The Aortic Translocation (Nikaidoh) Operation

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Presentation transcript:

The Aortic Translocation (Nikaidoh) Operation Steven R. Leonard, MD, FACS, FAAP, Hisashi Nikaidoh, MD, FACS, FAAP Operative Techniques in Thoracic and Cardiovascular Surgery Volume 13, Issue 3, Pages 172-180 (September 2008) DOI: 10.1053/j.optechstcvs.2008.06.002 Copyright © 2008 Elsevier Inc. Terms and Conditions

Figure 1 (A) Cardiopulmonary bypass is established using bicaval cannulation. The aortic cannula is placed as cephalad as possible in the ascending aorta. (B) The aortic root is mobilized circumferentially from the right ventricular outflow tract. A wider rim of the right ventricular free wall is left attached to the anterior aspect of the aortic root. The proximal coronary arteries are mobilized off the underlying myocardium. Injury to major coronary artery branches must be avoided. Ao = aorta; LCA = left coronary artery; Lig. art. = ligamentum arteriosum; MPA = main pulmonary artery; RA = right atrium; RCA = right coronary artery; VSD = ventricular septal defect. Operative Techniques in Thoracic and Cardiovascular Surgery 2008 13, 172-180DOI: (10.1053/j.optechstcvs.2008.06.002) Copyright © 2008 Elsevier Inc. Terms and Conditions

Figure 2 (A) The main pulmonary artery is divided just above the pulmonary valve. The branch pulmonary arteries should be mobilized distally to the pulmonary hila. Division of the ligamentum arteriosum is also important for complete mobilization of the pulmonary arteries. (B) The proximal pulmonary root is opened longitudinally into the superior aspect of the ventricular septal defect and the pulmonary valve tissue is excised. This allows the left ventricular outflow tract to be widely opened to accommodate the aortic root. Lig. art. = ligamentum arteriosum; MPA = main pulmonary artery; MV = mitral valve; Pulm. v. = pulmonary valve; VSD = ventricular septal defect. Operative Techniques in Thoracic and Cardiovascular Surgery 2008 13, 172-180DOI: (10.1053/j.optechstcvs.2008.06.002) Copyright © 2008 Elsevier Inc. Terms and Conditions

Figure 3 (A) The aortic root is sutured into the left ventricular outflow tract with continuous polypropylene suture. If the VSD is not too large, the rim of myocardium along the anterior aspect of the aortic root may be sutured directly to the inferior aspect of the ventricular septal defect to close the defect. (B) However, if the VSD is large, it may be necessary to place a patch between the aortic root and the inferior margin of the defect for adequate closure. (C) Moving the aortic root directly posterior into the left ventricular outflow tract will usually not cause kinking or stretching of the coronary arteries. Pivoting the aortic root around the origin of the left coronary artery may result in stretching of the right coronary artery. The coronary artery ostia should be reimplanted in the aortic root if there is any question of kinking or stretching of the coronary arteries. RCA = right coronary artery; VSD = ventricular septal defect. Operative Techniques in Thoracic and Cardiovascular Surgery 2008 13, 172-180DOI: (10.1053/j.optechstcvs.2008.06.002) Copyright © 2008 Elsevier Inc. Terms and Conditions

Figure 4 The medial aspect of the distal end of the divided main pulmonary artery is sutured to the left lateral aspect of the ascending aorta with running polypropylene suture. Care should be taken to avoid pulling the pulmonary artery so far anteriorly that the right pulmonary artery becomes stretched, as this may cause stenosis of the right pulmonary artery. The proximal left pulmonary artery is incised to prevent narrowing of this branch. LPA = left pulmonary artery. Operative Techniques in Thoracic and Cardiovascular Surgery 2008 13, 172-180DOI: (10.1053/j.optechstcvs.2008.06.002) Copyright © 2008 Elsevier Inc. Terms and Conditions

Figure 5 A large pericardial patch is used to reconstruct the right ventricular outflow tract. The patch extends into the incision in the left pulmonary artery and is sutured in place with running polypropylene suture. Alternatively, the right ventricular outflow tract can be reconstructed using a homograft or similar valved tissue conduit. Operative Techniques in Thoracic and Cardiovascular Surgery 2008 13, 172-180DOI: (10.1053/j.optechstcvs.2008.06.002) Copyright © 2008 Elsevier Inc. Terms and Conditions

Figure 6 (A) Applying the Lecompte maneuver to the pulmonary artery may decrease the incidence of branch pulmonary artery stenosis. The aorta is transected well above the aortic valve and the pulmonary artery bifurcation is moved anterior to the ascending aorta. (B) The divided aorta is approximated with running polypropylene suture. VSD = ventricular septal defect. Operative Techniques in Thoracic and Cardiovascular Surgery 2008 13, 172-180DOI: (10.1053/j.optechstcvs.2008.06.002) Copyright © 2008 Elsevier Inc. Terms and Conditions

Figure 7 (A) The posterior aspect of the distal main pulmonary artery is sutured to the anterior wall of the ascending aorta. (B) A large pericardial patch is used to complete reconstruction of the right ventricular outflow tract. Incisions in the proximal right and left pulmonary arteries may decrease the incidence of branch pulmonary artery stenosis. (C) The ASD is closed through a right atrial incision with direct suture technique or with a patch. ASD = atrial septal defect. Operative Techniques in Thoracic and Cardiovascular Surgery 2008 13, 172-180DOI: (10.1053/j.optechstcvs.2008.06.002) Copyright © 2008 Elsevier Inc. Terms and Conditions