Andersons pediatric cardiology 990
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TheprincipleofthisprocedureisshowninFig.37.21.Itinvolvespatchingthe
interventricularcommunicationsothattheoutputoftheleftventricleisdirected
totheaorta.Thepulmonaryvalveisoversewnandthepulmonarytrunkdivided
orligated.Continuitybetweenthepulmonaryarteryandtherightventricleis
establishedbyaconduit(Fig.37.22).Themaindrawbackofthisprocedureisthe
highlikelihoodforreinterventionincludingconduitreplacement.91
FIG.37.21 PrinciplesunderscoringtheRastelliprocedureusedfor
anatomiccorrectionofpatientswithtransposition,aventricularseptal
defect,anddeviationofthemuscularoutletseptum(left).Apatchisplaced
tocreateanintraventriculartunnel(middle),andanextracardiacconduitis
placedbetweentherightventricle(RV)andthepulmonaryarteries(right).
FIG.37.22 EndresultoftheRastelliprocedure,withaconduitfromthe
morphologicallyrightventricletothepulmonaryarteries.VSD,Ventricular
septaldefect.
Réparationàl'EtageVentriculaire(REV)
Procedure
Thisoperationinvolvesextensiveresectionoftheoutletseptumandtheuseofa
patchtobaffleoxygenatedbloodfromtheleftventricletotheaorta.92The
LeComptemaneuveristhenperformed,asforthearterialswitch,andthe
pulmonaryoutflowtractisreconstructedbydirectlysuturingtheposteriorrimof
thepulmonarytrunktoarightventriculotomy(Fig.37.23).Excellentratesof
survivalhavebeenreportedaftertheREVprocedure,albeitwithpostoperative
obstructiontotherightventricularoutflowoccurringinone-quarterofpatients,
possiblyrelatedtotheanteriorlocationofthepulmonaryarteriessubsequentto
theprocedure.93Tocombatthisproblem,theso-calledMetrasmodificationhas
beenusedinwhichasegmentofaorticautograftisusedtoreconstructtheright
ventricularoutflowtract,keepingthepulmonaryarteriesintheiranatomic
positionposteriortotheaorta.94IntheaforementionedEuropeanmulticenter
review,theREVandtheMetrasmodificationhadfavorablelong-termsurvival
andevent-freesurvivalcomparedwiththeRastelligroup;however,fewerof
theseprocedureswereperformed.91
FIG.37.23 PrinciplesoftheREVoperation.AswiththeRastellioperation,
theprocedureisusedforcorrectionofpatientswithaventricularseptal
defectandsubpulmonaryobstructionproducedbyposteriordeviationof
theoutletseptum(left).Themuscularoutletseptumisresectedandthe
aortaandthepulmonarytrunkaredivided(middle).Theleftventricle(LV)is
thenpatchedtotheaortathroughtheventricularseptaldefectand,using
theLeComptemaneuvertobringthepulmonaryarteriesanteriortothe
newlyreconstructedaorta,thedistalcomponentofthedividedpulmonary
trunk(PT)isanastomosedtoarightventriculotomy,theanterioraspectof
thepulmonaryoutflowbeingrestoredusingapericardialpatch(right).
NikaidohProcedure,orAorticTranslocation.
Thisprocedurerepresentsaveryusefultechniqueinpatientswithobstructionto
leftventricularoutflowandoffersasoundoptiontopatientswithanatomic
variantsthatmayrenderthemunsuitablefortheRastelliorREVprocedure.95
Thisincludespatientswithasmallrightventricle,thosewithaninletor
restrictiveventricularseptaldefect,thosewithstraddlingoroverridingofthe
atrioventricularvalves,andthosewithalargecoronaryarterycrossingtheright
ventricularoutflowtract.Theprocedure(Fig.37.24)involvesharvestingthe
aorticroot,alongwiththeattachedcoronaryarteries,fromtherightventricle.
Thestenosedpulmonaryvalveisexcisedandtheoutletseptumdivided.The
aorticrootisthentranslocatedposteriorlytolieovertheleftventricle.The
interventricularcommunicationisclosed,andtherightventricularoutflowtract
isreconstructedwithpericardium.Thepulmonaryarteries,remainingposterior
totheaorta,areconnectedtotherightventriclewithahomograft.The
LeComptemaneuvermayberequired,andsometimesthecoronaryarteriesmust
