Arteryel Switch Operasyonlarında Aortopulmoner Çap Uyumsuzluğunu Gidermek İçin Nonkoroner Sinüs Plikasyonu

Year 2024, , 67 - 72, 29.04.2024

Onur Doyurgan , Ahmet Kuddusi İrdem , Yiğit Kılıç , Fatih Özdemir , Hasan Balık , Osman Akdeniz

https://doi.org/10.35440/hutfd.1330996

Abstract

Öz
Amaç: Ciddi aortopulmoner çap uyumsuzluğu arteryel switch operasyonu sırasında karşılaşılan bir problemdir. Sinotubuler bileşke geometrisini bozarak postoperatif neoaortik kapak yetmezliğine neden olabilir. Bu çalışmada aortopulmoner çap uyumsuzluğunu gidermek için uyguladığımız cerrahi teknikleri ve bu prosedürün sonuçlarını inceledik. Materyal ve metod: Hastanemizde Aralık 2017-Mayıs 2023 tarihleri arasında büyük arter transpozisyonu (BAT) tanısı ile opere edilen hastalar arasından pulmoner arter / aort çap uyuşmazlığını gidermeye yönelik cerrahi prosedür uygulanan hastalar çalışmaya alındı. Hastalar nonkoroner sinüs plikasyonu yapılanlar ve diğer teknikler uygulananlar olarak iki gruba ayrıldı. Pulmoner arter / aort çap uyuşmazlığı sinotubuler bileşkede pulmoner arter çapının aorta çapının iki katından fazla olması olarak tanımlandı. Bulgular: Arteryel switch operasyonu yapılan 127 hastadan 23’ünde (%18,1) aortopulmoner çap uyumsuzluğu mevcuttu. Aortopulmoner çap uyumsuzluğu olan hastaların 15’ine (%65,2) nonkoroner sinüs plikasyonu, 5’ine (%21,7) aort anterior duvarına longitudinal insizyon ile genişletme, 2’sine (%8,7) pulmoner arterden doku rezeksiyonu ve 1’ine (%4,4) aort anterior duvarda otolog perikard yama ile genişletme yapıldı. Hastaların 15’i erkek, ortanca yaşı 14 gün ve ortanca ağırlığı 3,3 kg olarak saptandı. Hastaların 9’u basit BAT iken 10 hastada büyük arter transpozisyonuna ventriküler septal defekt, 4 hastada Taussig-Bing anomalisi, 4 hastada aortik ark patolojisi eşlik ediyordu. İki hasta sol ventrikül disfonksiyonu nedeniyle ve bir hasta sepsis nedeniyle yaşamını yitirdi. Gruplar arasında perioperatif veriler açısından anlamlı farklılık bulunmadı. Takipte hafif neoaortik kapak yetmezliği oranı nonkoroner sinüs plikasyonu yapılan hastalarda %33,3 (n=5), diğer tekniklerin uygulandığı hastalarda %37,5 (n=3) bulundu. Hiçbir hastada neoaortik kapak darlığı veya orta/ciddi neoaortik kapak yetmezliği saptanmadı. Sonuç: Nonkoroner sinüs plikasyonu arteryel switch operasyonlarında aortopulmoner çap uyumsuzluğunu gidermeye yönelik basit, düşük riskli ve uygulaması kolay bir prosedürdür. Bu teknik kullanılarak aort ve pulmoner arter arasındaki asimetri ortadan kaldırılabilir ve daha doğal bir anatomi oluşturulması sağlanabilir.

Keywords

büyük arter transpozisyonu, arteryel switch operasyonu, aort, pulmoner arter

Noncoronary Sinus Plication to Correct Aortopulmonary Diameter Mismatch in Arterial Switch Operations

