13 Iwata H, Kataoka M, Yamakawa Y et al. Esophageal schwannoma. Ann Fig.1 Right ventric- Thorac Surg 1993; 56: 376– 377 ular outflow tract and 14 Eberlein TJ, Hannan R, Josa M, Sugarbaker DJ. Benign schwannoma of mobilization of the the esophagus presenting as a giant fibrovascular polyp. Ann Thorac aortic root without Surg 1992; 53: 343 –345 the LMCA (LVOT: left ventricular outflow Received February 8, 2006 tract; Ao: ; VSD: ventricular sep- tal defect). Correspondence: Dr. Hsin-Yuan Fang · Department of · Changhua Christian Hospital · 135 Nanhsiao Street · Changhua · Taiwan 500 · Phone: + 88 6 4723 85 95 · Fax: + 88 6 4722 82 89 · E-mail: [email protected]; [email protected] hr Communications Short

Modified Nikaidoh Procedure for Transposition of Great Arteries, Ventricular Septal Defect and Left Ventricular Outflow Tract Obstruction telli procedure has been used as a first choice of correction in O. A. Sayin1, M. Ugurlucan1, L. Saltik2, Z. Sungur3, E. Tireli1 many cases with satisfactory early and late results [2]. In 1984, 1 Department of Cardiovascular Surgery, Istanbul University Istanbul Medical Nikaidoh first described a new surgical approach for the correc- Faculty, Istanbul, Turkey tion of this pathology. The approach consisted of an aortic trans- 2 Department of Pediatric , Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey location without coronary transfer with biventricular outflow 3 Department of Anesthesiology, Istanbul University Istanbul Medical Faculty, tract reconstruction [3]. Istanbul, Turkey In this report, we present a patient with TGA-VSD-LVOT obstruc- tion who was successfully treated with a modified Nikaidoh pro- Abstract cedure.

558 The surgical management of transposition of the great arteries with ventricular septal defect and left outflow tract ob- Case Report struction is a real challenge in congenital surgery. The Ras- telli operation has been used for many years with satisfactory A 3.5-year-old cyanotic child was referred to our clinic with the early and late results. A newer operation described by Nikaidoh diagnosis of TGA-VSD-LVOT obstruction. He had undergone right seems to take anatomy more into account and has been per- and left modified Blalock-Taussig shunt operations when he was formed with promising outcomes. In this report, we present a 1 month and 2.5 years old, respectively. The cardiac catheteriza- Downloaded by: Kevin Chang. Copyrighted material. patient with transposition of the great arteries, ventricular septal tion revealed a restrictive VSD with LVOT obstruction and normal defect and left ventricular outflow tract obstruction who was coronary arteries. successfully treated with a modification of the Nikaidoh proce- dure. The operation was performed through under low flow (CPB) at moderate hypother- Key words mia (25 8C). Myocardial protection was achieved with antegrade Transposition of great arteries · ventricular septal defect · left cold crystalloid and topical ice slush. High aortic ventricular outflow tract · Rastelli procedure · Nikaidoh procedure and bicaval cannulation was performed. As soon as CBP was ini- tiated, both shunts were legated. After cross-clamping, the prox- imal one-centimeter segments of the right coronary artery (RCA) Introduction and left main coronary artery (LMCA) were extensively prepared and mobilized. The LMCA button was detached from the aorta Transposition of the great arteries (TGA) with ventricular septal and the defect was patched with pericardial tissue. The aortic defect (VSD) and left ventricular outflow tract (LVOT) obstruc- root was completely dissected with a 5-mm cuff from the right tion represents 0.67% of all congenital heart defects [1]. The sur- ventricular outflow, together with the RCA still attached to it gical management of this pathology is a real challenge. The Ras- (Fig.1). After that, the main was dissected above the pulmonary valves and the dysplastic valves were ex- cised. The LVOT was enlarged by dissecting the infundibular sep- Bibliography tum down to the restrictive VSD. The hypertrophic muscles on Thorac Cardiov Surg 2006; 54: 558 –560 © Georg Thieme Verlag KG · Stuttgart · New York the left side of the ventricular septum were resected. A glutaral- DOI 10.1055/s-2006-924415 · ISSN 0171-6425 dehyde fixed pericardial patch was used to create an inferior bor-

Sayin OA et al. Modified Nikaidoh Procedure … Thorac Cardiov Surg 2006; 54: 548 –566 straddling AV valves, may complicate this operation. Besides, the long-term results of the Rastelli operation, especially left ventric- ular dysfunction and arrhythmia, may lead to unexpected late mortality [2, 4]; thus, in recent years, this has made cardiac sur- geons more wary of carrying out a Rastelli procedure.

