**2.1.2 Surgical technique**

212 Aortic Valve Surgery

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

**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).

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

pressure of 0.7 and pulmonary transvalvular gradient of 30 mmHg.

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

years). The mean weight was 7,0 kg (range 2,6 kg – 11,3 kg).

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 arterial translocation operation.
