Interposition of a modified aortic homograft conduit as main pulmonary trunk in anatomic correction of transposition of the great arteries

J

THORAC CARDIOV ASC

S URG 82:429-435, 1981

Interposition of a modified aortic homograft conduit as main pulmonary trunk in anatomic correction of transposition of the great arteries Report of two cases and technical considerations Anatomic correction oftransposition of the great arteries and ventricular septal defect has been performed successfully in two patients. The technique employed differed in several aspects from the so-called Jatene procedure: (I) Both great arteries were transected at low level; (2) the switch of the coronary arteries was carried out after transection of both great arteries; (3) a modified aortic homograft conduit was used to bridge the gap between the proximal aortic root and the distal main pulmonary artery: (4) the "new" main pulmonary arterial trunk was positioned on the right side of the ascending aorta: and (5) the ascending aorta was enlarged in order to match the dilated proximal pulmonary stump. The advantages o{ these modifications over other techniques reported in the literature are discussed.

Gian Piero Piccoli, M.D.,* and David I. Hamilton, M.B., B.S., F.R.C.S., Liverpool, United Kingdom

About seventy percent of patients with transposition of the great arteries (TGA) and large ventricular septal defect (VSD) die within the first 6 months of life.' In the survivors, the progression of pulmonary vascular disease is rapid.i " Commonly they are treated with a balloon atrial septostomy':" at the time of the first catheterization or with a Blalock-Hanlon" septectomy. The second surgical step can be either a palliative procedure'?"!" (banding of the pulmonary artery) followed later by total repair or an early corrective repair in the first year of life.!' A hemodynamic correction can be achieved by transposing the atrial inftow"":" with or without VSD closure, according to the severity of pulmonary vascular disease. IX. III An anatomic correction From the Cardiothoracic Surgical Unit, Royal Liverpool Children's Hospital, Liverpool, United Kingdom. G. P. Piccoli was supported by a grant from The National Heart Research Foundation. Received for publication Dec. 30, 1980. Accepted for publication Feb. II, 1981. Address for reprints: David I. Hamilton, M.B., B.S., F.R.C.S., Consultant Cardiothoracic Surgeon, Royal Liverpool Children's Hospital, Myrtle Street, Liverpool L7 7DG, United Kingdom. *Present address: Div. Chirurgia Cardiovascolare, Istituto Cardiologico "G. M. Lancisi," Via Baccarani 6, 60100 Ancona, Italy.

can be performed at the ventricular level with the insertion of a valved external conduit in patients previously palliated 20-22 or with a complete intraventricular repair, provided that the VSD is large, without any extracardiac conduit." The operative mortality of patients with TGA and large VSD treated with these techniques is still high. 7 , X. 14. 20, 22, 24 For this reason, the concept of anatomic correction at great artery level, first postulated more than 20 years ago,25-31 seems to be worthy of further consideration.P""! Discouraged by the poor results obtained with the Mustard procedure associated with transatrial patch closure of the VSD in this group of patients, we have performed a switch of the great arteries with trans ventricular patch closure of the VSD in a total of two cases.

Case reports CASE I. A female patient was born on Jan. I, 1979, following an uncomplicated pregnancy and delivery. Cyanosis and a heart murmur were noted at birth. She presented with mild dyspnea while feeding, and digitalis and diuretics were used to control congestive heart failure. The infant was referred to this hospital on Aug. 14, 1979. Examination on admission revealed a satisfactorily nourished infant, weighing 4.8 kg, with moderate cyanosis. There was a Grade 3/6 systolic murmur at the left sternal edge with a single second sound. The electrocardiogram showed right ventricular hy-

0022-5223/811090429+07$00.7010 © 1981 The C. V. Mosby Co.

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Fig. 1. A. Lateral right ventricular angiogram in Case I. The contrast medium opacifies the right ventricle (RV). the aorta (A a) and, passing through a perimenbranous-malalignment ventricular septal defect (V), the pulmonary artery (PA). Tricuspid valve incompetence, determined by the catheter, causes opacification of the right atrium (RA). The disproportion between the size of the main PA and the ascending Ao is evident. B, Posteroanterior hepatoclavicular left ventricular angiogram of Case 2. The contrast medium opacifies the left ventricle (LV) and the pulmonary artery ( PA). The perimembranous-malal ignment ventricular septal defect (V) and multiple muscular septal defects (vv) are visualized. The size of the main PA is significantly reduced at the level of the band (b).

