Prêtre, René

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[15] Bautista-Hernandez V, Marx GR, Bacha EA, del Nido PJ. Aortic root trans-location plus arterial switch for transposition of the great arteries with leftventricular outﬂow tract obstruction: intermediate-term results. J Am CollCardiol 2007;49:485–90.[16] Morell VO, Jacobs JP, Quintessenza JA. Surgical management of transpos-ition with ventricular septal defect and obstruction to the left ventricularoutﬂow tract. Cardiol Young 2005;15 (Suppl 1):102–5.[17] Brown JW, Ruzmetov M, Huynh D, Rodefeld MD, Turrentine MW, FioreAC. Rastelli operation for transposition of the great arteries with ventricu-lar septal defect and pulmonary stenosis. Ann Thorac Surg 2011;91:188–93; discussion 93–4.[18] Alsouﬁ B, Awan A, Al-Omrani A, Al-Ahmadi M, Canver CC, Bulbul Z et al.The Rastelli procedure for transposition of the great arteries: resection ofthe infundibular septum diminishes recurrent left ventricular outﬂow tractobstruction risk. Ann Thorac Surg 2009;88:137–42; discussion 42–3.[19] Rubay J, Lecompte Y, Batisse A, Durandy Y, Dibie A, Lemoine G et al.Anatomic repair of anomalies of ventriculo-arterial connection (REV).Results of a new technique in cases associated with pulmonary outﬂowtract obstruction. Eur J Cardiothorac Surg 1988;2:305–11.[20] Lange R, Cleuziou J, Horer J, Holper K, Vogt M, Tassani-Prell P et al. Riskfactors for aortic insufﬁciency and aortic valve replacement after the arter-ial switch operation. Eur J Cardiothorac Surg 2008;34:711–7.[21] Losay J, Touchot A, Capderou A, Piot JD, Belli E, Planche C et al. Aorticvalve regurgitation after arterial switch operation for transposition of thegreat arteries: incidence, risk factors, and outcome. J Am Coll Cardiol2006;47:2057–62.[22] Emani SM, Beroukhim R, Zurakowski D, Pigula FA, Mayer JE, del Nido PJet al. Outcomes after anatomic repair for D-transposition of the great ar-teries with left ventricular outﬂow tract obstruction. Circulation 2009;120(11 Suppl):S53–8.[23] Dasmahapatra HK, Freedom RM, Moes CA, Musewe M, Sherret H, ColesJG et al. Surgical experience with left ventricular outﬂow tract obstructionin patients with complete transposition of the great arteries and essentiallyintact ventricular septum undergoing the Mustard operation. Eur JCardiothorac Surg 1989;3:241–8; discussion 9.[24] Reddy VM, Rajasinghe HA, Teitel DF, Haas GS, Hanley FL.Aortoventriculoplasty with the pulmonary autograft: the ‘Ross-Konno’ pro-cedure. J Thorac Cardiovasc Surg 1996;111:158–65; discussion 65–7.APPENDIX. CONFERENCE DISCUSSIONDr M. Hazekamp (Leiden, Netherlands): Especially in situations where the pul-monary valve is small and cannot be used for arterial switch, sometimes it’svery difﬁcult to decide beforehand what will be the best option - Rastelli, REV,Nikaidoh operation or univentricular palliation. And I think it’s important thatyou tried to make a complexity score of LVOTO and get some system into it. Ithink that’s very worthwhile for the individual surgeon. It seems that in manyinstances, particularly with a small and not usable pulmonary valve, Nikaidohseems to be the best option, but I think you should not forget to mention theREV or the modiﬁed REV operation which, in the multicentre study that we didwith the European Congenital Heart Surgeons Association, came out as also avery good option. And while for some reason it’s only used in French-speakingcountries, probably for historical reasons, it merits attention because it’s a goodoperation as well.I agree with you fully that when the pulmonary valve is reasonably big, nottoo dysplastic, in almost all cases you can do an arterial switch operation withresection of the outﬂow tract obstruction.I have several comments. I also agree with you that whenever the right cor-onary artery crosses in front of the aortic valve, then probably it’s better not todo a Nikaidoh operation because you may get into big problems.I thank you for using the Leiden classiﬁcation of coronary anatomy, butmaybe in your manuscript you should change it slightly, because when you talkabout a right coronary crossing over the RVOT towards the right, you name it,for example, 1LR-2CX, but it should be 