiyama, MD, Mitsuru Aoki, MD, Syou Akiyama, MD, Yuki Nakamura, MD, Ikuo Hagino, MD, and Tadashi Fujiwara, MD Department of Cardiovascular Surgery, Chiba Children’s Hospital, Chiba, Japan
A 9-month-old boy with polysplenia, double-outlet right ventricle (DORV), transposition of the great arteries (TGA), a large ventricular septal defect (VSD), straddling Accepted for publication July 1, 2013. Address correspondence to Dr. Aoki, Department of Cardiovascular Surgery, Chiba Children Hospital, 579-1 Heta, Midori, Chiba 266-0007, Japan; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.07.063
FEATURE ARTICLES
Ann Thorac Surg 2014;97:1431–3
1432
CASE REPORT KOSHIYAMA ET AL TRUNCAL SWITCH FOR DORV STRADDLING MV
mitral valve, pulmonary stenosis (PS), and a normalsized pulmonary annulus underwent ventricular septation at the right side of the straddling mitral chord as well as an en bloc truncal switch procedure to minimize reduction of right ventricular (RV) volume from the intraventricular conduit. Echocardiography 5 months postoperatively showed laminar flow without obstruction through both ventricular outflow tracts, normal ventricular function, trivial aortic regurgitation, and mild pulmonary regurgitation (PR). This procedure is a good option for biventricular repair in the presence of a straddling mitral valve. (Ann Thorac Surg 2014;97:1431–3) Ó 2014 by The Society of Thoracic Surgeons
T FEATURE ARTICLES
he Rastelli procedure [1] has become the standard for biventricular repair of transposition of the great arteries (TGA), ventricular septal defect (VSD), and pulmonary stenosis (PS). However, in the presence of a double-outlet right ventricle (DORV) and straddling mitral valve, univentricular repair is usually performed because of the significant right ventricular (RV) volume reduction from intraventricular rerouting that can be caused by the Rastelli procedure [2]. We report a case of successful biventricular repair of DORV with TGA, straddling mitral valve, PS, pulmonary regurgitation (PR), and a normal-sized pulmonary annulus with an en bloc truncal switch procedure. A full-term male neonate (3.1 kg) presenting with cyanosis was referred to our hospital immediately after birth. A diagnosis of polysplenia, DORV, TGA, subpulmonary VSD, straddling mitral valve, mild PS, mild PR, restrictive patent foramen ovale, and an azygos connection was made by echocardiography and computed tomography (Fig 1A). Balloon atrial septectomy was performed but was inadequate because of the azygos connection. Catheterization at the age of 30 days showed mild PS with a pressure gradient of 10 mm Hg and a normal pulmonary annular diameter (7.4 mm). Primary arterial switch was
Fig 1. (A) Preoperative 3-dimensional computed tomographic scan in sagittal plane showing straddling mitral valve papillary muscle in right ventricle (RV). Rastelli procedure would cause significant right ventricular volume reduction. Dotted lines indicate intraventricular rerouting plane in cases of Rastelli procedure (white) and truncal switch procedure (red). (B) Postoperative 3-dimensional computed tomographic scan in sagittal plane showing laminar flow through both the left ventricular outflow tract (LVOT) and right ventricular outflow tract (RVOT), without obstruction, and minimal RV volume reduction. Red dotted line indicates intraventricular rerouting patch. (Ao ¼ aorta; PA ¼ pulmonary artery; VS ¼ ventricular septum.)
Ann Thorac Surg 2014;97:1431–3
not considered a good option because of the PS and PR. Over the course of the patient’s hospitalization, his cyanosis and bradycardia progressed because of sinus node dysfunction. Therefore, the patient underwent atrial septectomy and dual-chamber pacemaker implantation through a median sternotomy at the age of 2 months. Intraoperative exploration showed a large perimembranous VSD extending anteriorly and inferiorly, as well as both right anterior aorta and left posterior pulmonary trunk arising from the right ventricle. The anterior papillary muscle of the mitral valve inserted into the RV anterior free wall beyond the thin anterior margin of the VSD. The pulmonary valve was thickened with commissural fusion. Coronary anatomy was Yacoub type A with an RV branch from the left main coronary artery. The Rastelli procedure did not seem a good option; creation of an intracardiac left ventricle–to-aorta route would cause a significant reduction in RV volume because of the straddling mitral valve and distant aorta (Fig 1A). Echocardiography at the age of 4 months showed a pulmonary valve with a pressure gradient of 36 mm Hg, mild PR, and a normal pulmonary annulus (9.9 mm), which was considered sufficient for a pulmonary valve but not for an aortic valve. Therefore, at 9 months of age and a body weight of 7.6 kg, an en bloc truncal switch procedure was performed under hypothermic cardiopulmonary bypass and antegrade cold cardioplegic arrest. The ascending aorta and pulmonary trunk were transected. Coronary buttons were detached and the proximal portions were mobilized as in the arterial switch operation. The RV branch from the left main coronary artery was divided. The aortic and pulmonary valves were then enucleated en bloc, together with the conus septum. The truncal block was rotated 180 degrees and carefully positioned to align with the coronary artery orifices and was then reimplanted in the LV outflow tract (LVOT). The coronary arteries were also reimplanted in the reverse corresponding aortic defects. A Lecompte maneuver was performed, and the ascending aorta was reconstructed with an end-to-end anastomosis. Intraventricular rerouting from the large perimembranous VSD to the translocated aortic valve was performed with a cut-open expanded polytetrafluoroethylene
(ePTFE) graft. The straddling mitral papillary muscle was incorporated in the left side of the rerouting patch without translocation by suturing the patch onto the RV free wall over the thin anterior margin of the VSD and around the right side of the straddling papillary muscle. The large ASD was closed using an ePTFE patch. After the aortic clamp was released, pulmonary valve commissurotomy and leaflet shaving were performed, and the pulmonary trunk was reconstructed using an end-to-end anastomosis. The gap between the RV outflow hole and the translocated pulmonary valve was supplemented with a cut-open ePTFE graft. The patient was weaned from cardiopulmonary bypass and the chest was closed primarily. Total pump time was 375 minutes and cross-clamp time was 255 minutes. His postoperative course was uneventful. Postoperative echocardiography and computed tomography showed laminar flow through both the LVOT and right ventricular outflow tract (RVOT) without obstruction. The patient has been followed for 20 months and is doing well. Echocardiography and catheterization at 10 months after operation showed normal ventricular function, trivial aortic regurgitation, mild PR, mild mitral regurgitation, no LVOT or RVOT obstruction, and normal RV pressure.
