title: The optimal procedure for the great arteries and left ventricular outflow tract obstruction. An anatomical study.
abstract: OBJECTIVE
  To describe the optimal surgical strategy in heart specimens with transposition of the great arteries (TGA) and left ventricular outflow tract obstruction (LVOTO).
  
  
  METHODS
  Thirty-three specimens with LVOTO were selected: TGA with intact ventricular septum (TGA/IVS) (10), TGA/VSD (21), and Taussig-Bing (2).
  
  
  RESULTS
  LVOTO in TGA/IVS consisted of combinations of bicuspid pulmonary valve (four), subpulmonary fibrous ridge (four), obstructive muscular conus (two) and bulging muscular septum (four). Arterial switch operation (ASO) with LVOTO resection/valvotomy was feasible in nine hearts. Obstructive anterior papillary muscle prohibited LVOTO relief in one specimen. In TGA/VSD and Taussig-Bing LVOTO consisted of combinations of bicuspid (nine) or unicommissural (one) pulmonary valve, fibrous ridge (three), obstructive muscular conus (five), malaligned outlet septum (six), accessory mitral valve tissue (two), straddling mitral valve (two) and anterior mitral valve rotation (four). VSDs were subpulmonary in 13 (9 perimembranous, 4 muscular), subaortic in 3 (2 perimembranous, 1 anterior muscular), doubly committed in 2, inlet in 3 (2 perimembranous, 1 muscular), non-committed and anterior in 1, and finally 1 VSD extended both into inlet and subpulmonary outlet septum. LVOTO resection and ASO with VSD closure was possible in 10. In six specimens, both a Rastelli and a Nikaidoh operation were feasible. For two hearts, a Nikaidoh procedure was the only option, while Rastelli was considered optimal in another specimen. Mitral valve anomalies prevented LVOTO relief in four, only permitting for Senning/VSD closure (one) or univentricular palliation (three).
  
  
  CONCLUSIONS
  LVOTO resection and pulmonary valvotomy frequently permits an ASO. Inlet VSD, impossibility of VSD enlargement, straddling mitral valve, distant aorta and small right ventricle make the Nikaidoh procedure the best option. Mitral anomalies preventing LVOTO relief can make biventricular repair impossible.
authors.affiliation: Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands. m.g.hazekamp@lumc.nl
authors.forename: Mark
authors.initials: M
authors.lastname: Hazekamp
authors.forename: Francisco
authors.initials: F
authors.lastname: Portela
authors.forename: Margot
authors.initials: M
authors.lastname: Bartelings
mesh_terms: D001011:Aorta / Q000473:pathology; D001021:Aortic Valve / Q000473:pathology; D006348:Cardiac Surgical Procedures / Q000379:methods; D003331:Coronary Vessels / Q000473:pathology; D004310:Double Outlet Right Ventricle / Q000473:pathology / Q000601:surgery; D006345:Heart Septal Defects, Ventricular / Q000150:complications / Q000473:pathology; D006346:Heart Septum / Q000473:pathology; D006352:Heart Ventricles / Q000473:pathology / Q000601:surgery; D006801:Humans; D008943:Mitral Valve / Q000473:pathology; D011651:Pulmonary Artery / Q000473:pathology; D011664:Pulmonary Valve / Q000473:pathology; D014188:Transposition of Great Vessels / Q000150:complications / Q000473:pathology / Q000601:surgery*; D014694:Ventricular Outflow Obstruction / Q000150:complications / Q000473:pathology / Q000601:surgery*