surgical options for tga and lvoto. - sts b...(7/68-1/00) •early mortality: 10 %. •late...
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Surgical options for TGA and LVOTO.
Christian Kreutzer MDHead, Congenital Heart Surgery
Hospital Universitario Austral Argentina
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No disclosures
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Therapeutic Goal in TGA, VSD and LVOTO.
•Biventricular repair..
•Systemic Left Ventricle.
•Low early M/M.
•Low late M/M
•Low reintervention rate.STS/EACTS Latin America Cardiovascular Surgery Conference 2018
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Anatomy• Multi Level LVOTO.
• Pulmonary Valve. (annulus and bicuspid)
• Sub pulmonary
• Posterior deviation of Conal Septum
• Abnormal Mitral valve attachments.
• Cleft Mitral Valve.
STS/EACTS Latin America Cardiovascular Surgery Conference 2018
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What are we doing• Paliation with BT shunt vs early correction.
• Progression of LVOTO.
• Neonatal Rastelli, Switch or Nikaidoh.
• Infant/toddler Rastelli with homografts. (Eur J Cardiothorac Surg. 2010 Dec;38(6):699-706
• Low early mortality.
• High late morbidity• RVOTO Reintervention.• LVOTO Reoperation.• Arrhythmias• LV failure.
• Late mortality even worse than atrial switch.
STS/EACTS Latin America Cardiovascular Surgery Conference 2018
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Mayo Clinic Study
• Rastelli for TGA: 231 pts. (7/68-1/00)
• Early mortality: 10 %.
• Late Survival: 48 % at 20 yrs.
• Freedom from reintervention: 18 % at 20 yrs.
• Causes of late death: Arrhythmia and LV fail.
Dearani et al. Pediatric Cardiac Surgery Annual 2001STS/EACTS Latin America Cardiovascular Surgery Conference 2018
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Boston Children’s Study
• Rastelli for TGA: 101 pts. (7/73-4/98)
• Early mortality: 7 %.
• Late Survival: 49 % at 20 yrs.
• Freedom from reintervention: 18 % at 20 yrs.
• Causes of late death: Arrhythmia and LV fail.
Kreutzer et al. J Thorac Cardiovasc Surg. 2000 Aug;120:211-223. STS/EACTS Latin America Cardiovascular Surgery Conference 2018
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90-98
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73-79
Interval (years)
Survival
p=0.79
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Interval (years)
Survival
Infants (n=25)
Toddlers and children (n=66)
Adolescents and adults (n=10)
p=0.21
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Late failure
• 17 deaths and 1 HTX.
• LV failure= 7, sudden death=5
• Significant predictors
Straddling TV p=0.0002
Dacron Cdt. p=0.009
longer LOS p=0.03
C-Ed. Conduits p=0.05
Kreutzer, et al Thorac Cardiovasc Surg. 2000 Aug;120:211-223. STS/EACTS Latin America Cardiovascular Surgery Conference 2018
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LVOTO reintervention
RVOTO reintervention
Interval (years)
Freedom from reintervention
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Infants (n=23)
Toddlers and children (n=61)
Adolescents and adults
Interval (years)
* (p=0.0001)
(*)
Freedom from RVOTO reintervention
STS/EACTS Latin America Cardiovascular Surgery Conference 2018
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Risk factors for reinterventions
• LVOTO reintervention= 17 % /15 yrs.
No VSD enlargment p=0.02
Longer CPB time p=0.02
LOS >= 14 d p=0.04
• RVOTO reintervention= 79 % /15 yrs.
Surgeon X p=0.001
Rt sided cdt. p=0.02
Infants p=0.0001
Weight < 9 Kg p=0.02
Male gender p=0.05
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“Kreutzer's article illustrates the results of
the perfect observance of surgical
orthodoxy. In view of the long-term
results, I wonder whether this observance
is still justified?”
Yves Lecompte, JTCVS, January 2002
STS/EACTS Latin America Cardiovascular Surgery Conference 2018
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TGA, VSD, LVOTO ¿Why Rastelli’s fail in the long term?