The procedure used and amended here is an aortic translocation together with biventricular outflow tract reconstruction and was first described by Nikoidoh in 1984. This seems to take anatomi- cal structures into account better in the correction of TGA-VSD- LVOT obstruction. However, there are only two large series of this procedure in the literature. The first one was by Nikaidoh, and, in his presentation, he explains his original technique of mobiliza-

tion of the aortic root without detaching the coronary arteries. In Communications Short his series, only four of seventeen patients were able to undergo complete translocation. Three of them required postoperative extracorporeal membrane oxygenation support. [5]. Most prob- ably, the coronary ischemia was the primary reason for the early support [1].

Fig. 2 Perioperative view of the completed aortic translocation and The second report is from Morell et al. In their technique, the cor- right ventricular outflow tract reconstruction. (RVOT: right ventricular onary arteries were devised from the aorta subsequent to aortic outflow tract; Ao: aorta; PA: pulmonary artery; LMCA: left main coro- translocation; coronary transfers were performed in order to nary artery). prevent coronary insufficiency. With their technique, coronary anomalies were found to be the major risk factor [1]. In contrast der by running 5.0-polyprolene sutures. The patch was placed to the experience of Morell and coworkers, coronary anomalies from the lower border of the VSD up to the outflow tract. The are not a major risk factor for the Rastelli procedure. aortic root, together with the RCA, was translocated completely to the new outflow tract by interrupted pledgeted 5.0 polypro- Harvesting the aortic root, together with the coronary arteries, lene sutures. After reconstruction of the new LVOT, the cross- may lead to kinking and coronary ischemia. In our single experi- clamp was removed. As the aorta was filled with , the ap- ence, complete transfer of the aortic root without any postopera- propriate location for the LAD button on the anterior of the aorta tive ischemic events was probably mediated by extensive prepa- was marked and recross-clamped. The marked location opened ration and mobilization of the proximal segments of the RCA and 559 with a 4.0 punch and the LMCA was anastomosed to the aorta. detachment of the LMCA. Furthermore, the sufficiently long xen- The posterior surface of the right ventricular outflow tract ograft for the RVOT reconstruction did not require a Lecompte (RVOT), anterior to the aorta, was reinforced with a circular peri- maneuver. Compared with the necessity for reoperations after cardial collar in order to facilitate the reconstruction of the RVOT Rastelli procedures, we believe that with our technique the ana- by anastomosis using an 18-mm Contegra conduit. The Lecompte tomical placement of the valve conduit will remain stress-free maneuver was not performed (Fig. 2). The patient was weaned under the sternum and will remain durable for a longer period Downloaded by: Kevin Chang. Copyrighted material. off CPB with low-dose inotropic support and was in sinus of time. rhythm. CPB and aortic cross-clamp times were 156 minutes and 110 minutes, respectively. The patient was extubated six In conclusion, aortic translocation and biventricular outflow hours after the operation. The postoperative course was un- tract reconstruction results in an exact anatomical correction eventful and he was discharged from the hospital on the 12th for patients with TGA-VSD-LVOT obstruction. The left ventricle postoperative day. aorta and right ventricle-pulmonary artery alignment offer the best subsequent cardiac performance. Although the Rastelli pro- The patient is still doing very well nine months after the opera- cedure is still the operation of choice for most surgeons for this tion. Control showed successful correction of pathology, patients who have additional anatomical problems, the pathology without any gradient between the outflow tracts, such as restrictive or inlet VSD, or straddling AV valve obstruc- and with only mild mitral regurgitation. Control computerized tion, may be corrected using the original Nikaidoh operation or tomography revealed normal positioning of the LVOT and RVOT. modifications of this procedure. We believe this operation will offer promising results in the future.

Discussion References TGA with VSD and LVOT obstruction is a rare and complex mor- phology among the congenital heart diseases. The surgical man- 1 Morell VO, Jacobs JP, Quintessenza JA. Aortic translocation in the agement of this pathology has been a real challenge. Even though management of transposition of the great arteries with ventricular septal defect and pulmonary : results and follow-up. Ann the Rastelli operation seems to be the best choice for this pathol- Thorac Surg 2005; 79: 2089 –2093 ogy, difficult anatomical morphologies, such as restrictive VSD or

