Strategy for biventricular outflow tract reconstruction: Rastelli, REV, or Nikaidoh procedure?

OBJECTIVE

Three techniques have been developed as the surgical management for patients with anomalies of ventriculoarterial connection, ventricular septal defect, and pulmonary outflow tract obstruction (stenosis): the Rastelli, Lecompte, (REV), and Nikaidoh procedures. This study was designed to compare these procedures in terms of hemodynamics of the reconstructed biventricular outflow tract, early clinical consequences, and follow-up.

METHODS

Between March 2004 and September 2006, a total of 30 consecutive patients underwent double root translocation procedures (modified Nikaidoh n = 11, REV n = 7, Rastelli n = 12). In the Nikaidoh procedure, both aortic and pulmonary roots were translocated. A single-valved bovine jugular vein patch was used to repair the stenotic pulmonary artery in both Nikaidoh and REV procedures. The Senning procedure was added for those with atrioventricular discordance.

RESULTS

The Nikaidoh procedure was the most time-consuming in terms of mean cardiopulmonary bypass and aortic crossclamp times. The average mechanical ventilation time was significantly shorter in the Rastelli group (63.3 +/- 89 hours) than that in the Nikaidoh group (188.7 +/- 159 hours, P = .016), but not different from that in the REV group (76.4 +/- 112.5 hours, P = .395). Two patients in the REV group and 1 in the Rastelli group died. There were no in-hospital or late deaths in the Nikaidoh group. Postoperative echocardiography demonstrated physiologic hemodynamics in the left ventricular outflow tract and normal heart function in the Nikaidoh group. Abnormal flow pattern in the left ventricular outflow tract was noted in both REV and Rastelli groups. There were no late deaths or reoperations in any group during follow-up.

CONCLUSION

The modified Nikaidoh procedure is a better surgical option for transposition of the great arteries, ventricular septal defect, and pulmonary stenosis in terms of physiologic cardiac hemodynamics. Its long-term benefits need to be evaluated with a larger number of patients and longer follow-up.