Victor O. Morell, MD
Central Message
Single- and double-root translocation have similar outcomes but are associated with risks of developing significant aortic insufficiency or need for reinterventions.
See Article page 1249.
The surgical management of complex transposition and double-outlet right ventricle (DORV) has evolved over the last 20 years. I remember the days when most surgeons' “technical armamentarium” consisted of the Rastelli procedure for straightforward patients and single-ventricle palliation in the presence of complex anatomy. The “resurrection” of the Bex-LeCompte/Nikaidoh
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,2
procedure and its modifications has allowed us to correct some of the most complex patients with very good outcomes.Stoica and colleges,
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in this retrospective, multicenter, observational study, reported that the outcomes of the Nikaidoh (single root) and en-bloc rotation (double root) procedures were similar except for 2 issues. One was the greater incidence of aortic insufficiency (AI) observed with the en-bloc rotation technique; the second was the greater incidence of right ventricular outflow tract (RVOT) reinterventions in the Nikaidoh group.- Stoica S.
- Kreuzer M.
- Dorobantu D.M.
- Kostolny M.
- Nosal M.
- Hosseinpour A.R.
- et al.
Aortic root translocation and en bloc rotation of the outflow tracts surgery for complex forms of transposition of the great arteries and double outlet right ventricle: a multicenter study.
J Thorac Cardiovasc Surg. 2022; 164: 1249-1260
The etiology of the AI is unclear, but when comparing the 2 techniques as described in the manuscript, there is one major difference: all patients who underwent en-bloc rotation had both coronary artery buttons reimplanted. In my personal experience with the aortic translocation procedure, AI has only developed in patients who underwent coronary reimplantation. Maybe this is just coincidence, but I do believe that minimizing the number of surgical suture lines in the native aortic root is a reasonable idea and might lead to the preservation of aortic valve function. Also, DORV morphology was more prevalent in the en-bloc group, which makes you wonder if this anatomy predisposes to the development of AI. The reality is that aortic translocation in its many forms is associated with a small but important risk of developing AI.
3
, - Stoica S.
- Kreuzer M.
- Dorobantu D.M.
- Kostolny M.
- Nosal M.
- Hosseinpour A.R.
- et al.
Aortic root translocation and en bloc rotation of the outflow tracts surgery for complex forms of transposition of the great arteries and double outlet right ventricle: a multicenter study.
J Thorac Cardiovasc Surg. 2022; 164: 1249-1260
4
The greater incidence of RVOT reinterventions observed in the Nikaidoh could have been easily prevented by avoiding conduit placement at the time of surgery. A direct right ventricle-to-pulmonary artery connection, my preferred technique, would have been a better option, since it's been shown to be effective in reducing RVOT reoperations.
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Of real clinical importance was the finding that the preserved pulmonary root in the en-bloc rotation group performs well on follow-up, confirming that in selected patients, a “double-root” translocation has clinical advantages.Patients with complex transposition and DORV are a heterogeneous group that remains a surgical challenge. Minimizing the number of cardiac reoperations or reinterventions is an important goal when deciding on the surgical technique. Therefore, it makes sense to avoid conduits in the RVOT and to take steps to minimize the development of AI. We still need to better define specific anatomical characteristics that will help us determine the best surgical technique for each individual patient. Based on this article, a double root has advantages and disadvantages, but at times a single is all you need!
References
- Anatomic correction of transposition of the great arteries.Ann Thorac Surg. 1980; 29: 86-88
- 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: 365-372
- Aortic root translocation and en bloc rotation of the outflow tracts surgery for complex forms of transposition of the great arteries and double outlet right ventricle: a multicenter study.J Thorac Cardiovasc Surg. 2022; 164: 1249-1260
- Aortic translocation and biventricular outflow tract reconstruction in the management of complex transposition of the great arteries with ventricular septal defect and pulmonary stenosis: results and follow-up.Ann Thorac Surg. 2005; 79: 2089-2093
- Aortic root translocation (Nikaidoh procedure): intermediate follow-up and impact of conduit type.J Thorac Cardiovasc Surg. 2015; 149: 1349-1355
Article info
Publication history
Published online: July 20, 2022
Accepted:
June 12,
2022
Received:
June 9,
2022
Footnotes
Disclosures: The author reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
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© 2022 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery
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- Aortic root translocation and en bloc rotation of the outflow tracts surgery for complex forms of transposition of the great arteries and double outlet right ventricle: A multicenter studyThe Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 5
- PreviewThere are several choices for the correction of complex transposition of the great arteries and double outlet right ventricle not amenable to the Rastelli-type surgery, but outcome data are limited to small series. This study aims to report results after the aortic root translocation and en bloc rotation of the outflow tract procedures.
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