Sayin OA et al. Modified Nikaidoh Procedure … Thorac Cardiov Surg 2006; 54: 548 –566 2 Lee JR, Lim HG, Kim YJ, Rho JR, Bae EJ, Noh CI, Yun YS, Ahn C. Repair of transposition of the great arteries, ventricular septal defect and left ventricular outflow tract obstruction. Eur J Cardiothorac Surg 2004; 25: 735 – 741 3 Nikaidoh H. Aortic translocation and biventricular outflow tract re- construction. A new surgical repair for transposition of the great ar- teries associated with ventricular septal defect and pulmonary steno- sis. J Thorac Cardiovasc Surg 1984; 88: 365 – 372 4 Dearani JA, Danielson GK, Puga FJ, Mair DD, Schleck CD. Late results of the Rastelli operation for transposition of the great arteries. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2001; 4: 3 –15 5 Yeh T, Ramaciotti C, Leonard SR, Nikaidoh H. Superior preservation of the left ventricular outlet after the aortic translocation (Nikaidoh) procedure. Presented at the Fourth World Congress of Pediatric Cardi- ology and , 2005

hr Communications Short Received March 25, 2006

Correspondence: Omer Ali Sayin, MD · Department of Cardiovascular Fig.1 Chest radiogram on the 5th day after the accident. Surgery · Istanbul University Istanbul Medical Faculty · Millet Caddesi, 34390 Capa/Fatih · Istanbul · Turkey · Phone: + 902124142 00 0312 66 · Phone: + 9053 26 3355 23 · Fax: + 902125 34 22 32 · E-mail: [email protected] Introduction

Bronchial ruptures due to blunt chest trauma are rare injuries [1]. In recent decades, an increase in traffic accidents has led to an increase in blunt tracheobronchial injuries [2]. Although most cases present with dramatic life-threatening symptoms, some Delayed Diagnosis of a Complete cases may run a much more benign course with minimal symp- Bronchial Rupture after Blunt toms [3].

Thoracic Trauma In this paper, we present a 32-year-old female patient with a left main bronchial transection due to a blunt chest trauma, diag- A. Demir, A. Olcmen, H. V. Kara, S. I. Dincer nosed by bronchoscopy, multidetector computed tomography Department of Thoracic Surgery, Yedikule Teaching Hospital for Chest Diseases and (MDCT) (Siemens, Sensation 4, Erlangen, Germany), virtual bron- Thoracic Surgery, Istanbul, Turkey choscopy and treated by end-to-end anastomosis. 560

Abstract Case Report

Bronchial ruptures due to blunt chest traumas are rarely encoun- The plain radiograms taken on the first and fifth day of a previ- tered injuries. They can be missed in the emergency room de- ously healthy 32-year-old woman who was injured in a traffic ac- pending on the clinical findings. We present a case report of a cident revealed multiple fractures including the right clavicula, Downloaded by: Kevin Chang. Copyrighted material. previously healthy 32-year-old woman who received multiple the costa, and left proximal humerus. No pathological findings rib and clavicula fractures on the right side in a traffic accident. were seen on her chest radiograms (Fig. 1). A control chest radio- The plain radiograms taken on the first and fifth day showed no gram which was taken 7 weeks later showed a totally collapsed other pathological findings than the above-mentioned fractures. left . The patient who was complaining of shortness of Her control chest radiography, which was taken 7 weeks later, breath was referred to our institution for further investigation. showed a totally opaque left hemithorax but no findings of pneu- A completely occluded left main bronchus was seen on bron- mothorax were present. Fiberoptic bronchoscopy and virtual choscopy, and sagittal and coronal reconstructed MDCT, and vir- bronchoscopy showed a left main bronchial rupture. The patient tual broncoscopy images taken afterwards showed total occlu- was treated with an end-to-end anastomosis via left posterolat- sion on the left main bronchus and total left pulmonary atelecta- eral thoracotomy. sis (Fig. 2).

Key words Two months after the accident, she underwent a left thoracoto- Thoracic surgery · complete bronchial rupture · blunt thoracic my which revealed a complete transection of the left main bron- trauma · virtual bronchoscopy chus. Granulation tissue and fibrosis had completely occluded the airway, filling the space between the two ends of the bron- chus, which were separated by approximately 1 cm but were sur- rounded by thick peribronchial tissue (Fig. 3). Both edges were resected at the border of the granulation tissue and viable tissues Bibliography were reached. A copious amount of clear mucus inside the distal Thorac Cardiov Surg 2006; 54: 560– 562 © Georg Thieme Verlag KG · Stuttgart · New York bronchus was aspirated. Primary end-to-end anastomosis of the DOI 10.1055/s-2006-924480 · ISSN 0171-6425 left main bronchus stem was done with continuous 4.0 polypro-

Demir A et al. Delayed Diagnosis of … Thorac Cardiov Surg 2006; 54: 548 –566