Table I. Preoperative cardiac catheterization Case J First cardiac cath. Pressure (mm Hg)

RA RV Ao LA LV PA

I

Oximetry

3 80 80 8 80

(%)

50 63 66; 71* 92 88 Not entered

Case 2 Second cardiac cath. Pressure (mm Hg)

5 85 85 5 85 84

I

Oximetry (%)

50 66 68 95 93 93

First cardiac cath, Pressure (mm Hg)

7 80 100 4 80 60

I

Oximetry (%)

58 88 85 99 99 84

Second cardiac cath. Pressure (mm Hg)

6 90 90 5 90

35

I

Oximetry (%)

45 50 52 96 91 78

Legend: RA, Right atrium. RV. Right ventricle. Ao, Aorta. LA, Left atrium. LV, Left ventricle. PA. Pulmonary artery. • Following balloon atrial septostomy.

pertrophy; cardiomegaly and congested lungs were demonstrated on the chest roentgenogram. Cardiac catheterization (Table I) and cineangiography (Fig. I, A) showed the presence of TGA with a VSD in the usual position and both ventricles were at systemic pressure. The pulmonary artery was not entered. Arterial oxygen saturation increased from 66% to 71% following balloon septostomy. Repeat catheterization on Nov. 8, 1979, confirmed the previous diagnosis and the persistence of pulmonary hypertension (Table I).

Operation was performed on Nov. 12, 1979. The weight was 5.6 kg. The findings were as follows: The smaller aorta arose anteriorly and on the right side of the larger main pulmonary artery. The coronary arteries arose from each of the two posterior aortic sinuses. The interatrial septum had a patent foramen ovale of 6 mm. The VSD was approximately I cm in diameter (perimembranous-malalignment type). The aorta was cannulated below the innominate artery and two venous cannulas were introduced into the venae cavae. Core

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Anatomic correction of TGA

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43 1

B

Fig. 2. Surgical technique. A, Preoperative relationship between the great arteries. B. Aortic and pulmonary artery resection 3 mm above the level of the valve leaflets. C. Switch of the coronary arteries after resection of both great vessels, followed by the anastomosis between the proximal stump of the pulmonary artery and the ascending aorta. Note the patch used to match the two different-sized vessels. D. Insertion of a modified aortic homograft conduit to bridge the gap between the proximal aortic stump and the distal pulmonary artery.

cooling was used with circulatory arrest for 80 minutes at a nasopharyngeal temperature of 16° C. Stay sutures were placed in the anterior sinuses of the pulmonary artery to mark the optimal site for switching the coronary arteries. Both great arteries were transected 3 mm above the level of the valve leaflets (Fig. 2, B). The coronary ostia were dissected out of the aortic root with a small button of sinus tissue around each ostium, and the coronary arteries were mobilized up to their first branch. Vertical incisions were made into the two anterior pulmonary artery sinuses, and the coronary ostia were sutured into these incisions with 7-0 Prolene sutures (Fig. 2, C). The distal aortic segment. being smaller in caliber than the pulmonary artery root, was incised vertically anteriorly and was attached to the pulmonary root with 6-0 Prolene sutures. Perfusion was restarted at the same low temperature.

An 18 mm diameter antibiotic-sterilized aortic homograft was turned inside out, and the mitral leaflet, the three aortic leaflets, and the noncoronary sinus were resected (Fig. 3). The remaining two sinuses of Valsalva were sutured into the recess in the anterior root to match the areas from which the coronary ostia had been removed, and the remainder of this suture line was completed with a continuous 6-0 Prolene suture. The distal end of the conduit was then sutured to the distal pulmonary artery, positioned on the right side of the left-sided ascending aorta (Fig. 2, D). Finally, during a second period of aortic cross-clamping, the right ventricle was opened and the VSD was closed with a Dacron patch. Cardiac takeover was remarkably good. The patient required mechanical ventilation and inotropic support for 6 days. Postoperatively cardiac rhythm was not

