TGA-VSD-LVOT Obstruction : REV (Réparation à l’Etage Ventriculaire) Procedure

Abstract

Background: Anomalies of the ventriculo-arterial connection with ventricular septal defect (VSD) and left ventricle outflow tract obstruction (LVOTO) are often repaired by using the Rastelli procedure. To obviate the main drawbacks of the Rastelli operation, Lecompte described in 1988 a new procedure called REV (Réparation à l’Etage Ventriculaire), which includes two major modifications: routine excision of the conal septum and reconstruction of the right ventricular outflow tract without conduit.

Technique: In all patients with a conal septum interposed between the VSD and the aortic orifice, the conal septum is excised extensively, even if the VSD is not restrictive; this allows the construction of a large and straight left ventricle-to-aorta tunnel. The pulmonary artery is reimplanted directly onto the right ventricle, typically after anterior translocation (French maneuver).

Indications: The REV operation is indicated in hearts characterized by malposition of the great arteries with a short (or absent) subpulmonary conus and a severe pulmonary outflow tract obstruction involving the pulmonary valve. In contrast, the presence of a remote VSD, abnormal insertion of the mitral valve and major abnormal insertions of the tricuspid valve on the conal septum are contraindications to a REV operation. Most of these latter malformations can be repaired using a Bex-Nikaidoh procedure. (See Chaps. 22 and 23)

Results: The current operative risk is low (<5 %). At 25 years, the probability of survival is 85 % whereas survival without reoperation is 45 %. In addition, the probability of reoperation for right ventricular outflow tract obstruction is 33 %, and for left ventricular outflow tract obstruction, 5 %.

Conclusions: The REV operation provides better results than the classical Rastelli procedure in terms of survival and need for reoperation for right or left ventricular outflow tract obstruction.