1RL-2CX, because you have the obser-ver in the facing sinus and he looks anticlockwise. Then the ﬁrst one you en-counter you should name ﬁrst. So maybe you should correct that in themanuscript. Furthermore, in your manuscript you describe one patient whoreceived arterial switch with relief or resection of LVOT obstruction with thepulmonary valve z-score of minus 5.6. And that’s, for me, a little bit difﬁcult tobelieve, so maybe you can comment on that. That’s the ﬁrst question.You also describe in your manuscript that this complexity score has one weakpoint and that’s something you didn’t mention here but I think it’s very importantto name it, because if you have, for example, mal-attachment of the tension appar-atus of the mitral valve, you have only one point in the complexity score becauseeverything else can be okay, but you are unable to do biventricular repair, so yougo to the worst side of surgery. Opposed to that, you may have a patient withpoints on the pulmonary valve, on the septum, etc, etc, but still you can go forbiventricular repair. So that must be addressed. So these were the two questions,pulmonary valve z-score minus 5.6 and this limitation of the complexity score.Dr Kotani: Regarding your ﬁrst question, that patient had a very small pul-monary valve measured at about z-score minus 5 on preoperative echo.Sometimes it’s difﬁcult to exactly measure the pulmonary valve in the setting ofcomplex LVOTO. In fact, in the OR, the pulmonary valve was a reasonable sizewith a z-score of minus 2, which allowed us to proceed with the switch operation.For the second question, I totally agree with your comment regarding thelimitations of this scoring system. The patient with mild multi-level obstruction,and the patient with one signiﬁcant single-level obstruction could end up withthe same score, so I think we need to reﬁne the complexity score.European Journal of Cardio-Thoracic Surgery 44 (2013) 1094–1095 EDITORIAL COMMENTdoi:10.1093/ejcts/ezt266 Advance Access publication 25 June 2013Arterial switch, Réparation à l’étage ventriculaire, Rastelli or Nikaidoh?René Prêtre*Cardiac Surgery Unit, University Hospital of Lausanne (CHUV), Lausanne, Switzerland* Corresponding author. Cardiac Surgery Unit, University Hospital of Lausanne (CHUV), 46 Rue du Bugnon, CH-1011 Lausanne, Switzerland.Tel: +41-21-3140641; fax: +41-21-314-2879; e-mail: rene.pretre@chuv.ch (R. Prêtre).Keywords: Transposition of the great arteries • Left ventricular outﬂow tract obstruction • Nikaidoh procedure • Rastelli operation •Coronary artery patternHonjo and co-workers, from the Toronto group, proposed an ana-tomical complexity score of the left ventricular outﬂow tractobstruction (LVOTO) to help in choosing between a variety of sur-gical corrections in face of dextro-transposition of the greatO. Honjo et al. / European Journal of Cardio-Thoracic Surgery1094arteries (d-TGA) and LVOTO [1]. The decision on the best repair inthe presented series of 28 patients was actually made in a standardfashion— with preoperative and intraoperative assessments—andthe results were simply fantastic, apparently with no error ofjudgement. The proposed echocardiographically-derived scoringsystem was applied retrospectively and was subsequently corre-lated to the surgical procedure chosen. Not surprisingly, a correl-ation between the echocardiographic ﬁndings and the surgicaloption applied was found and coefﬁcients of obstruction werefurther set.Will this new scoring system truly help us? We are not sure. Thecritical decision in this group of patients is mostly whether an ar-terial switch operation (ASO), with opening of the outﬂow tract,can still be achieved instead of an ‘intracardiac repair’, like the‘Réparation à l’étage ventriculaire’ (REV), Rastelli or Nikaidoh pro-cedures. The choice between these operations or a single ventriclepathway will continue to be guided by an ’eyeballing’ of the LVOTin echocardiographic views and will ultimately be inﬂuenced byintraoperative ﬁndings, as acknowledged by the surgical results ofthis study [2–4]. The preoperative echocardiography (with orwithout an obstruction scoring system) gives a clue—often a strongone—as to the possible options. Its