The science and art of aortic and/or pulmonary root translocation

Figures

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  Figure 1. The four main anatomical types of sub-semi-lunar infundibulum or conus arteriosus: subpulmonary, subaortic, bilateral (subaortic and subpulmonary), and absent or very deficient. The upper row of diagrams shows the infundibulum (crosshatched) and great arteries as seen from the front (frontal view). The lower row of diagrams shows the infundibulum (crosshatched), the semilunar valves – the aortic valve, indicated by the coronary arteries, and the pulmonary valve, indicated by the absence of coronary arteries – and the atrioventricular valves – the mitral valve, being a two-leaflet valve, and the tricuspid valve, being a three-leaflet valve – as seen from below (inferior view), similar to a subxiphoid two-dimensional echocardiogram. In all diagrams, a ventricular D-loop is assumed to be present. The subpulmonary conus is normal. Resorption of the subaortic conal-free wall permits aortic–mitral fibrous continuity. The presence of a subpulmonary infundibulum prevents pulmonary valve–atrioventricular valve fibrous continuity. A subpulmonary conus is associated with solitus normally related great arteries (diagrammed here), inversus normally related great arteries, and in tetralogy of…

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  Figure 2. Aortic root translocation (Nikaidoh procedure). Completed aortic root translocation (ventricular septal defect closed with right ventricle free wall, anteriorly positioned pulmonary artery confluence, right atrial incision for ASD closure). Ao: Ascending aorta, LV: Left ventricle, PA: Main pulmonary artery, RA: Right atrium, RV: right ventricle, SVC: Superior vena cava, ASD: Atrial septal defect, TV: Tricuspid valve (reproduced with permission from Nikaidoh[18])

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  Figure 3. Ross-switch-Konno procedure. The aortic autograft is excised, and the coronaries are mobilized; the main pulmonary artery is transected and an incision is extended across the pulmonary valve annulus and outlet septum connecting to the ventricular septal defect accomplished by insertion of a triangular-shaped VSD patch. The aortic autograft is re-inserted into the left ventricular outflow. The aortic root autograft is then rotated 180° so that the defects from the coronary buttons face anteriorly. The coronaries are then reimplanted. Before reestablishing ascending aortic continuity, the branch pulmonary arteries are mobilized and brought anterior to the aorta (Lecompte maneuver) in preparation for right ventricular outflow reconstruction (reproduced with permission from Bautista-Hernandez et al.[24])

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  Figure 4. Pulmonary root translocation. (a) The pulmonary root is dissected out, and its origin is closed using a glutaraldehyde-treated autologous pericardial patch. (b) After partial resection of the conal septum, a Dacron patch is used to create a tunnel from the left ventricle to the aorta. (c) The pulmonary root is sutured to the right ventriculotomy with a running 6-0 polydioxanone suture, and the right ventricular outflow tract is completed using an in situ pericardial patch combined with a glutaraldehyde-treated autologous pericardial patch. (d) The final appearance after the procedure. (Reproduced with permission from da Silva et al.[33])

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  Figure 5. En bloc rotation of outflow tracts (half-turned truncal switch). (a) The aorta was located anteriorly, and the main pulmonary artery was located posteriorly. The aorta was transected 10 mm above the coronary orifices. (b) Antero–superior view of the truncal root. The dotted line indicates the incised line. The supposed incised line on the main pulmonary artery runs obliquely from the posterior wall of the pulmonary annulus to the anterior wall of the pulmonary bifurcation. (c) The main pulmonary artery was incised obliquely so as to keep the anterior wall to the proximal side. Both coronary arterial buttons were resected. (d) Along the aortic annulus, the anterior wall of the right ventricle was incised. The dotted line indicates the incised line on the infundibular septum. (e) The midline of the fibrous continuity between the pulmonary valve and the mitral valve was incised. The truncal block involving both semilunar valves was separated from the ventricular outflow tract. The resected truncal block was half turned. (f) The half-turned truncal block was anastomosed to the ventricular outflow tract. First, the posteriorly translocated aortic annulus was anastomosed to the left…