Complete Transposition of the Great Arteries

  • Viktor Hraška
  • Peter Murín

Abstract

Complete transposition of the great arteries is the most common form of neonatal cyanotic heart disease. Transposition is the result of malformation of the conus arteriosus. This complex always has discordant ventriculoarterial alignment, such that the aorta arises entirely or largely from the right ventricle, and the pulmonary artery arises entirely or largely from above the left ventricle. The general categories of complete transposition of the great arteries are as follows: complete transposition of the great arteries with intact ventricular septum (simple form), complete transposition of the great arteries with a ventricular septal defect (complex form), and complete transposition of the great arteries with a ventricular septal defect and left ventricular outflow tract obstruction. The surgical method of choice for complete transposition of the great arteries without left ventricular outflow tract obstruction is an arterial switch operation, performed during the first weeks of life. Currently, the low operative mortality (<5%), low incidence of reintervention (<10%), and promising functional long-term outcome have been well documented. The optimal treatment strategy for complete transposition of the great arteries combined with a ventricular septal defect and left ventricular outflow tract obstruction remains challenging due to its great range of anatomical variability and unsatisfying long-term results. The Rastelli operation has been the method of choice for the past four decades. The procedure can be performed with low early mortality.

Keywords

Septal Defect Patent Ductus Arteriosus Atrial Septal Defect Ventricular Septal Defect Great Artery 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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Supplementary material

Clip 1: Preoperative findings.

978-3-642-24169-7_1_MOESM2_ESM.mp4 (6.9 mb)
Clip 2: After subtotal removal of the thymus and harvesting of the pericardium, the coronary arteries are examined closely, and the proximal epicardial course is identified.

Clip 3: The pulmonary trunk is marked at the site where the coronaries will be transferred. Extensive circumferential dissection of the great vessels is performed. The aorta is mobilized up to the proximal arch. The pulmonary arteries are thoroughly dissected free, including the first branches in the hilum of the lung, to allow mobility of the vessels.

Clip 4: The aortic cross-clamp is applied, and antegrade cold crystalloid cardioplegia is delivered. Both great vessels are transected.

Clip 5: Harvesting of the button of the right coronary and circumflex artery.

Clip 6: Harvesting of the left anterior descending artery.

Clip 7: Implantation of the left anterior descending coronary artery.

Clip 8: Implantation of the button with the right and circumflex coronary arteries. In order to avoid distortion or kinking of the circumflex artery, the button must be implanted higher than normal on the neoaorta.

Clip 9: Reconstruction of the neopulmonary trunk with an autologous pericardial patch and the neoaortic anastomosis.

Clip 10: Closure of the atrial septal defect, de-airing of the left part of the heart through the left appendage, and reconstruction of the pulmonary bifurcation on the beating heart during rewarming.

Clip 11: Placement of the left atrial line through the left atrial appendage and insertion of pacing wires.

Clip 12: Postoperative echocardiogram findings showed good biventricular function, unobstructed left ventricular outflow tract/right ventricular outflow tract.

Fullversion

978-3-642-24169-7_1_MOESM14_ESM.mp4 (6.9 mb)
Clip 1: Preoperative findings.
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Clip 2: External anatomy of the heart.

Clip 3: Dissection of the pulmonary arteries, transection of the patent ductus arteriosus, aortic cross-clamp, delivery of cardioplegia.

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Clip 4: Harvesting of the button of the left coronary artery.

Clip 5: Harvesting the button of the right coronary artery.

Clip 6: Creation of circular opening on the anterior wall of the neoaortic root.

Clip 7: Implantation of the button of the right coronary artery.

Clip 8: Implantation of the button of the left coronary artery.

Clip 9: Reconstruction of the neopulmonary trunk with an autologous pericardial patch.

Clip 10: End-to-end anastomosis of the neoaortic root and the ascending aorta.

Clip 11: Closure of the atrial septal defect, de-airing of the left part of the heart through the left appendage, and reconstruction of the pulmonary bifurcation on the beating heart during rewarming.

Clip 12: Completed arterial switch.

Fullversion

Clip 1: External anatomy of the heart.

