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A Better Approach for Left Ventricular Training In Received: 28 September 2018 | Revised: 7 November 2018 | Accepted: 29 December 2018 DOI: 10.1111/chd.12749 ORIGINAL ARTICLE A better approach for left ventricular training in transposition of the great arteries and intact interventricular septum: Bidirectional cavopulmonary anastomosis and pulmonary artery banding Mehmet Salih Bilal MD1 | Arda Özyüksel MD1,2 | Mustafa Kemal Avşar MD1 | Şener Demiroluk MD3 | Osman Küçükosmanoğlu MD4 | Yalım Yalçın MD5 1Department of Cardiovascular Surgery, Medicana International Hospital, Abstract Istanbul, Turkey Objective: Management of the patients with transposition of the great arteries and 2 Department of Cardiovascular intact ventricular septum may be challenging beyond the newborn period. Herein, we Surgery, Biruni University, Istanbul, Turkey would like to present our alternative strategy for training the left ventricle in these 3Department of Anesthesiology, Medicana International Hospital, Istanbul, Turkey patients. 4Department of Pediatric Methods: Six patients with transposition of the great arteries and intact ventricular Cardiology, Medicana International Hospital, Istanbul, Turkey septum were evaluated in our clinic. Two of them were palliated with Glenn proce- 5Department of Pediatric dure and pulmonary banding as a definitive treatment strategy at other centers. Four Cardiology, Florence Nightingale Hospital, patients were operated on and a bidirectional cavopulmonary anastomosis in combi- Istanbul, Turkey nation with pulmonary artery banding was performed (stage‐1: palliation and ven- Correspondence tricular training) in our center. In four out of these six patients, arterial switch Arda Özyüksel, Department of Cardiovascular Surgery, Medicana operation was performed with takedown and direct re‐anastomosis of the superior International Hospital, Beylikdüzü Caddesi, vena cava to right atrium after an interstage period of 21‐30 months (stage‐2: ana- No:3, Beylikdüzü, Istanbul, Turkey. Email: [email protected] tomical repair). Results: Any mortality was not encountered. The left ventricular mass indices in- creased from 18‐32 to 44‐74 g/m2 in patients undergoing the anatomical repair. All of the patients were uneventfully discharged following the second stage. The mean follow‐up period was 20 months (9‐32 months) following stage 2. All of the patients are doing well with trivial neoaortic regurgitation and normal biventricular function. Conclusions: Bidirectional cavopulmonary anastomosis with pulmonary artery band- ing may be a promising left ventricle training approach in ventriculoarterial discord- ance when compared to the traditional pulmonary artery banding with concomitant systemic‐to‐pulmonary artery shunt procedures which still carry a significant inter- stage morbidity and mortality. KEYWORDS arterial switch operation, bidirectional Glenn procedure, intact ventricular septum, modified Blalock–Taussig shunt, transposition of the great arteries 464 | © 2019 Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/chd Congenital Heart Disease. 2019;14:464–469. BILAL ET al. TGA for TGA decades. cipal form of management for late presentations of patients with ever, ever, these procedures have significant morbidity how preferred, are procedures artery shunt systemic‐to‐pulmonary and mortality. traditionalIVS).In approach, pulmonary artery bandingand/or (PAB) TGA is mandatory when the interventricular septum is intact (TGA‐ natal period, preparing or “retraining” the forLV ASO in cases with monary artery in four out of six cases. down of the cavopulmonary anastomosis and debanding of the pul subsequent successful ASO procedures were performed with take‐ cavopulmonary anastomosis (Glenn procedure) along with PAB. The perform caseswe trainingwhich such procedurein for bidirectional systemic function begins to decrease gradually. or ventricular septal defect (VSD), the ability of the LV to sustain a left ventricle (LV), most commonly a patent ductus arteriozus (PDA) 5%‐7% 5%‐7% of congenital heart defects. D‐looped transposition of the great arteries (TGA) accounts for 1 secundum atrial septal defects as the sources wereof defined mixingas stage‐1 palliation betweengroup. Five of these patients had with PAB were performed in our center. Overall, these six patients operated and a bidirectional cavopulmonary aiminganastomosis to along increase systemic saturation patients the palliate to order levels. in centers foreign at on operated Fourwere patients were entation were varying between 5 the infancy period in our clinic. The ages of the patients at the pres Six patients were evaluated with the diagnosis of TGA‐IVS beyond 2 beyond beyond this period. aging; however, the clinical situation becomes moreterial switchtroublesome operation (ASO) within first 4 of ASO. creasedmorbidity andmortality which evenovercomemay therisks support.Moreover,this stormy postoperative course leadmayin to with unsuccessful extubation and prolonged necessity of inotropic and even sudden death. ular dysfunction, brady and tachyarrhythmias, baffle obstructions, recognized long‐term complications include systemic right ventric temic ventricle and atrioventricular valve, respectively. However, where the right ventricle and the tricuspid valve serve for the sys congenitallyto corrected transposition thegreatarteriesof (cc‐TGA) Senning and Mustard operations convert TGA to a situation similar operative period. operative re aortic gurgitation,resizing, decreaseshunt in for pulmonary band gradient intervention in the early secondary a post necessitating output, hypoxemia cardiac low as such complications to due 15% as The mortality of this first step of a two‐stage ASO may be as high Herein, we would like to present an alternative left ventricular theabsencesourceInvolume pressure a of and/or of loadtheon | | INTRODUCTION PATIENTS 10 8,9 3 In fact, the atrial switch procedures, namely the The intensive care unit stay may be complicated 2 The atrial switch procedures were the prin the were procedures switch atrial The 3-5 AND months and 3 METHODS 1 Surgical outcomes of the ar the of outcomes Surgical weeks of life is encour years. of Two them 6 Beyond the neo the Beyond 7 - - - - - - - - - - - - TABLE 1 Summary of the patients who underwent anatomical repair following stage‐1 palliation Patient Age/BW at Age/BW at Interstage Technique of Glenn LV mass index at LV mass index at RV/LV ratio at Inotropic support Result/follow‐up no. stage‐1 stage‐2 period takedown stage‐1 (g/m2) stage‐2 (g/m2) stage‐2 after stage‐2 period 1 5 mo/4 kg 2 yrs/12 kg 21 mo Direct SVC‐RA 23 74 0.79 None Well/32 mo anastomosis 2 8 mo/5 kg 3 yrs/13 kg 27 mo Direct SVC‐RA 25 44 0.91 Adrenaline and Well/28 mo anastomosis milrinone 3 9 mo/5 kg 3.5 yrs/16 kg 29 mo Direct SVC‐RA 18 52 0.77 None Well/14 mo anastomosis 4 13 mo/7 kg 4 yrs/15 kg 30 mo Direct SVC‐RA 32 59 0.94 Milrinone and Well/9 mo anastomosis dobutamine Abbreviations: BW, body weight; CPB, cardiopulmonary bypass; LV, left ventricle; RA, right atrium; RV, right ventricle; SVC, superior vena cava. | 465 466 | BILAL ET al. oxygenated and deoxygenated blood and one patient had a history transthoracic echocardiography revealed good biventricular func- of balloon atrial septostomy at the newborn period. tion. However, in the sixth postoperative hour, adrenaline and mil- Targets of stage‐1 palliation were determined as a loose PAB for rinone infusions were started due to the decreased left ventricular left ventricular preparation and bidirectional cavopulmonary anas- ejection fraction (35%‐40%) and mild to moderate neoaortic valve tomosis for providing adequate systemic oxygenation. Patent duc- regurgitation with findings of low cardiac output. The patient’s ven- tus arteriosus were ligated with silk sutures in two patients at the tricular function gradually recovered after 72‐96 hours. He was ex- first stage. All the patients were operated via midline sternotomy, tubated after 7 days and transthoracic echocardiography revealed and standard hemodynamical parameters were achieved at the end LVEF: 55% with mild aortic regurgitation at the time of discharge. of Glenn anastomosis and PAB. Glenn anastomosis was performed Patient 4 received prophylactic milrinone and dobutamine at the with veno‐venous shunting between the superior vena cava (SVC) termination of CPB, which were gradually ceased in the follow‐up. and right atrium (RA), without implementing cardiopulmonary by- All of the patients were discharged uneventfully following the pass. An appropriately sized venous cannula was inserted to SVC, second‐stage definitive repair. Postoperative transthoracic echocar- preferably near the junction with the innominate vein. Another ve- diography evaluations were scheduled at regular intervals. The mean nous cannula was inserted to RA. When the SVC was clamped during follow‐up was 17 months (5‐28 months) and all of the patients are the anastomosis, blood flow to the RA was easily preserved by this doing well in this period. technique. On the other hand, the Glenn procedure was performed first, followed by PAB. This provided a safe and more accurate way for tightening the pulmonary band when adequate systemic oxygen 4 | DISCUSSION saturation and ventricular pressure ratios were concerned. The tar- get systemic oxygen saturation in blood gas analysis was 80%‐90% The history of surgery for TGA has paralleled the history of cardiac at a FiO2 of 50% and a tidal ventilation volume of 10‐12 ml/kg. The surgery. Moreover, attempts to palliate cyanotic newborns with TGA targeted pulmonary band
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