Metras D, Kreitmann B, Riberi A, Yao J G, el-Khoury E, Wernert F, Pannetier-Mille A
Service of Cardiothoracic Surgery, La Timone Children's Hospital, Marseilles, France.
J Thorac Cardiovasc Surg. 1997 Nov;114(5):746-53; discussion 753-4. doi: 10.1016/S0022-5223(97)70078-3.
In most cases of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction, a Lecompte procedure (réparation à l'étage ventriculaire) is possible without interposition of a conduit between the right ventricle and pulmonary artery. However, the anterior location of the pulmonary arteries after the Lecompte maneuver may be a potential cause for right ventricular outflow obstruction, which continues to be reported in 5% to 25% of cases. We have used a tubular segment of aortic autograft to connect the pulmonary artery, left in the orthotopic posterior position (without the Lecompte maneuver), to the right ventricle in 10 consecutive patients with transposition, ventricular septal defect, and left ventricular outflow tract obstruction.
Ten consecutive patients aged 2 months to 11 years (mean 32 months) have undergone a modified Lecompte operation. Eight had severe pulmonary stenosis, two had pulmonary atresia, and four had a restrictive ventricular septal defect at the time of the operation. Two had multiple ventricular septal defects. Seven had undergone one (n = 5) or two (n = 2) previous modified Blalock-Taussig shunts. All patients underwent a total correction with left ventricular-aortic intraventricular connection (four needed a ventricular septal defect enlargement), connection between the right ventricle and pulmonary arteries with a tubular segment of autograft aorta, without the Lecompte maneuver (anterior location of the bifurcation of the pulmonary arteries) on the right (n = 6) or the left (n = 4) of the aorta. No valvular device was used for the right ventricular outflow repair.
No early or late deaths occurred. One patient with multiple ventricular septal defects needed an early (2 weeks) reoperation for a residual muscular ventricular septal defect. All patients are currently in New York Heart. Association class I, without medications, in sinus rhythm, at a mean follow-up of 30 months. Late results up to 3.6 years show no calcification on the chest roentgenogram, and at the most recent echocardiogram, right ventricular pressures were low (25 to 40 mm Hg, mean 33 mm Hg) and no significant gradient (over 10 mm Hg) was found between the right ventricle and pulmonary arteries. Left and right ventricular function was satisfactory.
This modification of the Lecompte operation using a segment of autograft allows an excellent early and late result, with no danger of compression of anteriorly placed pulmonary arteries, no significant right ventricular outflow obstruction, and normal appearance of the tubular autograft. In view of laboratory and clinical evidence, normal growth of the autograft can be anticipated. It allows an elective correction of transposition, ventricular septal defect, and left ventricular outflow tract obstruction without a previous Blalock-Taussig shunt (three patients) and correction at a young age (three patients younger than 1 year).
在大多数伴有室间隔缺损和左心室流出道梗阻的大动脉转位病例中，可行Lecompte手术（心室水平修复），无需在右心室和肺动脉之间置入管道。然而，Lecompte操作后肺动脉的前部位置可能是右心室流出道梗阻的潜在原因，在5%至25%的病例中仍有报道。我们连续对10例患有大动脉转位、室间隔缺损和左心室流出道梗阻的患者，使用主动脉自体移植管段将位于原位后方位置（未行Lecompte操作）的肺动脉与右心室相连。
连续10例年龄在2个月至11岁（平均32个月）的患者接受了改良的Lecompte手术。8例有严重肺动脉狭窄，2例有肺动脉闭锁，4例在手术时有限制性室间隔缺损。2例有多发性室间隔缺损。7例曾接受过1次（n = 5）或2次（n = 2）改良的Blalock-Taussig分流术。所有患者均接受了左心室-主动脉心室内连接的完全矫正（4例需要扩大室间隔缺损），用自体主动脉管段连接右心室和肺动脉，未在主动脉右侧（n = 6）或左侧（n = 4）进行Lecompte操作（肺动脉分叉的前部位置）。右心室流出道修复未使用瓣膜装置。
无早期或晚期死亡发生。1例有多发性室间隔缺损的患者因残余肌部室间隔缺损需要早期（2周）再次再次再次手术。所有患者目前纽约心脏协会心功能分级均为I级，无需药物治疗，窦性心律，平均随访30个月。长达3.6年的晚期结果显示，胸部X线片无钙化，在最近的超声心动图检查中，右心室压力较低（25至40 mmHg，平均33 mmHg），右心室和肺动脉之间未发现明显压差（超过10 mmHg）。左、右心室功能良好。
使用自体移植管段对Lecompte手术进行的这种改良可取得优异的早期和晚期效果，不存在前方肺动脉受压的风险，无明显的右心室流出道梗阻，且自体移植管外观正常。鉴于实验室和临床证据，可以预期自体移植管能正常生长。它允许在未行Blalock-Taussig分流术（3例患者）的情况下择期矫正大动脉转位、室间隔缺损和左心室流出道梗阻，并能在幼年（3例年龄小于1岁的患者）进行矫正。
