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Pulmonary Root Translocation Without LeCompte Maneuver for D-Transposition of the Great Arteries With Ventricular Septal Defect and Pulmonary Stenosis

Wednesday, March 28, 2018

Gupta N, Raju V. Pulmonary Root Translocation Without LeCompte Maneuver for D-Transposition of the Great Arteries With Ventricular Septal Defect and Pulmonary Stenosis. March 2018. doi:10.25373/ctsnet.6027293.

This patient was a 7-year-old female child evaluated for cyanosis and failure to thrive since birth. She had an arterial saturation of approximately 70% on room air. She was diagnosed with dextro-transposition of the great arteries (D-TGA) with a large subaortic ventricular septal defect (VSD) and severe pulmonary valve stenosis (PS). Her ventricles were both good-sized with normal pulmonary artery branch anatomy. She was referred to the authors for surgical repair.

The pericardium was harvested and treated with 0.6% gluteraldehyde for 15 minutes. The aorta, the main pulmonary artery (MPA), right pulmonary artery (RPA), and left pulmonary artery (LPA) were dissected. The coronary anatomy was noted. The pulmonary root was dissected from the aortic root, taking care to avoid injury to the coronary arteries. Both pulmonary artery branches were dissected up to the hilum on either side. Cardiopulmonary bypass (CPB) was established with aortic, high superior vena cava, and inferior vena cava cannulation. The left ventricle (LV) was vented through the right superior pulmonary vein. The patient was cooled to 28 degrees Celsius. The RPA and LPA were completely dissected up to the hilar branches. Further dissection of the pulmonary root from the aortic root was carried out. The aorta was cross-clamped, and the heart was arrested with del Nido cardioplegia solution.

A right ventriculotomy was made well below the aortic valve and extended to just below the aortic valve. Conal muscle bundles were excised in the right ventricular outflow tract (RVOT). The capacity of the VSD to be routed to the aorta was confirmed. The pulmonary root was then harvested entirely from the LV without damaging the coronary artery, aortic valve, or mitral valve. The large subaortic VSD was routed in to the aortic valve using a large pericardial patch and a 6-0 Prolene™ suture. The routing of the VSD in to the aorta was made possible by a combined right atrium and right ventricle (RV) approach. The opening in the LV was closed with an additional pericardial patch. The harvested pulmonary valve opening did not admit more than a 10 size Hegar dilator. The applicable Z score was 1.6 mm (1.4 - 2.1 mm), hence the authors decided to cut across the pulmonary valve annulus. The pulmonary root and pulmonary arteries were moved to the RVOT without any difficulty. The authors did not divide the aorta nor did they perform a LeCompte maneuver to bring the entire pulmonary root, the pulmonary artery, and its branches to the RVOT incision. As mentioned by da Silva (1), the technique of pulmonary root translocation keeps the aorta untouched in its original anterior position, without any coronary artery manipulation. Thus, postoperative aortic valve dysfunction or coronary artery distortion is not expected after pulmonary root translocation.

The continuity between the pulmonary root and the RVOT was established directly in the posterior layer using a 6-0 Prolene™ suture. A large pericardial patch was used anteriorly, extending from the RVOT to the proximal MPA across the annulus. The PFO was left behind. After deairing, the cross-clamp was released and the heart picked up immediately. The patient came off CPB with minimal inotropic support. Direct needle pressure measurement showed a 0.7 RV/LV pressure ratio. Transesophageal echocardiography ruled out new onset aortic or mitral regurgitation. The child had an uneventful postoperative period and was sent home on the eighth postoperative day. The patient had an uneventful recovery and was doing well after two months (NYHA class1). There was a mild gradient across the newly constructed RVOT (25 mm peak gradient), which was noted in her recent echocardiogram.


Reference

  1. da Silva JP, Baumgratz JF, da Fonseca L. Pulmonary root translocation in transposition of great arteries repair. Ann Thorac Surg. 2000;69(2):643-645.

Comments

Dr. Raju has added another surgical approach for d-TGA/VSD/PS. I have no question in regard to the success of this approach. However, I would like to raise a concern of the long term reliability of left ventricular outflow tract. When we move the aortic root posteriorly making direct aorto-mitral continuity, this posterior move will compromise the distal pulmonary artery, possibly necessitating Lecompt maneuver. Since the aorta was not moved in this report, distal pulmonary artery was protected. Thus, a large pericardial patch into the spatulated pulmonary valve annulus was sufficient. Finally, a patch closure of left ventricular outlet could have been avoided if aortic translocation is accomplished. Further experience and additional observation are needed for d-TGA/VSD/PS.

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