Comment
CASE REPORT BOBYLEV ET AL AORTA–RIGHT VENTRICULAR TUNNEL
1433
2. Hazekamp M, Portela F, Bartelings M. The optimal procedure for the great arteries and left ventricular outflow tract obstruction. An anatomical study. Eur J Cardiothorac Surg 2007;31:879–87. 3. Kreutzer C, De Vive J, Oppido G, et al. Twenty-five-year experience with Rastelli repair for transposition of the great arteries. J Thorac Cardiovasc Surg 2000;120:211–23. 4. Fang M, Wang H, Zhu H, et al. Half rotation of the truncus arteriosus plus arterial switch for transposition of the great arteries with ventricular septal defect and pulmonary outflow tract obstruction. Eur J Cardiothorac Surg 2011;40:579–83. 5. Nikaidoh H. Aortic translocation and biventricular outflow tract reconstruction. A new surgical repair for transposition of the great arteries associated with ventricular septal defect and pulmonary stenosis. J Thorac Cardiovasc Surg 1984;88: 365–72. 6. Yeh T, Ramaciotti C, Leonard SR, Roy L, Nikaidoh H. The aortic translocation (Nikaidoh) procedure: midterm results superior to the Rastelli procedure. J Thorac Cardiovasc Surg 2007;133:461–9. 7. Yamagishi M, Shuntoh K, Matsushita T, et al. Half-turned truncal switch operation for complete transposition of the great arteries with ventricular septal defect and pulmonary stenosis. J Thorac Cardiovasc Surg 2003;125:966–8. 8. Mair R, Sames-Dolzer E, Vondrys D, Lechner E, Tulzer G. En bloc rotation of the truncus arteriosus—an option for anatomic repair of transposition of the great arteries, ventricular septal defect, and left ventricular outflow tract obstruction. J Thorac Cardiovasc Surg 2006;131:740–1.
Surgical Repair of Aortoventricular Tunnel Connected to the Apex of the Right Ventricle in a Neonate
The Rastelli procedure [1] has been widely applied to biventricular repair of TGA with VSD and PS or DORV with TGA and PS. However, its long-term results have not been satisfactory because of LVOT obstruction, conduit obstruction, arrhythmias, and a surprisingly low long-term survival [3]. Moreover, the Rastelli procedure is contraindicated in the presence of a straddling mitral valve, for which univentricular repair is usually performed [2, 4]. In addition, a distant aorta resulting from DORV results in a long intracardiac tunnel. In these cases, aortic translocation procedures [5] are good alternative techniques for biventricular repair because of a relatively small RV volume reduction. A high incidence of serious complications such as coronary insufficiency and late RVOT obstruction [6] were reported for the original aortic translocation procedure by Nikaidoh [5]. To solve these problems, half-turned truncal switch and en bloc truncal switch procedures have recently been reported, with good early results [4, 7, 8]. Our patient had mild pulmonary valvular and subvalvular stenosis with a normalsized annulus. It was possible to use the pulmonary valve for the RVOT with commissurotomy and leaflet shaving, thereby preserving valvular function and growth potential. We believe the en bloc truncal switch procedure is the best option to accomplish biventricular repair in cases of DORV with TGA, straddling mitral valve, and mild PS with a normal-sized pulmonary annulus.
ortoventricular tunnel is a rare congenital malformation, which can lead to heart failure in neonates. This extracardiac channel may connect the ascending aorta above the sinotubular junction to the cavity of the left or right ventricle. Only 17 of cases of aorta–right ventricular tunnel (ARVT) have been reported in the
References
Accepted for publication June 10, 2013.
1. Rastelli GC, Wallace RB, Ongley PA. Complete repair of transposition of the great arteries with pulmonary stenosis. A review and report of a case corrected by using a new surgical technique. Circulation 1969;39:83–95.
Address correspondence to Dr Bobylev, Division of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, CarlNeuberg-Str. 1, 30625 Hannover, Germany; e-mail: bobylev.dmitry@ mh-hannover.de.
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Dmitry Bobylev, MD, Masamichi Ono, MD, PhD, Anneke Neumann, MD, Harald Bertram, MD, and Alexander Horke, MD Divisions of Cardiothoracic, Transplantation, and Vascular Surgery and Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
We describe a neonate in whom early symptoms of heart failure developed because of a rare aorta–right ventricular tunnel connected to the apex of the right ventricle. Successful immediate surgical repair was carried out with closure of both ends of the tunnel. (Ann Thorac Surg 2014;97:1433–6) Ó 2014 by The Society of Thoracic Surgeons
A
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.06.121
FEATURE ARTICLES
Ann Thorac Surg 2014;97:1433–6
