**2. Double arterial translocation with preservation of the pulmonary valve, surgical technique**

This procedure was achieved employing cardiopulmonary bypass with hypothermia at 25°C and myocardial protection with warm induction blood cardioplegic solution at a proportion of 3:1 followed by hypothermic cardioplegic solution and modified ultrafiltration. Initially an incision inferior to the aortic valve was made, excising the ascending aorta (including aortic valve and coronary arteries) beneath the annular level of aortic valve from the right ventricle. Then we performed the excision of the pulmonary root, including pulmonary valve, beneath the annular level of the pulmonary valve from the left ventricle [figure 1]. After section of the infundibular septum in direction to the VSD, the LVOT and the VSD was closed with glutharaldeide-fixed bovine pericardium patch [figure 2]. The resulting gap of the aortic translocation was partially closed with fresh autologous pericardium. Finally the ascending aorta with the aortic valve and the coronary arteries were sutured into the left ventricle outflow and the pulmonary root with the pulmonary valve was sutured into the right ventricular outflow [figure 3].

Correction of Transposition of Great Arteries with Ventricular Septal Defect and Left Outflow

Tract Obstruction with Double Arterial Translocation with Preservation of the Pulmonary Valve 211

Fig. 3. Double arterial translocation with preservation of the pulmonary valve. The resulting opening from resection of the ascending aorta was partially closed to the right with a fresh autologous pericardial patch. The ascending aorta with the coronary arteries and the aortic valve was sutured to the left ventricle outflow tract and the pulmonary trunk with the

Between November 1994 and June 2011, a total of 212 consecutive children with TGA were submitted to surgical treatment at the Hospital São Joaquim da Real e Benemérita Associação Portuguesa de Beneficência as follows: simple TGA (n = 110; 51,8%); TGA, VSD (n = 66; 31,1%); TGA, VSD and LVOTO (n = 34; 16,0%). The diagnosis was based on color echodopplercardiographic findings. The following procedures were used in children with TGA, VSD and LVOTO: modified BT shunt (n = 10), Rastelli procedure (n = 13), Jatene procedure (n = 3) and arterial translocation procedure (n = 8), with two further divisions modified Nikaidoh (n = 5) and double arterial translocation with preservation of pulmonary

In the modified BT shunt group, the VSD was not committed in two patients. Two patients had mitral valve straddling. Two patients had sistemic-pulmonar collateral arteries and one patient had multiple VSD. Seven patients were neonates, one was 2 months old and two patients were 1 year old. The mean weight was 4,3 kg (range 1,8 kg – 8,8 kg). In the Rastelli group three patients had previous modified BT shunt. Two patients had restrictive VSD. One patient had mitral valve insuficience and one patient had right pulmonary artery stenosis. Five patients were neonates, five patients were younger than 1 year of age (mean age was 6,2 months; range 2 months-eleven months), three patients were older than 1 year of age (mean age was 5,6 years; range 3 years – ten years). The mean weight was 7,9 kg (range 3,0 kg – 28,0 kg). In the Jatene procedure two patients were neonates and one patient was 4 months old. The mean weight was 3,8 kg (range 2,9 kg – 5,2 kg). In the arterial translocation group two patients had previous modified BT shunt and one patient had two

pulmonary valve was sutured to the right ventricle outflow tract

**2.1 Patients, general** 

valve (n = 3).

Fig. 1. Double arterial translocation with preservation of the pulmonary valve. Withdrawal of the ascending aorta with the aortic valve and coronary arteries from the right ventricle and removal of the pulmonary trunk with the pulmonary valve from the left ventricle

Fig. 2. Double arterial translocation with preservation of the pulmonary valve. After section of the pulmonary ring and infundibular septum toward the interventricular communication, an enlargement of the left ventricle outflow tract and a closure of interventricular communication was carried out using a glutaraldehyde-fixed bovine pericardium graft