Abstract

Background: Severe aortopulmonary diameter mismatch is a problem encountered during arterial switch operation. It may cause postoperative neoaortic valve insufficiency by disrupting the geometry of the sinotubular junction. In this study, we analyzed the surgical techniques and outcomes of aortopulmonary diameter mismatch.
Materials and Methods: Patients who underwent surgical procedures to correct pulmonary artery/aortic diameter mismatch between December 2017 and May 2023 in our hospital were included in the study. Patients were divided into two groups as those who underwent noncoronary sinus plication and those who underwent other techniques. Pulmonary artery/aortic diameter mismatch was defined as a pulmonary artery diameter more than twice the diameter of the aorta at the sinotubular junction.
Results: Aortopulmonary diameter mismatch was present in 23 (18.1%) of 127 patients who underwent arterial switch opera-tion. Of the patients with aortopulmonary diameter mismatch, 15 (65.2%) underwent noncoronary sinus plication, 5 (21.7%) underwent dilatation through a longitudinal incision in the anterior aortic wall, 2 underwent tissue resection from the pulmo-nary artery, and 1 (4.4%) underwent dilatation with an autologous pericardial patch in the anterior aortic wall. Fifteen patients were male (p=0,371), median age was 14 days (p=0,825) and median weight was 3.3 kg (p=0,392). While 9 patients had simple TGA, transposition of the great arteries was associated with ventricular septal defect in 10 patients, Taussig-Bing anomaly in 4 patients and aortic arch pathology in 4 patients. Two patients died due to left ventricular dysfunction and one patient died due to sepsis. There was no significant difference in perioperative data between the groups. The rate of mild neoaortic valve regurgitation at follow-up was 33.3% (n=5) in patients with noncoronary sinus plication and 37.5% (n=3) in patients with other techniques (p=0,842). Neoaortic valve stenosis or moderate/severe neoaortic valve insufficiency was not detected in any patient.
Conclusions: Surgical techniques used to correct aortopulmonary diameter mismatch have similar results. Noncoronary sinus plication is a simple, low-risk and easy-to-perform procedure to correct aortopulmonary diameter mismatch in arterial switch operations. Using this technique, the asymmetry between the aorta and pulmonary artery can be eliminated and a more natural anatomy can be created.

Key Words: Transposition of great arteries, Arterial switch operation, Aorta, Pulmonary artery

Keywords

Transposition of great arteries, Arterial switch operation, Aorta, Pulmonary artery

