Canan AYABAKAN, Rıza TÜRKÖZ, Kürşad TOKEL, Emre ÖZKER, Bülent SARITAŞ

Surgical options in complex transposition of great arteries

Bu çalışmada büyük arter transpozisyonu, ventriküler septal defekt ile birlikte sol ventrikül çıkım yolu darlığı veya arkus aort darlığında cerrahi yaklaşımın belirlenmesine yönelik deneyimimiz sunuldu ve kısa ve orta dönem sonuçlar bildirildi.Çalışmaplanı:Şubat 2007 - Temmuz 2012 tarihleri arasında büyük arter transpozisyonu, ventriküler septal defekt, sol ventrikül çıkım yolu veya arkus aort darlığı nedeniyle ameliyat edilen toplam 18 hasta (9 erkek, 9 kız; ortanca yaş 4.25 ay; dağılım 12 gün-96 ay) retrospektif olarak incelendi.Bul gu lar: Kardiyak patolojiler dört hastada büyük arter transpozisyonu, ventriküler septal defekt ve aort koarktasyonu, iki hastada büyük arter transpozisyonu, ventriküler septal defekt ve valvüler pulmoner darlık ve 12 hastada büyük arter transpozisyonu, ventriküler septal defekt, valvüler veya subvalvüler pulmoner darlık idi. İkisi modifiye Konno ameliyatı olmak üzere, toplam dokuz hastaya ventriküler septal defekt kapatılması ile birlikte arteriyel switch ameliyatı ve sol ventrikül çıkım yolu darlığına yönelik işlemler uygulandı. Diğer işlemler, dört hastada arteriyel switch ameliyatı ile birlikte ventriküler septal defekt kapatılması ve arkus rekonstrüksiyonu, üç hastada Rastelli ameliyatı ve iki hastada Nikaidoh ameliyatı idi. Ortanca kardiyopulmoner baypas ve kros klemp süreleri sırasıyla 228.5 dk. ve 107 dk. idi. Yoğun bakım ünitesinde kalış süresi ortanca 102.5 saat (dağılım 28-765 saat) iken, ortanca entübasyon süresi 40.5 saat (dağılım 17-275 saat) idi. Hastaların tümü ortanca yedi gün içinde (dağılım 5-55 gün) taburcu edildi. Ortanca takip süresi 37.7 ay (dağılım 15 gün-74 ay) idi. Rastelli ameliyatı yapılan iki hasta, düşük kalp debisi nedeniyle yoğun bakım ünitesinde kaybedildi. Son ekokardiyografik incelemede sol ventrikül çıkım yolu ameliyatı olan hastalarda ortanca sol ventrikül çıkım yolu gradyanı 12.4 mmHg (dağılım 2-38 mmHg) iken, arkus rekonstrüksiyonu yapılan hastalarda inen aort ortanca gradyanı 13.5 mmHg (dağılım 7.8-28 mmHg) idi. Neoaortik biküspid kapağı ve arka septal dizilim bozukluğu olan yalnızca bir hasta, sol ventrikül çıkım yolu gradyanı 38 mmHg olduğu için tekrar ameliyat edildi.So nuç: Çalışma bulgularımız, arteriyel switch ameliyatının sol ventrikül çıkım yolu darlığı rezeke edilebilir ise, tercih edilen bir seçenek olduğunu göstermektedir. Seçilmiş hastalarda intraventriküler yeniden yönlendirme işlemleri seçenek olabilir. En uygun cerrahi tekniğin seçilmesinin her hastada spesifik anatomik özelliklerin anlaşılmasını gerektirdiği kanısındayız

Büyük arterlerin kompleks transpozisyonunda cerrahi seçenekler

In this study, we present our experience in selecting surgical approach for transposition of the great arteries and left ventricular outflow tract obstruction or aortic arch obstruction with ventricular septal defect and to report early and mid-term results.Methods: Between February 2007 and June 2012, a total of 18 patients (9 males, 9 females; median age 4.25 months; range, 12 days to 96 months) who were operated for transposition of the great arteries, ventricular septal defect, and left ventricular outflow tract obstruction or aortic arch obstruction were retrospectively analyzed.Results: Cardiac pathologies were transposition of the great arteries, ventricular septal defect and coarctation of aorta in four patients; transposition of the great arteries, ventricular septal defect and valvular pulmonary stenosis in two patients, and transposition of the great arteries, ventricular septal defect, valvular or subsubvalvular pulmonary stenosis in 12 patients. Arterial switch operation with ventricular septal defect closure and left ventricular outflow tract obstruction procedures were performed in nine patients, two of which were modified Konno operations. The other operations were arterial switch operation with ventricular septal defect closure and arcus reconstruction in four patients, Rastelli operation in three patients, and Nikaidoh operation in two patients. Median cardiopulmonary bypass and cross-clamp times were 228.5 min and 107 min, respectively. The median length of stay in the intensive care unit was 102.5 hours (range, 28 to 765 hours), while the median duration of intubation was 40.5 hours (range 17 to 275 hours). All patients were discharged within median seven days (range 5 to 55 days). The median follow-up was 37.7 months (range, 15 days to 74 months). Two patients who underwent Rastelli operation died due to low cardiac output in the intensive care unit. At the final echocardiographic examination, the median left ventricular outflow tract gradient was 12.4 mmHg (range, 2 to 38 mmHg) in the patients operated for left ventricular outflow tract obstruction, whereas the median descending aorta gradient was 13.5 mmHg (range, 7.8 to 28 mmHg) in the patients with arcus reconstruction. Only one patient with bicuspid neoaortic valve and posterior septal malalignment was reoperated due to a left ventricular outflow tract gradient of 38 mmHg.Conclusion: Our study results suggest that arterial switch operation is a preferable alternative, if the left ventricular outflow tract obstruction is resectable. Intraventricular re-routing procedures may be the choice in selected patients. We believe that choosing the optimal surgical technique demands appreciation of the particular anatomic features in each individual patient

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