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A

B

o •.~ -r, ';::::£::2:>

Fig. 3. A homograft conduit (A) is turned inside out (B), and the mitral leaflet, the three aortic leaflets, and the noncoronary sinus are resected (dotted line, C). Modified aortic homograft conduit (D) used to bridge the gap between the proximal aortic stump and the distal pulmonary artery. stable, behaving in a similar fashion to the sick sinus syndrome. The patient was discharged 28 days after operation, receiving diuretic, digoxin, and antiarrhythmic treatment. The electrocardiogram showed sinus rhythm with complete right bundle branch block. This infant was examined 8 months postoperatively. She was extremely well and active. She had no cyanosis, no evidence of cardiac failure, and no residual cardiac murmur. The electrocardiogram was unchanged and the roentgenogram of the chest showed a normal cardiac silhouette. CASE 2. A female patient, born on Dec. 29, 1975, was first referred to this hospital at 17 days of age with cyanosis and evidence of congestive heart failure. The clinical findings were consistent with a diagnosis of TGA with VSD. Cardiac catheterization confirmed this clinical diagnosis. There was a small gradient between the left ventricle and the main pulmonary artery (Table I). Attempts to control the cardiac failure with medical treatment proved to be unsatisfactory, and pulmonary artery banding was performed on March 10. 1976. She then progressed fairly well for 2 years. Because of increasing polycythemia and cyanosis, a second cardiac catheterization was performed on Sept. 18, 1978 (Table I). Cardiac angiography confirmed discordant ventriculoarterial connections and narrowing of the main pulmo-

nary artery at the site of the previous banding. In addition, shunts between the ventricles were present at several levels. A third study was performed on Oct. 28, 1978, to define the interventricular septum, the size of the ventricles, and the position of the VSDs. Two ventricles were visualized; a VSD in the subpulmonary position was identified with multiple VSDs in the muscular septum (Fig. I, B). Operation was performed on March 5, 1980. Findings were as follows: The smaller aorta was anterior and to the right of the larger main pulmonary artery. Banding reduced the size of the pulmonary artery by about 70%. The coronary arteries arose from the two posterior sinuses of the aorta. There was a large perimernbranous-rnalalignment type VSD, with some chordae tendineae of the tricuspid valve straddling the left side of the septum. The lower part of the interventricular septum was fenestrated, with multiple VSDs. The surgical technique adopted was similar to that described in Case I. Matching the smaller distal aorta to the enlarged proximal pulmonary stump was achieved by enlarging the ascending aorta with a piece of aortic homograft wall (Fig. 2, C). An 18 mm diameter modified aortic homograft conduit was interposed between the proximal aortic root and the distal pulmonary artery. Circulatory arrest lasted for 85 minutes. Difficulties were encountered during the second period of aortic occlusion in repairing the VSDs. The peri membranous defect was closed with a Dacron patch after resection of two secondary chordae tendineae which crossed the defect. The muscle bundles that constituted the lower part of the septum were resected to produce a large single communication from the multiple small defects previously present. A second Dacron patch was used to reconstruct the lower part of the interventricular septum. This procedure required 42 minutes of anoxic cardiac arrest. Not surprisingly, cardiac takeover was sluggish and the postoperative period stormy. Low cardiac output with right and left ventricular failure developed, and inotropic support was requ ired for 18 days. Several attempts at spontaneous ventilation failed, and finally the patient was extubated after 3 weeks. The clinical findings were suggestive of a residual shunt at the ventricular level with tricuspid valve incompetence. After slow improvement, the patient was discharged to her home 94 days after the operation on a regimen of diuretics and digoxin. On examination 6 months postoperatively, she was found to be in satisfactory condition, with congestive heart failure controlled by the medical treatment.