References

• Villafane J, Regina Lantin-Hermoso M, Bhatt AB, Tweddell JS, Geva T, Nathan M, et al. D Transposition of the great arteries. J Am Coll Cardiol. 2014;64:498-511.
• Losay J, Touchot A, Serraf A, Litvinova A, Lambert V, Piot JD, et al. Late outcome after arterial switch operation for transposi-tion of the great arteries. Circulation. 2001;104:(12 Suppl 1):I121-6.
• Vargo P, Mavroudis C, Stewart RD, Backer CL. Late complicati-ons following the arterial switch operation. World J Pediatr Congenit Heart Surg. 2011;2:37-42.
• Prifti E, Crucean A, Bonacchi M, Bernabei M, Murzi B, Luisi SV, et al. Early and long term outcome of the arterial switch ope-ration for transposition of the great arteries: predictors and functional evaluation. Eur J Cardiothorac Surg. 2002;22:864-73.
• Martins CN, Filho BG, Lopes RM, Silva F. Mid- and long term neo-aortic valve regurgitation after Jatene surgery: prevalence and risk factors. Arq Bras Cardiol. 2018;111:21-8. 6. Doyurgan O, Özdemir F, Akdeniz O, İrdem AK, Okur NM, Salık F, et al. Is arterial switch operation possible with neonatology-focused intensive care unit modality. Turk Gogus Kalp Dama. 2021;29(2):136-42. 7. Lange R, Cleuziou J, Hörer J, Holper K, Vogt M, Tassani Prell P, et al. Risk factors for aortic insufficiency and aortic valve rep-lacement after the arterial switch operation. Eur J Cardiotho-rac Surg. 2008;34:711-7. 8. Van der Bom T, van der Palen RLF, Bouma BJ, vanVeldhuisen SL, Vliegen HW, Konings TC, et al. Persistent neo-aortic growth during adulthood in patients after an arterial switch operation. Heart. 2014;100:1360-5.
• Marino BS, Wernovsky G, McElhinney DB, Jawad A, Kreb DL, Mantel SF, et al. Neo-aortic valvar function after the arterial switch. Cardiol Young. 2006;16:481-9.
• Koolbergen DR, Manshanden JSJ, Yazdanbakhsh AP, Bouma BJ, Blom NA, de Mol BA, et al. Reoperation for neoaortic root pathology after the arterial switch operation. Eur J Cardiotho-rac Surg. 2014;46:474-9.
• McMahon CJ, Ravekes WJ, O’Brian Smith E, Denfield SW, Pignatelli RH, Altman CA, et al. Risk factors for neo-aortic root enlargement and aortic regurgitation following arterial switch operation. Pediatr Cardiol. 2004;25:329-35.
• Hwang HY, Kim W-H, Kwak JG, Lee JR, Kim YJ, Rho JR, et al. Mid-term follow-up of neoaortic regurgitation after the arte-rial switch operation for transposition of the great arteries. Eur J Cardiothorac Surg. 2006;29:162-7.
• Talwar S, Gupta A, Sreenivas V, Choudhary SK, Airan B. Fate of neoaortic valve in patients undergoing arterial switch opera-tion for transposition of great arteries. Am J Cardiovasc Thorac Surg. 2017;2:1-6.
• Lalezari S, Mahtab EAF, Bartelings MM, Wisse LJ, Hazekamp MG, Gittenberger-de Groot AC. The outflow tract in transposi-tion of the great arteries: an anatomic and morphologic study. Ann Thorac Surg. 2009;88:1300-5.
• Cohen MS, Marino BS, McElhinney DB, Robbers-Visser D, van der Woerd W, Gaynor JW, et al. Neo-aortic root dilation and valve regurgitation upto 21 years after staged reconstruction for hypoplastic left heart syndrome. J Am Coll Cardiol. 2003;42:533-40.
• Grotenhuis HB, Ottenkamp J, Fontein D, Vliegen HW, Wes-tenberg JJ, Kroft LJ, et al. Aortic elasticity and left ventricular function after arterial switch operation: MR imaging-initial experience. Radiology. 2008;249:801-9.
• Murakami T, Nakazawa M, Momma K, Imai Y. Impaired dis-tensibility of neoaorta after arterial switch procedure. Ann Thorac Surg. 2000;70:1907-10.
• Formigari R, Toscano A, Giardini A, Gargiulo G, DiDonato R, Picchio FM, et al. Prevalence and predictors of neoaortic re-gurgitation after arterial switch operation for transposition of the great arteries. J Thorac Cardiovasc Surg. 2003;126:1753-9.
• Losay J, Touchot A, Capderou A, Piot JD, Belli E, Planché C, et al. Aortic valve regurgitation after the arterial switch opera-tion for transposition of the great arteries. J Am Coll Cardiol. 2006;47:2057-62.
• Mohammadi S, Serraf A, Belli E, Aupecle B, Capderou A, La-cour-Gayet F, et al: Left-sided lesions after anatomic repair of transposition of the great arteries, ventricular septal defect, and coarctation: surgical factors. J Thorac Cardiovasc Surg. 2004;128:44-52.
• Ma K, Li S, Hu S, Hua Z, Yang K, Yan J, et al. Neoaortic valve regurgitation after arterial switch: ten years outcomes from a single center. Ann Thorac Surg. 2016;102:636-42.
• Arcieri L, Cantinotti M, Pak V, Bernabei M, Assanta N, Murzi B. The V shape reduction plasty to reduce the neoaortic root-ascending aorta discrepancy in children undergoing arterial switch operation. J Card Surg. 2014;29:410-2.
• Pereira FLA, Martins CN, Lopes RM, Drummond MF, Fantini FA, Vrandecic EC, et al. Impact of pulmonary artery reduction during arterial switch operation: 14 years follow-up. Interact Cardiovasc Thorac Surg. 2020;30(6):917-24.
• Arcieri L, Brambilla A, Ravaglioli A, Viacava C, Federici D, Poli V, et al. Neo-aortic posterior sinus of Valsalva reduction and closed coronary artery transfer as a method to approach aor-topulmonary mismatch in transposition of great arteries. J Card Surg. 2021;36(10):3665-70.