Transposition of the great arteries with ventricular septal defect and pulmonary stenosis: what is the best surgical option?

Regarding the Letter to the Editor from Luciana Fonseca [1], referring to the work of Gláucio Furlanetto [2] on "Transposition of the great arteries with ventricular septal defect and pulmonary stenosis: what is the best surgical option."

In order to add another option to the comments of the technical work of Furlanetto, may I stress the experiment results with the Lecompte operation.

Due to known problems with the use of valved tubes in the Rastelli operation [3] in our service (EPM - UNIFESP), from February 1994 to July 2009, we have operated nine patients to date with TGA + VSD + LVOTO, using the technique of Lecompte [4], with satisfactory results (a 11.1% mortality = death). These initial results were published in the Brazilian Journal of Cardiovascular Surgery [5].

We must point out some advantages and disadvantages of this technique:

Advantages:

1. Procedure performed in lower age patients (2 years);

2. Use of bivalved or trivalved porcine pulmonary prosthesis avoiding the use of valved tubes;

3. Interchangeable technique: Rastelli operation into Lecompte, in patients with obstruction of the valved conduit of adequate size to the patient's weight (the first patient in our series had previous Rastelli and acute obstruction of the tube);

4. Eight patients in our series with follow-up of 2 years to 16 years, all in functional class I-II without reoperation;

5. There was no need for manipulation of the coronary arteries.

Disadvantages:

1. Need for cross section and reconstruction of the ascending aorta in order to perform the Lecompte maneuver;

2. Mobilization and anteriorization of the pulmonary artery;

3. Difficulty of reconstruction of the RVOT when the pulmonary artery is side by side and at the right side of the aorta.

In answer to the author's question: "What is the best surgical option for correction of TGA + VSD + PA?", We must consider the Lecompte operation as a viable and replicable in any Pediatric Cardiac Surgery Service of our midst.

I congratulate the authors for their efforts and results with the Nikaidoh operation.

"Always look for a challenge that is big enough for you"

Walton Lillehei

Miguel Angel Maluf, São Paulo/SP


REFERENCES

1. Fonseca L. Transposição das grandes artérias com comunicação interventricular e estenose pulmonar: qual a melhor opção cirúrgica? Rev Bras Cir Cardiovasc. 2010;25(2):283-4.

2. 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]

3. Rastelli GC, McGoon DC, Wallace RB. Anatomic correction of transposition of great arteries with ventricular septal defect and subpulmonary stenosis. J Thorac Cardiovasc Surg. 1969;58(4):545-52. [MedLine]

4. Lecompte Y, Neveux JY, Leca F, Zannini L, Tu TV, Duboys Y, et al. Reconstruction of the pulmonary outflow tract without prosthetic conduit. J Thorac Cardiovasc Surg. 1982;84(5):727-33. [MedLine]

5. Maluf MA, Catani R, Silva C, Diógenes S, Carvalho W, Carvalho A, et al. Procedimento de Lecompte para a correção de transposição das grandes artérias, associada à comunicação interventricular e obstrução de via de saída do ventrículo esquerdo. Rev Bras Cir Cardiovasc. 2006;21(4):433-43.

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Reply

As we can see, the surgical correction of transposition of great arteries (TGA) with ventricular septal defect (VSD) and obstruction of left ventricular outflow tract (LVOTO) has several alternatives and there is a consensus among the various groups that are dedicated to cardiac defects. We can divide the treatment of this heart disease in addressing the outflow tract of the left ventricle and the outflow tract of the right ventricle. The tunneling performed in the Rastelli operation between the left ventricle and the aorta located in the right ventricle is tortuous and is more likely to produce obstruction in the segment in the medium term. The Lecompte operation improves the outflow tract of the left ventricle because with the resection of the infundibular septum the tunneling between the left ventricle and the aorta is more direct, but in both surgeries either the aorta and the pulmonary trunk have no anatomical location. Reconstruction of left ventricular outflow tract in the Rastelli operation is performed with a valved conduit and in the Lecompte operation with a monocuspid autologous pericardium patch. Dr. Miguel Maluf used in the Lecompte operation a fixed bicuspid porcine prosthesis and achieved good results in eight patients in a follow-up of 2-16 years.

The use of the Nikaidoh operation anatomically corrects the outflow tract of the left ventricle, but places no valve at the outflow tract of the right ventricle. In an article by Hu et al. [1], published in the J Thorac Cardiovasc Surg. 2008; 135:331-8, showed better hemodynamic performance of the modified Nikaidoh operation during the immediate postoperative period when compared to the Lecompte and Rastelli surgeries.

The experience acquired in the use of both monocuspid and valved tubes in congenital heart defects and the verification of dysfunction in the medium term of these prostheses, particularly in children younger than 1 year, led us to propose a new technique, called aortic and pulmonary translocation with full preservation of the pulmonary valve, which differs from the Nikaidoh operation because the reconstruction of the outflow tract of the right ventricle using the pulmonary valve intact and placed in anatomical position. The follow-up of a larger number of patients with this type of surgery is essential for determining whether this procedure is superior to the one that uses monocuspid, bicuspid, or homograft valved conduits in the right ventricle outflow tract.

Gláucio Furlanetto, São Paulo/SP


REFERENCES

1. Hu SS, Liu ZG, Li SJ, Shen XD, Wang X, Liu JP, et al. Strategy for biventricular outflow tract reconstruction: Rastelli, REV, or Nikaidoh procedure? J Thorac Cardiovasc Surg. 2008;135(2):331-8. [MedLine]