Discussion Since 1976 the surgical techniques employed for the anatomic correction of TGA have been based on the Jatene modification" of the Baffes procedure." Meanwhile, a review of the more recent reports">": :l9-4.; suggests that certain technical points are worthy of special consideration. The first is the optimal level of transection of the great arteries. Jatene 's group" and others:l9,~o.~2-45 advised cutting both arteries well away from the heart and at the same level, in order to avoid kinking and compression of the new anteriorly positioned pulmonary arterial trunk on the posteriorly transferred left coronary artery. To avoid the same problem,

Volume 82 Number 3 September, 1981

others" advocated cutting the aortic stump as proximally as possible and the pulmonary artery as distally as possible and using a conduit as the new main pulmonary artery. In 1976, Yacoub, Radley-Smith, and Hiltorr" proposed transecting both great arteries at the valve level and reconstructing the pulmonary root with a conduit. We adopted this technique in our two patients to give the best exposure of the sinuses of Valsalva and to facilitate the transfer of the two coronary arteries. The use of a homograft conduit avoided any compression of the left coronary artery by the reconstructed main pulmonary trunk. The second consideration refers to the spatial relationship of the transposed great arteries. Jatene's group" and others": 42 positioned the new pulmonary arterial trunk on the left side of the aorta. Yacoub" and others'": :14,40 preferred placing the aorta on the left side of the main pulmonary artery. In accordance with this suggestion, we avoided looping the homograft around the aorta. This loop, in fact, is not a normal relationship between the great arteries in TGA. 46, 47 This also avoids sternal compression on the reconstructed pulmonary trunk.": 22 The third concept refers to the repositioning of the coronary arteries into the posterior vessel, There is common agreement that they must be removed together with a small button of aortic wall,:l2-41 but Jatene and associates" and others": :19 switched the coronaries before transecting the great arteries, Ross, Rickards, and Sommerville" divided the aorta after excising the coronary ostia and divided the pulmonary artery only after reimplantation of the coronaries into the posterior vessel. We presume that many of the technical difficulties encountered in the reconnection of the coronary arteries to the new systemic vessel resulted from insufficient vision of their implantation sites." , 45 The division of the great arteries at a low levdl2-:l5 gives excellent access to the sinuses of Valsalva, facilitates the detachment and reimplantation of the coronary arteries, and avoids all the problems that can result from blind maneuvers. The fourth consideration refers to the equilization of the narrow distal aorta with the enlarged proximal stump of the posterior vessel. This discrepancy has been equalized by matching the two suture lines with an end-to-end anastomosis by Mauck,"! Harinck," and their associates, Jatene and co-workers" and others'": 39 suggested reducing the size of the dilated proximal stump of the pulmonary artery. In 1976, Yacoub, Radley-Smith, and Hiltorr" proposed widening the distal aorta with a longitudinal incision in its anterior wall. Subsequently, this technique was modified by inserting

Anatomic correction of TGA

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a triangular patch to enlarge the aortic circumference.i" We adopted both of these latter approaches in our two cases to obtain a homogenous size between the distal ascending aorta and its new posterior root. This seems essential to avoid turbulence or distortion of the valvular leaflets, problems which to some extent could explain the systemic valve incompetence observed in the follow-up by some authors.41 The fifth concept refers to the type of conduit used to bridge the gap between the proximal end of the aorta and the distal end of the pulmonary artery. For this purpose synthetic prostheses.": as. :15. :l7 homologous dura mater tubes," and homologous ascending aortic grafts" have been inserted. As far as we know, the method applied in our cases is original. We used a fresh, antibiotic-preserved, aortic valve homograft conduit without a mitral component, without aortic valve leaflets, and with only two residual sinuses of Valsalva. The proximal end of the conduit was anastomosed to the proximal end of the aorta, and the residual left and right aortic homograft sinuses were used to repair the defects caused by removal of the coronary ostia. The distal end of the conduit was anastomosed to the distal end of the pulmonary artery, which was lying on the right side of the switched ascending aorta. The interposition of the modified aortic valve homograft used as the main pulmonary trunk presents several advantages over a synthetic tubular prosthesis, used for the same purpose. It avoids the postoperative bleeding experienced with Dacron tubes. It adapts better to the surrounding anatomic structures, decreasing the risk of mediastinal compression, and gives the possibility of using a larger conduit in small infants. The residual left and right aortic homograft sinuses of Valsalva, used to repair the defects in the aortic root, prevent any distortion that might be produced by the closure of these holes with a continuous running suture''": :19 and avoid the use of supplementary patches.t'<": :16, as, 40. 41 Adopting these criteria, we successfully performed anatomic correction in two patients with TGA and VSD. The problems in our second case seemed related to the difficulties encountered in the repair of the "Swiss cheese" septum, rather than in performing the switch of the coronaries and the great arteries. We believe that switching of the great arteries is a valuable approach for the surgical correction of TGA with pulmonary hypertension, although we prefer the classical inflow correction for the simple forms. As suggested by Yacoub," we postulate (I) a combined low transection of the aorta and the pulmonary artery; (2) a side-by-side relationship between the transposed arteries, with the ascending aorta on the left and the