Clip 2: Mobilization of the right and left coronary arteries.

Clip 3: Implantation of the button of the right and left coronary arteries.

Clip 4: Reconstruction of the neopulmonary artery.

Clip 5: Completed arterial switch.

Fullversion

Clip 1: Preoperative angiography.

Clip 2: The operation is conducted in a similar fashion to that of the arterial switch operation for simple transposition. First, the typical subpulmonary ventricular septal defect is closed with a patch, working through the tricuspid valve, and the prominent conal septum is partially transected to release the subaortic obstruction of the right ventricular outflow tract. The clip demonstrates the coronary artery transfer and reconstruction of the aorta and pulmonary artery.

Fullversion

Clip 1: Preoperative findings.

Clip 2: After subtotal removal of the thymus and harvesting of the pericardium, the external anatomy is examined closely. The pulmonary trunk is marked at the site where the coronaries will be transferred. Extensive circumferential dissection of the great vessels is performed. The aorta is mobilized up to the proximal arch. The pulmonary arteries are thoroughly dissected free, including the first branches in the hilum of the lung, to allow mobility of the vessels.

Clip 3: Intracardiac anatomy is evaluated.

Clip 4: Transection of the muscle bar.

Clip 5: Patch closure of ventricular septal defect and detachment of straddling papillary muscle of tricuspid valve.

Clip 6: Reattachment of the papillary muscle of tricuspid valve.

Clip 7: Transection of the aorta and harvesting of the button of the circumflex artery.

Clip 8: Harvesting of the left anterior descending artery and the right coronary artery.

Clip 9: Transection of pulmonary artery and Lecompte maneuver.

Clip 10: Commissurotomy of pulmonary valve (neoaortic valve).

Clip 11: Implantation of the circumflex coronary artery.

Clip 12: Implantation of the button with the right and left anterior descending coronary arteries.

Clip 13: The neoaortic anastomosis.

Clip 14: Closure of the atrial septal defect, de-airing of the left part of the heart through the left appendage, and reconstruction of the neopulmonary trunk and pulmonary bifurcation on the beating heart during rewarming.

Clip 15: Postoperative echocardiogram.

Fullversion

Clip 1: Preoperative echocardiogram and angiogram.

Clip 2: External anatomy of the heart.

Clip 3: Right ventriculotomy.

Clip 4: Intracardiac anatomy.

Clip 5: Creation of the intraventricular tunnel.

Clip 6: Transection of the great arteries.

Clip 7: Closure of the pulmonary valve and the Lecompte maneuver.

Clip 8: End-to-end anastomosis of the ascending aorta.

Clip 9: Direct connection of the pulmonary artery with the ventriculotomy and stent removal.

Clip 10: Pericardial patch plasty of the right ventricular outflow tract and the left pulmonary artery.

Clip 11: Final outcome.

Fullversion

Clip 1: Preoperative echocardiogram.

Clip 2: Mobilization of the great vessels.

Clip 3: Being on pump, the proximal aspects of the coronary arteries are extensively mobilized.

Clip 4: Harvesting the aortic root.

Clip 5: Transection of both great vessels and transection of the outlet septum.

Clip 6: Excision of pulmonary valve.

Clip 7: Posterior translocation of the aortic root.

Clip 8: Reconstruction of the aorta.

Clip 9: Patch closure of the ventricular septal defect.

Clip 10: Downsizing of the right ventricular outflow tract.

Clip 11: During rewarming, an anterior autologous pericardial patch is utilized to augment the main pulmonary artery and complete the right ventricle to pulmonary artery connection.

Clip 12: Final outcome.

