Aortic Translocation for TGA with VSD and PS

Aortic translocation for the treatment of patients with transposition of the great arteries, ventricular septal defect and pulmonary stenosis appears to be an operation whose time has come.  This operation was first reported by Hisashi Nikaidoh nearly 20 years ago, in 1984 [1]. At that time Dr. Nikaidoh published a single-author paper in the Journal of Thoracic and Cardiovascular Surgery describing two successful aortic translocations without coronary transfer and biventricular outflow tract reconstruction for transposition of the great arteries associated with ventricular septal defect and left ventricular outflow tract obstruction.

The operation that most surgeons have become comfortable using for this diagnosis is the Rastelli procedure, which was developed at the Mayo Clinic in the mid-1960s.  For various reasons, the aortic translocation operation did not initially catch on and Dr. Nikaidoh was one of the few surgeons who continued to perform it over the past 20 years.

In my view, there have been a number of factors that have played into aortic translocation being an operation whose time has come.  The first of these is the unexpectedly high late mortality of the Rastelli procedure.  In Christian Kreutzer’s review of the Boston series [2], published in the Journal of Thoracic and Cardiovascular Surgery, the Kaplan-Meier survival at 20 years was 52%.  The primary causes of late death were sudden death – presumably an arrhythmia – and left ventricular dysfunction. One of the factors that may affect the contractile function of the heart is the abnormal ventricular septum with a large prosthetic component (the ventricular septal defect baffle).  In the Mayo Clinic series updated in 2001 by Joseph Dearani [3], the survival was 59% at 20 years.  Hence, surgeons have come to view the Rastelli operation, although quite successful for a number of patients, as perhaps not the ideal solution for these patients. The aortic translocation technique, in contrast, aligns the left ventricle and aorta without a large prosthetic patch.  This improves long-term left ventricular function and decreases the substrate for ventricular arrhythmias

The other factor that has led to the much wider acceptance of this procedure, I believe, is congenital heart surgeons’ experience with two other operations, the arterial switch operation and the Ross procedure.  The number of techniques that surgeons have developed for successfully transferring coronary arteries in the arterial switch procedure can be directly applied in the aortic translocation technique if the coronary arteries appear kinked at the time of the translocation.  The experience of harvesting the pulmonary autograft for the Ross procedure in a similar fashion has trained the congenital heart surgeon to perform aortic translocation for the Nikaidoh procedure. These two factors have diminished the “technical” obstacles of a fairly daunting procedure.

Long-term follow-up of the patients undergoing aortic translocation will lead to results, hopefully, that are improved compared with the long-term follow-up following the Rastelli procedure.  Of course there are confounding variables, such as the now improved strategies for the Rastelli procedure and the earlier timeframe in which these patients are operated on, avoiding prolonged cyanosis.

Dr. Morell has done a beautiful job of describing the technical aspects of the aortic translocation procedure and we can thank Dr. Hisashi Nikaidoh for having the original concept and courage to achieve success with this technique 20 years ago.  I believe this is an operation whose time has come.

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;88:365-72.
2. Kreutzer C, De Vive J, Oppido G, Kreutzer J, Gauvreau K, Freed M, Mayer JE Jr, Jonas R, del Nido PJ. Twenty-five-year experience with Rastelli repair for transposition of the great arteries. J Thorac Cardiovasc Surg 2000;120:211-23.
3. Dearani JA, Danielson GK, Puga FJ, Mair DD, Schleck CD. Late results of the Rastelli operation for transposition of the great arteries. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2001;4:3-15.