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Eur J Cardiothorac Surg 2004;26:1226-1227
© 2004 Elsevier Science NL
Letter to the Editor |
Dipartimento Medico-Chirurgico di Cardiologia Pediatrica, Ospedale Pediatrico Bambino Gesù,Roma, Italy
Received 30 June 2004; accepted 24 August 2004.
* Tel.: +39 06 6859 2465; fax: +39 06 6859 2257. (E-mail: dicarlod{at}opbg.net).
In a interesting article recently published in the EJCTS [1], Lee and co-workers compare their results with the Rastelli operation and the REV procedure (termed by the authors "Lecompte procedure") for patients with Transposition of the great arteries, ventricular septal defect and left ventricular outflow tract obstruction (TGA, VSD, LVOTO). Late results differed significantly in the two surgical groups: reoperations for right/left ventricular outflow tract obstruction (RVOTO, LVOTO) were more frequent in the Rastelli group, so that freedom from reoperation proportion was 40% for the Rastelli group and 96% for the REV group. Other institutions, who had the opportunity to use both these procedures, reported similar data [2].
Although the authors' results are excellent, their incidence of reoperation for RVOTO in the REV group is somehow surprising: five of 24 survivors, or 21%, in an average follow-up interval of 5.9 years. The authors did not employ the Lecompte manoeuvre nor the aortic wedge resection; the native pulmonary artery trunk (PAT) could be directly anastomosed to the upper part of the right ventriculotomy just by widely dissecting the pulmonary branches. This attitude has been reported previously [3].
Dr Lecompte always recommended to resect a generous wedge portion of the ascending aorta, in order to avoid excessive traction on the repositioned pulmonary confluence [4]. What has, then, to be expected if the pulmonary confluence is left behind the ascending aorta? The upper ventriculotomy may well be at reach of the native PAT, but the anastomosis will cause, in my view, undue traction, ‘elastic band’ effect and reduction of the diameter of either pulmonary branch, depending on what side of the aorta is chosen for the anastomosis itself.
REV, in this aspect, greatly differs from the Arterial Switch Operation (ASO) [5]: the site of PAT reimplantation is not another semilunar valve annulus but a right ventriculotomy, the upper limit of which is dictated by the position of the aortic valve. The author's parallel between these two techniques seems to me inappropriate.
The authors state that Vouhé and co-workers [2], who adopted the anterior relocation of PAT, found an incidence of RVOTO similar to theirs (six patients, 26%) at 55 months average follow-up. In fact, Vouhè's definition of residual obstruction was rather broad (>25mmHg RV-PA gradient), only two of his patients (5.7%) required reoperation. In Lecompte's series, 18 of 117 long-term survivors (15%) were reoperated on because of RVOTO, in an average follow-up interval of 7.6 years.
The authors claim that the cause of obstruction was calcification of the monocusp valve. This may well be a contributing factor, but I wonder whether the spacial arrangement of the great arteries has more to do with the elevated incidence of RVOTO.
In conclusion, the authors must be congratulated for their interesting analysis of the Rastelli and REV procedures. I wonder whether the superiority of late results with the REV procedure could not have been even more apparent, had Lee and co-workers adhered strictly to Lecompte's description of this ingenious procedure.
References
This article has been cited by other articles:
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  L. K. von Segesser ICVTS brings virtual conferencing to CTSNet Interactive CardioVascular and Thoracic Surgery, February 1, 2005; 4(1): 1 - 2. [Full Text] [PDF]
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