The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
Eur J Cardiothorac Surg. 2013 Dec;44(6):1085-94; discussion 1094. doi: 10.1093/ejcts/ezt283. Epub 2013 Jun 25.
Transposition of the great arteries (TGA) and left ventricular outflow tract obstruction (LVOTO) with or without ventricular septal defect have multiple surgical treatment options. We sought to identify pre- and intraoperative factors that determine the timing of repair, procedure type and subsequent LVOT outcome.
Twenty-eight (8.2% of all TGA) patients with TGA with LVOTO (double outlet ventricle, n = 5, TGA/intact septum, n = 1) between 2000 and 2012 were reviewed. Anatomical factors were identified by prerepair echocardiography. LVOTO complexity was characterized by the degree of obstruction (0 = none, 0.33 = mild, 0.66 moderate and 1 = severe) at various levels: pulmonary valve (PV) dysplasia/hypoplasia, posterior deviation of the infundibular septum, fibromuscular ridge, tissue tag and abnormal chordal attachment. Summation of the obstruction score, at each level, yielded the LVOT complexity score. The descriptive analysis of intraoperative decision-making at late repair was performed.
early arterial switch operation (ASO) + LVOT resection (n = 9, 32%), late ASO + LVOT resection (n = 3, 10%), Nikaidoh (n = 8, 29%), Rastelli (n = 6, 21%), single-ventricle palliation (n = 2, 7%). The primary LVOT obstruction mechanism was posterior deviation of the infundibular septum (n = 16, 57%) and PV dysplasia (n = 6, 21%). The early ASO group had a lower PV complexity score (0.42 ± 0.22 vs 0.96 ± 0.55, P = 0.007), tissue tag score (0.03 ± 0.15 vs 0.26 ± 0.34, P = 0.018) and LVOT complexity score (2.11 ± 0.86 vs 3.2 ± 0.96, P = 0.006). The LVOT complexity score in the Nikaidoh group was higher than in the late ASO group (P = 0.019). Of 16 candidates for the Nikaidoh procedure, 6 patients underwent a Rastelli operation due to coronary artery patterns (single coronary, n = 3, 1RL-2Cx, n = 2 or an abnormal left anterior descending coronary artery course, n = 1). Two patients underwent single-ventricle palliation due to the interference of essential chordae. All patients survived the operation. The 3-year survival was 96%. One patient who underwent late ASO required re-LVOT resection.
A newly developed scoring system, the LVOT complexity score, helped to quantify the LVOT complexity and was correlated with our choice of the surgical procedure of TGA with LVOTO. The current strategy achieved reasonable survival and LVOT outcome with three quarters of the patients having an anatomically aligned LVOT. The coronary anatomy pattern was the primary determinant in the decision-making between the Nikaidoh procedure and the Rastelli operation.
大动脉转位（TGA）合并左心室流出道梗阻（LVOTO）伴或不伴室间隔缺损有多种手术治疗选择。我们试图确定决定修复时机、手术类型和随后的 LVOT 结果的术前和术中因素。
回顾 2000 年至 2012 年间 28 例（所有 TGA 的 8.2%）TGA 合并 LVOTO（双出口心室，n=5；TGA/完整间隔，n=1）患者。通过修复前超声心动图确定解剖学因素。LVOTO 复杂性通过以下几个方面的梗阻程度来描述：肺动脉瓣（PV）发育不良/发育不全、漏斗间隔后倾、纤维肌性嵴、组织标签和异常腱索附着。各部位梗阻评分之和即为 LVOT 复杂性评分。对晚期修复时的术中决策进行描述性分析。
早期动脉调转手术（ASO）+LVOT 切除术（n=9，32%）、晚期 ASO+LVOT 切除术（n=3，10%）、Nikaidoh 术（n=8，29%）、Rastelli 术（n=6，21%）、单心室姑息术（n=2，7%）。主要的 LVOT 梗阻机制为漏斗间隔后倾（n=16，57%）和 PV 发育不良（n=6，21%）。早期 ASO 组的 PV 复杂性评分（0.42±0.22 比 0.96±0.55，P=0.007）、组织标签评分（0.03±0.15 比 0.26±0.34，P=0.018）和 LVOT 复杂性评分（2.11±0.86 比 3.2±0.96，P=0.006）均较低。Nikaidoh 组的 LVOT 复杂性评分高于晚期 ASO 组（P=0.019）。在 16 名适合行 Nikaidoh 手术的患者中，6 名患者因冠状动脉模式（单支冠状动脉，n=3，1RL-2Cx，n=2 或异常左前降支走行，n=1）而改行 Rastelli 手术。2 名患者因必需的腱索干扰而行单心室姑息术。所有患者均存活。3 年生存率为 96%。1 名晚期 ASO 患者需要再次行 LVOT 切除术。
新开发的 LVOT 复杂性评分系统有助于量化 LVOT 复杂性，并与我们对 TGA 合并 LVOTO 手术方式的选择相关。目前的策略通过三种四分之三的患者具有解剖学对齐的 LVOT，实现了合理的生存率和 LVOT 结果。冠状动脉解剖模式是在 Nikaidoh 术与 Rastelli 术之间进行决策的主要决定因素。
