Biventricular Repair in Patients with Transposition of the Great Arteries, Ventricular Septal Defect and Pulmonary Stenosis: Rastelli, Nikaidoh or REV Procedures?

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Abstract

Background: Biventricular repair of transposition of the great arteries with ventricular septal defect and pulmonary stenosis includes the Rastelli operation, the REV (reparation a l’etage ventriculaire) and the Nikaidoh procedure. The treatment of choice is still controversial due to the anatomic variability of this condition and to the suboptimal results of the different surgical techniques proposed.

Objectives: 1. To evaluate the results of biventricular repair procedures performed in our hospital in patients with transposition of the great arteries with ventricular septal defect and pulmonary stenosis. 2. To compare morbidity and mortality with the Rastelli operation and the Nikaidoh procedure in the subgroup of patients with non-committed ventricular septal defect.

Methods: Between 1991 and 2015, 76 patients operated on in our center underwent the Rastelli operation [n=60 (78.9%)], the Nikaidoh procedure [n=13 (17%)] and the REV procedure [n=3 (4%)].

Results: In the immediate postoperative period, 24 patients presented ventricular dysfunction, 18 had arrhythmias and 11 developed subaortic stenosis. None of the patients presented signs of significant aortic regurgitation. During a mean follow-up of 9.9 years (±6 years), 52 patients developed dysfunction of the right ventricle-to-pulmonary artery conduit, 14 patients presented left ventricular outflow tract obstruction, 12 patients had arrhythmias and 1 patient developed moderate aortic regurgitation. Long-term survival at 5 and 10 years was 96%, and 92% at 15 years. Fifty-five percent of the patients required reintervention at 6.2 years (±5), particularly due to dysfunction of the right ventricle-to-pulmonary artery conduit (77%). Nine patients died, 7 in the immediate postoperative period. Mortality was associated with non-committed ventricular septal defect (p=0.02), ventricular dysfunction (p=0.02), arrhythmias (p=0.01) and reoperations (p=0.0000) in the immediate postoperative period. In the group of patients with non-committed ventricular septal defect, the Rastelli operation was associated with higher mortality (p=0.01) and subaorticobstruction in the immediate and late postoperative periods (p=0.04 and p=0.01, respectively), compared with the Nikaidoh procedure.

Conclusions:– Patients undergoing the Rastelli operation, the Nikaidoh procedure and the REV procedure have favorable long-term
survival.– Reinterventions are common (55%), particularly due to dysfunction of the right ventricle-to-pulmonary artery conduit.– In patients with non-committed ventricular septal defect, the Nikaidoh procedure emerges as a better therapeutic option than the Rastelli operation.