STS/EACTS Latin America Cardiovascular Surgery Conference 2018
• LVOTO and LV. Failure Graham T. et al. J.Thorac & CV. Surg 1987;93:775-84. Palik I. Et al. Am. Heart J. 1986; 112: 1271-8)
• Arrhythmia and sudden death.
• Reoperation. (Aorta or conduit behind the sternum)
¿Lessons Learnt? (Univ Indiana, Brown J, WJPCHS, in press)
Ann Thorac Surg. 2009 Jul;88(1):137-42; Al Halees.
• Always enlarge the VSD and resect conal septum.
• Avoid Rastellis in non committed VSD.
• Avoid Rastellis in mild LVOTO. (Circulation. 2009 15;120(11 Suppl):S53-8) Emani R.
• “The bigger the pulmonary annulus the more tortuous the LVOT will be afterRastelli”
• Achieve pulmonary competence with PVR.• Surgical.
• Interventional.
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So, what Now?
• Modification of the RVOT reconstruction in Rastelli:
• Non Homograft Rastelli: APVC, Contegra, Cor Matrix.
• Explore other alternatives:
• Arterial switch operation and resection.
• Nikaidoh or “Ross Konno Arterial switch”.
• REV.
• One and a Half ventricle repair.
• Univentricular repair.
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Arterial Switch• The best option when possible.
• Do not delay the repair!! (Circulation. 2009 15;120(11 Suppl):S53-8) Emani R
• Mild Hypoplastic pulmonary annulus. (z -2)
• Mild Dysplasia. At least bicuspid PV.
• Complete resection of conal septum.
• Traction stitches
• VSD closure.
• ASO without Ao P miss match.
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Nikaidoh or Ross Konno Switch
• Aortic translocation and Reimplantation in the LVOT.
• With coronary reimplantation.
• Ideally for mild mod PV Hypoplasia or dysplastic PV
• Appropiate when VSD is not committed.
• No baffle, RV volume not affected.
• Use of Lecompte Manouver and RV PA conduit.
• Sternal compression is diminished.
• Technical difficulty, late AI. Morrel V, Surgery of Conotruncal Anomalies
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Reparatión a le étage Ventriculaire
• Resection of conal septum.
• (VSD baffling) Direct LV Ao connection.
• Lecompte manouver for RV PA connection.
• Huge ascending aorta.
• Posterior compression of pulmonary branches.
• Anterior compression by sternum.
• Pulmonary Regurgitation.
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Rastelli with APVCJune 1983 – Nov 2018
STS/EACTS Latin America Cardiovascular Surgery Conference 2018
• Enlargement of VSD.
• Baffling with PTFE or pericardium.
• Pericardial valved conduit for RV PA
connection.
• Mortality 4 / 54 = 7,4 %
• None in the last 18 years.
• Late mortality: 4/45.
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Rastelli with APVC
68.5 %
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PVR for PR
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Summary
• Best option Rastelli:
• PA or PS with severe PV ann hypoplasia. Z < 5.
• Straight LVOT after VSD baffling.
• Related conoventricular VSD.
• Mitral Valve abnormal attachments & Cleft in TGA.
• NO TV Straddling
• NO RV hypoplasia.
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Summary II• Best option ASO when mild hypo PV annulus present. (Z > 2)
• Decent PV. Mild grade of dysplasia
• Best option Nikaidoh when
• PV annulus between Z= -2 to -5 and or Dysplastic PV.
• Delayed Repair. (3 m to 1 yr)
• VSD is non committed (inlet type), Straddling TV and/or restrictive.
• Best option 1 and 1/2 or Fontan:
• Hypo RV.
• Unfavorable coronary anatomy.
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Summary III
• There is no optimal procedure for all TGA VSD and LVOTO.
• Many anatomical variants.
• Avoid forcing indications of a procedure when the anatomic
setting is not appropiate.
• Apply the best procedure to a specific anatomy.
• Excellent results can be achieved. Eur J Cardiothorac Surg. 2016 Oct;50(4):617-625 Hraska V
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