Fullversion

Recommended Reading

  1. Bautista-Hernandez V, Marx GR, Bacha EA et al (2007) Aortic root translocation plus arterial switch for transposition of the great arteries with left ventricular outflow tract obstruction: intermediate-term results. J Am Coll Cardiol 49:485–490PubMedCrossRefGoogle Scholar
  2. Bex JP, Lecompte Y, Baillot F et al (1980)Anatomical correction of transposition of the great arteries. Ann Thorac Surg 29:86–88PubMedCrossRefGoogle Scholar
  3. Dearani JA, Danielson GK, Puga FJ et al (2001) Late results of the Rastelli operation for transposition of the great arteries. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 4:3–15PubMedCrossRefGoogle Scholar
  4. Gittenberger-de Groot AC, Sauer U et al (1983) Coronary artery anatomy in transposition of the great arteries: a morphologic study. Pediatr Cardiol 4(Suppl):S15–S24Google Scholar
  5. Hu SS, Liu ZG, Li SJ et al (2008) Strategy for biventricular outflow tract reconstruction: Rastelli, REV, or Nikaidoh procedure? J Thorac Cardiovasc Surg 135:331–338PubMedCrossRefGoogle Scholar
  6. Jaggers JJ, Cameron DE, Herlog R et al (2000) Transposition of the great arteries. Annal Thor Surg 69(Suppl):S205–S235CrossRefGoogle Scholar
  7. Jonas RA (2004) Transposition of the great arteries. In: Jonas RA (ed) Comprehensive surgical management of congenital heart disease Arnold, London, pp 256–278Google Scholar
  8. Kreutzer C, De Vive J, Oppido G et al (2000) Twenty-five–year experience with Rastelli repair for transposition of the great arteries. J Thorac Cardiovasc Surg 120:211–223PubMedCrossRefGoogle Scholar
  9. Lecompte Y, Vouhé P (2003) Réparation à l’Etage Ventriculaire (REV procedure): not a Rastelli procedure without conduit. Oper Tech Thorac Cardiovasc Surg 8:150–159Google Scholar
  10. Losay J, Touchot A, Serraf A et al (2001) Late outcome after arterial switch operation for transposition of the great arteries. Circulation 104(Suppl1):121–126Google Scholar
  11. Morell VO, Wearden PD (2008) Nikaidoh operation for transposition of the great arteries with a ventricular septal defect and pulmonary stenosis. MMCTS. doi:10.1510/mmcts.2006.002337Google Scholar
  12. Morell VO, Wearden PD (2008) Technique of aortic translocation for the management of transposition of the great arteries with a ventricular septal defect and pulmonary stenosis. Oper Tech Thorac Cardiovasc Surg 13:181–187Google Scholar
  13. Nido del PJ (2005) Transposition of the great arteries (complex forms). In: Sellke FW, del Nido PJ, Swanson SJ (eds) Sabinston and Spencer surgery of the chest, vol. 2, 7th edn. Elsevier Saunders, Philadelphia, pp 2153–2163Google Scholar
  14. Nikaidoh H (1984) Aortic translocation and biventricular outflow tract reconstruction: a new surgical repair for transposition of the great arteries associated with ventricular septal defect and pulmonary stenosis. J Thoracic Cardiovasc Surg 88:365–372Google Scholar
  15. Prêtre R, Gendron G, Tamisier D et al (2001) Results of the LeCompte procedure in malposition of the great arteries and pulmonary obstruction. Eur J Cardiothorac Surg 19:283–289PubMedCrossRefGoogle Scholar
  16. Rastelli GC, Wallace RB, Ongley PA (1969) Complete repair of transposition of the great arteries with pulmonary stenosis: a review and report of a case corrected by using a new surgical technique. Circulation 39:83–95PubMedGoogle Scholar
  17. Salih C, Brizard CH, Penny DJ et al (2010) Transposition. In: Anderson RH, Becker EJ, Penny D et al (eds) Pediatric cardiology, 3rd edn. Churchill-Livingstone, Philadelphia, pp, 795–817Google Scholar
  18. Wetter J, Belli E, Sinzobahamvya N et al (2001) Transposition of the great arteries associated with ventricular septal defect: surgical results and long-term outcome. Eur J Cardiothorac Surg 20:816–823PubMedCrossRefGoogle Scholar
  19. Weyand K, Haun C, Blaschczok H et al (2010) Surgical treatment of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction: midterm-results. World J Pediatr Congenital Heart Surg 2:163–169CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • Viktor Hraška
    • 1
  • Peter Murín
    • 1
  1. 1.Department of Cardiac SurgeryGerman Pediatric Heart Centre, Sankt AugustinSankt AugustinGermany

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