Transposição das grandes artérias com comunicação interventricular e estenose pulmonar: qual a melhor opção cirúrgica?

Dear Editor,


We read with interest the article published by Furlanetto et al.[1] (BJCVS 25.1) that have demonstrated with two cases successfully operated, the creativity and technical capacity of Brazilian surgeons. It is up to us to remind you our article published in this Journal in 2003, regarding the long-term evolution (1 to 6.5 years) of the pulmonary root translocation to right ventricle outflow tract in the treatment of transposition of the great arteries associated with ventricular septal defect (VSD) and pulmonary stenosis (PS), with left ventricle blood flow diversion to the aorta through the VSD[2]. This technique, named Pulmonary Translocation, was described by da Silva et al.[3] having been published by invitation of the editor in the journal Operative Techniques in Thoracic and Cardiovascular Surgery in 2009[4], with 39 cases and excellent long term results. The pulmonary translocation keeps the function of pulmonary valve, and maintains the aorta in its original position, without risk of coronary manipulation or aortic insufficiency. The technique described by Furlanetto et al., compared to Hu et al.[5] technique, has the advantages to avoid Lecompte maneuver, reducing the time of aortic cross clamp, as well as to preserve the pulmonary function with mild stenosis. However, in both cases reported by these authors, the echocardiograms have shown mild aortic insufficiency in the immediate post-operative period, which in our experience has not occurred in any patient. In addition, the bovine pericardium patch treated with glutaraldehyde employed by these authors tends to calcify, impeding the growth of aortic and pulmonary rings, with possibility of distortion in long term follow-up, aggravating the aortic insufficiency. In our technique we achieved adequate reconstruction of left and right ventricles outflow tracts, with simpler technique and shorter extracorporeal circulation and aortic clamping times, keeping the growth potential of pulmonary ring with employment of in situ autologous pedicled pericardium [4] to complete the anterior aspect of this anastomosis. We believe that the follow-up of a large number of patients will clarify the real long term benefits of these singular techniques.


Luciana da Fonseca, São Paulo/SP


REFERENCES

1. Furlanetto G, Henriques SS, Pasquinelli FS, Furlanetto BHS. Nova técnica: translocação aórtica e pulmonar com preservação da valva pulmonar. Rev Bras Cir Cardiovasc. 2010;25(1):99-102. [MedLine]

2. Fonseca L, Baumgratz JF, Castro RM, Franchi SM, Vila JHA, Lopes LM, et al. Resultados tardios da translocação da raiz pulmonar na correção da transposição das grandes artérias. Rev Bras Cir Cardiovasc. 2003;18(4):326-31.

3. da Silva JP, Baumgratz JF, da Fonseca L. Pulmonary root translocation in transposition of great arteries repair. Ann Thorac Surg. 2000;69(2):643-5. [MedLine]

4. Silva JP, Fonseca L. Pulmonary root translocation. Operative Techniques in Thoracic and Cardiovascular Surgery. 2009;14(1):23-34.

5. Hu SS, Li SJ, Wang X, Wang LQ, Xiong H, Li LH, et al. Pulmonary and aortic root translocation in the management of transposition of great arteries with ventricular septal defect and left ventricular outflow tract obstruction. J Thorac Cardiovasc Surg. 2007;133(4):1090-2. [MedLine]

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Reply


We would like to thank the comments posted by Dr. Luciana da Fonseca and elucidate the comment to remember the publication held by da Silva et al.[1], who performed the translocation of the pulmonary artery in the transposition of the great arteries and pulmonary stenosis in 2003, it is unnecessary because the work was referred and commented in the article (reference 4). The technique proposed by us also differs from the technique of Hu et al.[2] because it entirely saves the pulmonary valve, does not apply the LeCompte procedure or the right ventriculotomy.

As for the involvement of the aortic valve, it is important to note that there was no moderate aortic insufficiency but mild aortic insufficiency, with no hemodynamic repercussions. Regarding the use of bovine pericardium treated with glutaraldehyde and growth of the aortic and pulmonary valves, we emphasize that this expansion should not compromise the growth of the aortic annulus because the expansion only makes up 25% to 20% of this ring, it will not interfere with the growth of the pulmonary annulus because this ring was reimplanted on the aortic orifice, which was partially closed with fresh autologous pericardium.

I also believe that the great advantage presented in this technique that we propose is to avoid tunneling the left ventricle into the aorta through the VSD, as with the Rastelli operation. This tunneling has a large loss of energy reflected in an important low output in the immediate postoperative period and it may evolve over the medium term obstruction of tunneling as a result of growth and contraction of the graft used. The great advantage of the technique of double aortic and pulmonary translocation is exactly avoiding this tunnel, correcting anatomically the outflow of the right and left ventricle and also preserving the pulmonary valve.


Gláucio Furlanetto, São Paulo/SP


REFERENCES

1. da Silva JP, Baumgratz JF, da Fonseca L. Pulmonary root translocation in transposition of great arteries repair. Ann Thorac Surg. 2000;69(2):643-5. [MedLine]

2. Hu SS, Li SJ, Wang X, Wang LQ, Xiong H, Li LH, et al. Pulmonary and aortic root translocation in the management of transposition of great arteries with ventricular septal defect and left ventricular outflow tract obstruction. J Thorac Cardiovasc Surg. 2007;133(4):1090-2. [MedLine]