Procedure

Nikaidoh operation for transposition of the great arteries with a ventricular septal defect and pulmonary stenosis

Section of Pediatric Cardiothoracic Surgery of the Heart, Lung and Esophageal Surgical Institute, University of Pittsburgh Medical School, Children's Hospital of Pittsburgh, Room 2820, 3705 Fifth Avenue, Pittsburgh, PA 15213, USA

^* Corresponding author: ^* Tel.: +1-412-692 5218; fax: +1-412-692 5817 E-mail:victor.morell{at}chp.edu

	Summary

Top Summary Introduction Surgical technique Results Discussion Acknowledgements References

 
The optimal surgical management of patients with transposition of the great arteries with a ventricular septal defect and pulmonary stenosis remains challenging. When compared to other surgical options, the Nikaidoh procedure results in a ‘more normal’ anatomic result, with better alignment of the right and left ventricular outflow tracts. Also, the pulmonary outflow is less likely to be compressed by the sternum, a major issue associated with the Rastelli repair. This technique is especially useful in the presence of an inlet or restrictive ventricular septal defect, a hypoplastic right ventricle, a straddling atrioventricular valve and/or anomalous coronary anatomy interfering with a distal right ventricular outflow tract incision.

Key Words: Aortic translocation • Nikaidoh procedure • Rastelli repair • Transposition of the great arteries

	Introduction

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In 1980, Bex and associates [1] were the first to introduce the concept of aortic translocation for the management of transposition of the great arteries (TGA) but it was Nikaidoh [2], in 1984, who popularized the technique for the treatment of TGA with a ventricular septal defect (VSD) and pulmonary stenosis (PS). The repair consists of harvesting the aortic root from the right ventricle, relieving the left ventricular outflow tract obstruction by dividing the outlet septum and excising the pulmonary valve, reconstructing the left ventricular outflow tract (LVOT) with the translocated aortic root and the VSD patch, and the right ventricular outflow tract (RVOT) with a pericardial patch. Modifications to the original technique include individual coronary transfer during translocation (to avoid the possibility of coronary ischemia), the use of the Lecompte maneuver, and RVOT reconstruction with a pulmonary homograft or direct right ventricle to pulmonary artery anastomosis. Although technically challenging, aortic translocation combines elements of commonly performed surgical techniques including the Ross, Konno and Jatene procedures.

	Surgical technique

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Via a standard median sternotomy incision cardiopulmonary bypass is established with a single right atrial cannula or with bicaval cannulation and a left ventricular vent. The patient is cooled to 28–30 °C. A piece of pericardium is harvested and placed in glutaraldehyde for the reconstruction of the right ventricular outflow tract. The branch pulmonary arteries are extensively mobilized to allow for the Lecompte maneuver.

With a beating heart, or under cardiac arrest, the aorta is harvested from the right ventricle (Videos 1 and 2, Schematic 1). Importantly, the proximal aspects of the coronary arteries need to be extensively mobilized in order to safely separate the aortic root from the right ventricle and to allow for the translocation of the aorta without undo tension and/or torsion on the coronaries. Alternatively, under cardiac arrest, the coronary buttons are harvested before the aortic root is separated from the right ventricle (Schematics 2–4).

Click on image to view video Video 1 The anterior aspect of the aortic root has been partially dissected from the right ventricle.

Click on image to view video Video 2 The aortic root has been completely separated from the right ventricle with the coronary arteries attached. Note the distended and competent aortic valve.

View larger version (57K): [in this window] [in a new window]   Schematic 1 The aortic root is harvested from the RV and the proximal pulmonary artery divided.

View larger version (49K): [in this window] [in a new window]   Schematic 2 With a posterior and leftward pulmonary trunk (A) only the right coronary button is harvested (B) and reimplanted (C). Note the clockwise rotation of the aortic root.

View larger version (50K): [in this window] [in a new window]   Schematic 3 With a posterior and rightward pulmonary trunk (A) only the left coronary button is harvested (B) and reimplanted (C). Note the counterclockwise rotation of the aortic root during translocation.

View larger version (45K): [in this window] [in a new window]   Schematic 4 When the pulmonary trunk is located posterior to the aortic root (A) both coronaries are harvested (B) and reimplanted (C).

