The Nikaidoh Operation: An Aortic Translocation Repair

The patient is a two-and-a-half-year-old child with d-TGA/VSD/PS who underwent aortic translocation. The patient’s anatomy was typical of d-transposition with VSD and PS. Both coronaries were favorable in that they were off of the epicardium.

To begin the procedure, the patient was positioned supine on the operating room table. A median sternotomy was performed, along with the usual preparation for bypass.

Next, the main coronaries were dissected out with electrocautery. Surgeons planned to perform this procedure with coronaries intact to reduce the chances of having neoaortic regurgitation.

Surgeons also planned to perform the translocation without taking separate coronary buttons; therefore, the coronaries had to be dissected off the myocardium and the epicardium much more than in an arterial switch, for example. For that purpose, a right-angle clamp was passed underneath each main coronary, right and left. The aortic root was dissected off the epicardium while going around the left coronary, taking great care not to injure that important structure.

The aorta was transected a few millimeters above the sinotubular junction, a cross-clamp was applied, and cardioplegia was given. Next, the stenotic main pulmonary artery was transected, again above the sinotubular junction, keeping as much tissue available for the main PA as possible, because of the plan to use a nonvalved reconstruction. 

The LeCompte maneuver was then performed, bringing the branch PAs anterior to the ascending aorta.

The aortic root was then separated from the RVOT, much in the manner of a Ross procedure. The interior wall of the RVOT was divided, thus separating the aortic root from the conus. Again, surgeons made sure that the semilunar valve was not damaged during this process. They used a combination of sharp scissors and electrocautery dissection, leaving about a millimeter or two of muscle rim attached to the valve, and taking great care not to injure the valve. The epicardium was dissected with electrocautery, making sure to keep the coronaries in place, as the neo-AI was predicted to be less if the aortic root remained undisturbed.

Next, the aortic root was separated from the LVOT with the coronaries intact. The aortic root was now attached only by the coronaries. The stenotic pulmonary valve was then divided to begin enlargement of the LVOT.  Much of it was kept as buttressing tissue posteriorly. The septum, which was posteriorly deviated, was also divided.

The team then moved on to closure of the VSD with sutures starting on the ventricular septum. First, the posterior LVOT was created by the splayed open main PA and pulmonary valve. The VSD suture was started at the fibrous attachment of the tricuspid valve. Surgeons use glutaraldehyde on the native pericardium. It has to be wide enough to create a bulge, creating the anterior portion of the LVOT, but not so wide that it bulges out into the RVOT and creates obstruction at that level. It can be helpful to pass a Hegar dilator through the LVOT in order to measure the exact width of the patch. A running suture technique was used with 5-0 Prolene and some interrupted sutures. It was confirmed that the LVOT was wide enough, and the team moved the detached aortic root over the LVOT and sutured it in that position, moving both coronaries posteriorly with ease.

Next, the excess muscle on the aortic root was trimmed off and interrupted mattress sutures were placed at each commissure. To begin aortic translocation, the suturing was done mostly from the outside, but in certain cases the needle goes inside out, taking great care not to injure the semilunar valve in particular underneath the coronaries. It can be tricky to create a hemostatic suture line, and it can be useful to place interrupted sutures at that level.

Once the posterior layer was completed, the anterior portion of the aortic root to VSD patch was performed in a running fashion. The end-to-end anastomosis between the aortic root and ascending aorta was performed with running 5-0 Prolene. There was no size mismatch since the aortic root was intact initially.

The pulmonary artery was then opened anteriorly to accept a transannular patch. A valveless reconstruction of the RVOT was planned.

There was a fair amount of stretching and moving the branch PAs downward caudally. In addition, the reconstructed aorta was bulging anteriorly, thus the team wanted to be careful not to end up with branch PS due to stretching of the branch PAs.

Next, the RVOT floor was created. The back wall of the opened main PA was not pulled all the way down to the VSD patch. Then, a bovine pericardial transannular patch was placed over the entire RVOT.

The heart started beating and seemed to be very vigorous and in sinus rhythm. The patient was rewarmed from a cooled core temperature of 32 degrees and one dose of cardioplegia was given.
 

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 Sep;88(3):365-72.
2. Olds A, Nakamura Y, Levasseur S, Shah A, Freud L, Chelliah A, Chai P, Quaegebeur J, Bacha E, Kalfa D. Outcomes of Surgical Repair of Complex D-Transposition of the Great Arteries. World J Pediatr Congenit Heart Surg. 2018 Nov;9(6):605-612. doi: 10.1177/2150135118789384.

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