Fig. 3. Double arterial translocation with preservation of the pulmonary valve. The resulting opening from resection of the ascending aorta was partially closed to the right with a fresh autologous pericardial patch. The ascending aorta with the coronary arteries and the aortic valve was sutured to the left ventricle outflow tract and the pulmonary trunk with the pulmonary valve was sutured to the right ventricle outflow tract

### **2.1 Patients, general**

210 Aortic Valve Surgery

Fig. 1. Double arterial translocation with preservation of the pulmonary valve. Withdrawal of the ascending aorta with the aortic valve and coronary arteries from the right ventricle and removal of the pulmonary trunk with the pulmonary valve from the left ventricle

Fig. 2. Double arterial translocation with preservation of the pulmonary valve. After section of the pulmonary ring and infundibular septum toward the interventricular communication,

an enlargement of the left ventricle outflow tract and a closure of interventricular communication was carried out using a glutaraldehyde-fixed bovine pericardium graft Between November 1994 and June 2011, a total of 212 consecutive children with TGA were submitted to surgical treatment at the Hospital São Joaquim da Real e Benemérita Associação Portuguesa de Beneficência as follows: simple TGA (n = 110; 51,8%); TGA, VSD (n = 66; 31,1%); TGA, VSD and LVOTO (n = 34; 16,0%). The diagnosis was based on color echodopplercardiographic findings. The following procedures were used in children with TGA, VSD and LVOTO: modified BT shunt (n = 10), Rastelli procedure (n = 13), Jatene procedure (n = 3) and arterial translocation procedure (n = 8), with two further divisions modified Nikaidoh (n = 5) and double arterial translocation with preservation of pulmonary valve (n = 3).

In the modified BT shunt group, the VSD was not committed in two patients. Two patients had mitral valve straddling. Two patients had sistemic-pulmonar collateral arteries and one patient had multiple VSD. Seven patients were neonates, one was 2 months old and two patients were 1 year old. The mean weight was 4,3 kg (range 1,8 kg – 8,8 kg). In the Rastelli group three patients had previous modified BT shunt. Two patients had restrictive VSD. One patient had mitral valve insuficience and one patient had right pulmonary artery stenosis. Five patients were neonates, five patients were younger than 1 year of age (mean age was 6,2 months; range 2 months-eleven months), three patients were older than 1 year of age (mean age was 5,6 years; range 3 years – ten years). The mean weight was 7,9 kg (range 3,0 kg – 28,0 kg). In the Jatene procedure two patients were neonates and one patient was 4 months old. The mean weight was 3,8 kg (range 2,9 kg – 5,2 kg). In the arterial translocation group two patients had previous modified BT shunt and one patient had two

Correction of Transposition of Great Arteries with Ventricular Septal Defect and Left Outflow

**2.1.2 Surgical technique** 

arterial translocation operation.

difference between all groups (p = 0.811).

avoids early reoperation to change the valved conduit.

**3. Results** 

**4. Comments** 

Tract Obstruction with Double Arterial Translocation with Preservation of the Pulmonary Valve 213

The palliative BT shunt was made by median sternotomy in seven patients, by right thoracotomy in two patients and by left thoracotomy in one patient. The interposition of a polytetrafluoroethylene (PTFE) tube was made between the innominate artery and the right pulmonary artery in nine patients, and between the left subclavian artery and the left pulmonary artery in one patient. In seven patients the diameter of the PTFE tube was 4 mm, and in three patients it was 5 mm. The Rastelli, Jatene and modified Nikaido procedures and double arterial translocation with preservation of the pulmonary valve were made by median sternotomy and moderate hypothermic cardiopulmonary bypass and myocardial protection with warm cardioplegic induction, followed by hypothermic blood cardioplegic solution at a proportion of 3:1 every 20 minutes. In the Rastelli procedure, the VSD was repaired through the right ventriculotomy in such a way to connect the left ventricle to aorta. The reconstruction of the pulmonary artery was performed with a glutaraldehydefixed bovine pericardium valved conduit in eight patients and with a glutaraldehyde-fixed bovine-valved jugular vein in six patients. In the Jatene group, the LVOTO was a subvalvar fibromuscular ridge. After aorta transection was performed resection of the localized LVOTO. The pulmonary trunk was transected proximal to its bifurcation. After the LeCompte maneuver, a button of the left and right coronary artery was excised from its sinus, and was inserted into the neoaorta. Coronary type was Yacoulb I in all patients. The reconstruction of the neopulmonar was done with a single, fresh autologous pericardium patch. In the modified Nikaidoh group the aorta was translocated with the aortic valve and coronary arteries to the left ventricle, after an enlargement of the left ventricle outflow tract and closure of VSD with a single glutaraldehyde-fixed preserved bovine pericardium patch. In this series of patients we used a valved conduit to reconstruct the right ventricular outflow. This approach was different from the original technique, in which the pulmonary trunk is used without a valve. We used a glutharaldeide-fixed valved bovine jugular vein in three patients. In one patient a glutharaldeide-fixed valved bovine pericardium conduit was used, and in one patient a Lhydro porcine valved pulmonary trunk [8]. During the analyzed period there was a change in the surgical procedure. At first, modified BT technique prevailed; later, Rastelli operation and Jatene operation were performed, and finally the

