Expanding the Limits of Posterior Aortic Translocation

Currently the posterior translocation of the aorta, the Nikaidoh procedure, is utilized in: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),corrected TGA (ccTGA) with VSD and complex LVOTO [4,5], anddouble 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 1The patient was 8 weeks old at the time of operation.DiagnosisTGA {1AD,Cx; 2R}inlet type of VSDvalvar and subvalvar pulmonary stenosisatrial septal defectHistoryAt 10 days old, the patient underwent a balloon atrioseptectomy.At 8 weeks old, semielective surgery was performed due to progressive cyanosis.ProcedurePosterior translocation of the aorta.Direct connection of the pulmonary artery with the right ventriculotomy and patch enlargement of the right ventricular outflow tract.Direct closure of the atrial septal defect.Video 2The patient was 9 years old at the time of the operation.Diagnosiscomplete AV canal defect Rastelli Adouble outlet right ventricle with subvalvar and valvar pulmonary stenosismonoatrium with left isomerismbilateral superior venae cavae with no bridging vein, and a left superior vena cava draining into an unroofed coronary sinusS/P modified Blalock–Taussig shuntHistoryAt 5 years old, the patient underwent a Blalock–Taussig shunt due to progressive cyanosis.At 9 years old, semielective surgery was performed due to progressive cyanosis and failure to thrive.ProcedurePosterior translocation of the aorta and a two-patch repair of the complete AV canal defect.Right ventricle to pulmonary artery conduit.Septation of the common atrium with pericardial patch, and redirection of the left superior vena cava into right atrium.Operative StepsTechnical points include the following:Extensive mobilization of the proximal coronary arteries to permit safe exposure of the aortic root and subsequent coronary transfer without tension.Harvest of the aortic root with a generous cuff of RV muscle (8 - 10 mm).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.Transection of the pulmonary trunk and retention of a remnant of pulmonary valve tissue for later suture line reinforcement.Incision of the outlet septum through the superior border of the VSD.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.LeCompte maneuver and the reconstruction of the ascending aorta.Closure of the VSD with an appropriately trimmed patch, preserving geometry of the aortic root.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.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.Learn more: https://www.ctsnet.org/article/expanding-limits-posterior-aortic-translocation

目前，升主动脉后移位手术（Nikaidoh手术）在以下情况中得到应用：完全性大动脉转位（d-TGA）伴随室间隔缺损（VSD）和左心室流出道梗阻（LVOTO）[1,2,3]（视频1）、校正型大动脉转位（ccTGA）伴随VSD和复杂型LVOTO[4,5]，以及双出口右心室（DORV）- TGA型伴随完全性心房室间隔缺损（CAVC）和肺动脉狭窄[6]（视频2）。在d-TGA、ccTGA和DORV伴随CAVC的解剖结构不足以进行Rastelli手术中的心室间隔瓣膜作为一部分时，将考虑采用Nikaidoh手术[7]。通常，在存在入口和/或限制性VSD、房室（AV）瓣膜跨越和/或CAVC以及边缘性右心室（RV）容量的情况下，Nikaidoh手术是一个宝贵的选项。视频1患者手术时年龄为8周大。诊断：TGA{1AD,Cx; 2R}入口型VSD，瓣膜和瓣下肺动脉狭窄，房间隔缺损。病史：在10天大时，患者接受了球囊房间隔造口术。在8周大时，由于发绀的进展，进行了选择性手术。手术：升主动脉后移位。肺动脉与右心室切口直接连接，并通过补片扩大右心室流出道。房间隔缺损的直接闭合。视频2患者手术时年龄为9岁。诊断：Rastelli术式修正的完全性AV通道缺损，双出口右心室伴随瓣下和瓣膜型肺动脉狭窄，单心房伴左心同构，双侧上腔静脉无桥静脉，左侧上腔静脉汇入未开放的心冠窦。手术前史：在5岁时，由于发绀的进展，患者接受了Blalock–Taussig分流术。在9岁时，由于发绀的进展和生长不良，进行了选择性手术。手术：升主动脉后移位和完全性AV通道缺损的双补片修复。右心室至肺动脉管道。通过心包补片分隔共同心房，并将左侧上腔静脉重新导向至右心房。手术步骤：技术要点包括以下内容：广泛游离近端冠状动脉，以便安全暴露主动脉根部并在无张力状态下进行随后的冠状动脉移植。采用宽裕的右心室肌肉袖口（8-10毫米）获取主动脉根部。横断升主动脉并切除一段主动脉，以便使重建的主动脉处于更靠后的位置，以适应LeCompte操作。横断肺动脉主干并保留一小部分肺瓣组织以备后续缝合线加固。通过VSD的上方边界切开出口隔膜。主动脉移位：将主动脉根部置于LVOT并使用连续缝合约三分之四的根部周长；通过包含原肺瓣环和肺动脉壁的第二缝合线加固该缝合线的一部分。LeCompte操作和升主动脉的重建。使用修剪得当的补片闭合VSD，以保留主动脉根部的几何形状。使用缝合垫缝合和重建右心室切口的侧面，通过直接右心室至肺动脉吻合或通过正位放置的肺同种异构体重建。对该技术的改进包括在移位过程中进行个体冠状动脉移植，以避免在大型血管位置不理想时发生冠状动脉缺血的可能性。了解更多信息：https://www.ctsnet.org/article/expanding-limits-posterior-aortic-translocation