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main pulmonary artery on the right; (3) a switch of the coronary arteries only under direct vision of the sinuses of Valsalva; (4) equalization of the size of the distal aorta with the proximal pulmonary stump, achieved by patch enlargement of the aortic lumen if necessary; and (5) the use of a conduit to bridge the gap between the distal pulmonary artery and the proximal aortic stump. The modified aortic valve homograft seems to offer more advantages than other types of conduit for this purpose. REFERENCES

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30 Idriss FS, Goldstein IR, Grana L, French D, Potts WJ: A new technic for complete correction of transposition of the great vessels. Circulation 24:5-11, 1961 31 Baffes TG, Ketola FH, Tatooles CJ: Transfer of coronary ostia by "triangulation" in transposition of the great arteries and anomalous coronary arteries. A preliminary report. Chest 39:648-655, 1961 32 Yacoub MH, Radley-Smith R, Hilton CJ: Anatomical correction of complete transposition of the great arteries and ventricular septal defect in infancy. Br Med J 1:1112-1114,1976 33 Yacoub MH, Radley-Smith R, Maclaurin R: Two-stage operation for anatomical correction of transposition of the great arteries with intact interventricular septum. Lancet 1:1275-1278, 1977 34 Yacoub MH: The case for anatomic correction of transposition of the great arteries. J THoRAc CARDtOVASC SURG 78:3-6, 1979 35 Yacoub MH: Anatomical correction of transposition of the great arteries, Operative Surgery, JW Jackson, ed., London, 1978, Butterworth & Co., Ltd., pp 136-143 36 Ross D, Rickards A, Sommerville J: Transposition of the great arteries. Logical anatomical arterial connection. Br MedJ 1:1109-1111,1976 37 Harinck E, Van Mill OJ, Ross D, Brom AG: Anatomical correction of transposition of the great arteries with persistent ductus arteriosus. One year after operation. Br Heart J 43:95-98, 1980 38 Jatene AD, Fontes VF, Paulista PP, Souza LCB, Neger F, Galantier M, Sousa JEMR: Anatomic correction of

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transposition of the great vessels. J THORAC CARDtOV ASC SURG 72:364-370, 1976 Kreutzer G, Neirotti R, Galindez E, Coronel AR, Kreutzer E: Anatomic correction of transposition of the great arteries. J THoRAc CARDtOVASC SURG 73:538-542, 1977 Abe T, Kuribayashi R, Sato M, Nieda S, Takahashi M, Okubo T: Successful Jatene operation for transposition of the great arteries with intact ventricular septum. A case report. J THoRAc CARDtOVASC SURG 75:64-67, 1978 Mauck HP Jr, Robertson LW, Parr EJ, Lower RR: Anatomic correction of transposition of the great arteries without significant ventricular septal defect or patent ductus arteriosus. J THORAC CARDtOV ASC SURG 74:631-635, 1977 Starr A: Discussion of Jatene et a('l" Kawashima Y: Discussion of Jatene et af" Lower RR: Discussion of Jatene et al" Ashcroft KE: Discussion of Jatene et al'" Wilkinson JL, Arnold R, Anderson RM, Acerete F: "Posterior" transposition reconsidered. Br Heart J 37: 757-766, 1975 Van Praagh R: Conotruncal malformation, Heart Disease in Infancy, BG Barratt-Boyes, JM Neutze, EA Harris, eds., Edinburgh, 1973, Churchill Livingstone, pp 141194 Major WK Jr, Matsuda H, Subramanian S: Failure of the Jatene procedure in a patient with D-transposition and intact ventricular septum. Ann Thorac Surg 22:386-388, 1976