Click on image to view video Video 3 The proximal pulmonary artery is partially transected.

Click on image to view video Video 4 The proximal pulmonary artery has been completely transected allowing for resection of the pulmonary valve leaflets and visualization of the morphologic left ventricular outflow tract.

Click on image to view video Video 5 The outlet septum is clearly identified.

Click on image to view video Video 6 The outlet septum is divided.

Click on image to view video Video 7 The posterior suture-line between the proximal aortic root and the pulmonary annulus is performed with a running suture. In this case, the right coronary button was separated from the aorta before moving the aortic root.

Click on image to view video Video 8 With a beating heart, the aortic root is sutured to the posterior pulmonary annulus.

View larger version (79K): [in this window] [in a new window]   Schematic 5 The outlet septum has been opened into the VSD and the aortic root is sutured to the pulmonary annulus. Note the harvested right coronary button.

Click on image to view video Video 9 The ventricular septal defect is clearly seen after the aortic translocation.

Click on image to view video Video 10 The VSD has been closed with a patch; the right ventricular outflow tract is inspected.

View larger version (44K): [in this window] [in a new window]   Schematic 6 The VSD is closed with a patch.

Click on image to view video Video 11 The proximal root is sutured directly to the crest of the VSD with interrupted-pledgeted-mattress sutures, avoiding the need of a patch.

Click on image to view video Video 12 After aortic transection the Lecompte maneuver is performed and a segment of ascending aorta excised.

Click on image to view video Video 13 With the ascending aorta back together, we are now ready to establish RV to PA continuity.

Click on image to view video Video 14 The main pulmonary artery is sutured to the RVOT. Note that the anterior wall of the PA has been opened longitudinally to the level of the bifurcation.

Click on image to view video Video 15 An anterior autologous pericardial patch is utilized to augment the main pulmonary artery and complete the RV to PA connection.

View larger version (55K): [in this window] [in a new window]   Schematic 7 The pulmonary artery is directly sutured to the distal right ventricular outflow tract opening.

View larger version (58K): [in this window] [in a new window]   Schematic 8 An anterior pericardial patch is used to complete the RV to PA anastomosis.

	Results

Top Summary Introduction Surgical technique Results Discussion Acknowledgements References

On his latest report, Nikaidoh [2] describes no intervention for left ventricular outflow tract problems and five interventions for right ventricular outflow tract problems (two for conduit stenosis and three for pulmonary insufficiency) in a group of eighteen patients with a mean follow-up of 13 years. His early mortality was of 5.2%, and there were no late deaths. Interestingly, half the patients have developed mild aortic insufficiency. In our series, three patients have required right ventricle to pulmonary artery conduit replacement because of conduit stenosis and one underwent aortic valve replacement because of severe aortic insufficiency. Table1 summarizes several institutional experiences with the aortic translocation procedure.

	Discussion

Top Summary Introduction Surgical technique Results Discussion Acknowledgements References

View larger version (40K): [in this window] [in a new window]   Schematic 9 The right ventricle to pulmonary artery connection is more susceptible to sternal compression in the Rastelli (A) than in the Nikaidoh (B) because of the non-anatomical origin of the conduit from the distal right ventricular outflow tract in the Rastelli repair.

Aortic translocation is a complex operation that has an acceptable early and late mortality, and should be considered for patients undergoing repair of transposition of the great arteries with a ventricular septal defect and pulmonary stenosis. Although the overall ‘published experience’ [1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17] with this technique is somewhat limited, the early and midterm results are encouraging, suggesting improved outcomes when compared to the Rastelli. Certainly, in patients with ‘inadequate anatomy’ for a Rastelli repair the Nikaidoh procedure becomes an attractive alternative.

	Acknowledgements

Top Summary Introduction Surgical technique Results Discussion Acknowledgements References

 
We would like to thank Dr. Angelo Rutty for the beautiful illustrations.

	References

Top Summary Introduction Surgical technique Results Discussion Acknowledgements References

 

1. Bex JP, Lecompte Y, Baillot F, Hazan E. Anatomical correction of transposition of the great arteries. Ann Thorac Surg 1980;29:86–88.[Abstract]
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