value is certainly the clear def-inition of the multiple components of the obstruction, but asurgeon needs more than a crude anatomy to deﬁnitively plan hisoperation. He needs information on the resectability of thesecomponents, something that often appears only during surgery.A straddling papillary muscle will get a low obstructive score butwill cause more trouble than an extensive tissue tag formation or abulging conal septum.The two opposing philosophies in the repair of TGA-LVOTOrelate to the choice of the second-best option after the ASO,namely either the REV/Rastelli procedure or the Nikaidoh proced-ure and its variant ‘the double root rotation’ [2–5]. Strong propo-nents of the Nikaidoh procedure, such as the Toronto group, donot really need a scoring system for the obstructive componentsas, per deﬁnition, they will reposition the aortic root beneaththem. As a matter of fact, the decision between the two proce-dures in the presented study was not inﬂuenced by the obstructivecomponents, but by the pattern of the coronary arteries alone.Strong proponents of the REV/Rastelli procedure consider that therelief of the obstructive components can be achieved in virtuallyall patients with an operation performed at the right time. Tothem, the Nikaidoh procedure is indicated mostly in cases of a re-strictive ventricular septal defect, of a small right ventricle or whenthe whole ‘double root’ can be rotated, and the scoring systemwill merely remain an academic tool [5]. In their experience, thegap of the mitro-aortic discontinuity correlates more with themagnitude of the intracardiac repair (to ensure a wide open leftoutﬂow tract) than with the pattern of the obstructing compo-nents [6]. In this controversy, only surgeons undecided betweenthese two schools of thought might take an interest in the scoringsystem [7].Still, the scoring system is a valuable new tool, mostly in caseswhere it can identify these patients with a potential complete orpartial function of the pulmonary valve. As for any scoring systemestablished retrospectively, it must now be validated prospectivelyand further ﬁne-tuned—especially in respect of the characteristicsof the sub-pulmonary area and the pulmonary root and leaﬂets—because this is the component of the proposed complexity scorethat will reveal the patients for whom a successful ASO is still pos-sible or on whom a ‘double root rotation’ can be performed [5].Conﬂict of interest: none declared.REFERENCES[1] Honjo O, Kotani Y, Bharucha T, Mertens L, Caldarone CA, Redington ANet al. Anatomic factors determining surgical decision-making in patientswith transposition of the great arteries with left ventricular outﬂow tract ob-struction. Eur J Cardiothorac Surg 2013;44:1085–94.[2] Brown JW, Ruzmetov M, Huynh D, Rodefeld MD, Turrentine MW, Fiore AC.Rastelli operation for transposition of the great arteries with ventricularseptal defect and pulmonary stenosis. Ann Thorac Surg 2011;91:188–93;discussion 93–4.[3] Di Carlo D, Tomasco B, Cohen L, Vouhe P, Lecompte Y. Long-term resultsof the REV (reparation a l’etage ventriculaire) operation. J ThoracCardiovasc Surg 2011;142:336–43.[4] Yeh T Jr., Ramaciotti C, Leonard SR, Roy L, Nikaidoh H. The aortic transloca-tion (Nikaidoh) procedure: midterm results superior to the Rastelli proced-ure. J Thorac Cardiovasc Surg 2007;133:461–69.[5] Mair R, Sames-Dolzer E, Vondrys D, Lechner E, Tulzer G. En bloc rota-tion of the truncus arteriosus–an option for anatomic repair of transpos-ition of the great arteries, ventricular septal defect, and left ventricularoutﬂow tract obstruction. J Thorac Cardiovasc Surg 2006;131:740–41.[6] Raisky O, Vouhe PR. Pitfalls in repair of conotruncal anomalies. SeminThorac Cardiovasc Surg Pediatr Card Surg Annu 2013;16:7–12.[7] Hazekamp MG, Gomez AA, Koolbergen DR, Hraska V, Metras DR, MattilaIP et al. Surgery for transposition of the great arteries, ventricular septaldefect and left ventricular outﬂow tract obstruction: European CongenitalHeart Surgeons Association multicentre study. Eur J Cardiothorac Surg2010;38:699–706.CONGENITALO. Honjo et al. / European Journal of Cardio-Thoracic Surgery 1095

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