Two patients died in the modified BT shunt group (20%), three patients died in the Rastelli group (23,0%) and one patient died in the arterial translocation group (20%). All patients in the Jatene group and in the double arterial translocation with preservation of the pulmonary valve all patients survived. The statistical analyses (Fisher's Exact Test) showed no

The surgical management of TGA with VSD and LVOTO is a surgical challenge. The Rastelli

The most appropriate timing of the Rastelli operation is controversial. When it is performed during early infancy, it is a physiologic correction and avoids systemic hypoxemia. On the other hand, the palliative procedure of modified BT shunt performed during early infancy

operation remains the most applied procedure for this congenital cardiopathy.

previous modified BT shunt. Three patients were neonates, one patient was 6 months old and four patients were older than 1 year of age (mean age was 1,6 years; range 1 year – 2 years). The mean weight was 7,0 kg (range 2,6 kg – 11,3 kg).

#### **2.1.1 Patients, double arterial translocation with preservation of the pulmonary valve**

Three children with TGA with perimembranous VSD and LVOTO type-fibromuscular tubular obstruction associated to hypoplasia of the pulmonary valve ring underwent doble arterial translocation with preservation of the pulmonary valve: Patient 1, female, aged two years, weighing 10.8 kg, underwent two previous Blalock-Taussig shunt surgeries. Preoperative color Doppler echocardiography revealed a LVOTO gradient of 40 mmHg. CPB time was 195 minutes and the aortic clamping time was 123 minutes. Pressure measurement after surgical correction revealed a ratio of systolic pressure between the RV and LV (RV/LV) of 0.6 and a pulmonary gradient of 25 mmHg. The postoperative Doppler echocardiography revealed a pulmonary transvalvular gradient of 42 mmHg; Patient 2, male, aged 6 months, weighting 7.3 kg. Preoperative Doppler echocardiography revealed LVOT gradient of 65 mmHg. CPB time was 184 minutes and aortic clamping time was 140 minutes. Pressure measurement after surgical correction revealed RV/LV systolic pressure of 0.8 and pulmonary transvalvular gradient of 30 mmHg. Postoperative Doppler echocardiography revealed a pulmonary transvalvular gradient of 31 mmHg. Heart computaticional angiotomography (CT) performed during the immediate postoperative period showed appropriate positioning of the pulmonary trunk, pulmonary artery and aorta in both patients (Figure 4).

Patient 3, male, aged 1 year, weighting 8.0 kg. Preoperative Doppler echocardiography revealed LVOT gradient of 31 mmHg. CPB time was 182 minutes and aortic clamping time was 155 minutes. Pressure measurement after surgical correction revealed RV/LV systolic pressure of 0.7 and pulmonary transvalvular gradient of 30 mmHg.

Fig. 4. Double arterial translocation with preservation of the pulmonary valve. CT angiography performed in the immediate postoperative period showed appropriate positioning of the pulmonary artery and pulmonary branches as well as the ascending aorta
