Expanding the Limits of Posterior Aortic Translocation

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.

Tips and Pitfalls

A Nikaidoh procedure is a complex operation which calls for careful judgment. Factors to consider include:

1. The surgery is extensive by nature and presents important risks, even in the most favorable circumstances.
2. The size of the pulmonary artery annulus determines the distance that the aorta will translocate across the native septal plane and the degree to which the LVOT is well-aligned. At one extreme, in the context of a small pulmonary annular diameter, neo-LVOT alignment would not be substantially more linear than that provided by a Rastelli procedure after VSD enlargement, and thus the advantages of posterior translocation would be lost.
3. If the coronary anatomy is “normal” for d-TGA {1AD,Cx;2R}, the root can be transferred with the coronary arteries attached, preserving the natural geometry of the sinotubular junction.
4. Variant coronary anatomy with an anterior loop should be considered a contraindication. In ccTGA with situs solitus, there is a high risk of heart block [5, 6].
5. The risk of aortic regurgitation should be considered. This is apparent immediately after surgery and confirms the importance of the technical aspects of the operation. One simple trick to assess proper function and geometry of the translocated root is to administer cardioplegia before shaping the outflow patch.  This ensures the neo-LVOT and neo-annulus established by the patch preserve the geometry and orientation of the aortic root. Subsequently, the VSD can be closed with an appropriately trimmed patch, preserving the geometry of the aortic root.

References

1. 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(3):365-372.
2. Bautista-Hernandez V, Marx GR, Bacha EA, del Nido PJ.  Aortic root translocation plus arterial switch for transposition of the great arteries with left ventricular outflow tract obstruction: intermediate-term results. J Am Coll Cardiol. 2007;49(4):485-490.
3. Morell VO, Wearden PD. Technique of aortic translocation for the management of transposition of the great arteries with a ventricular septal defect and pulmonary stenosis. Oper Tech Thorac Cardiovasc Surg. 2008;13(3):181-187.
4. Hraska V. Anatomic correction of corrected transposition {I,D,D} using an atrial switch and aortic translocation. Ann Thorac Surg. 2008;85(1):352-353.
5. Hu SS, Liu ZG, Li SJ, et al. Strategy for biventricular outflow tract reconstruction: Rastelli, REV, or Nikaidoh procedure? J Thorac Cardiovasc Surg. 2008;135(2):331-338.
6. Sugiura J, Bierbach B, Hraska V. Expanding the limits of posterior aortic translocation: biventricular correction of complex transposition with complete atrioventricular septal defect and heterotaxy. Ann Thorac Surg. 2016;101(2):762-764.
7. Weyand K, Haun C,  Blaschczok H, et al. Surgical treatment of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction: midterm results. World J Pediatr Congenit Heart Surg. 2010;1(2):163-169.