Extending the surgical boundaries in the management of the left ventricular outflow tract obstruction in discordant ventriculo-arterial connections – a surgical and morphological study

Abstract

When there is obstruction of the left ventricular outflow tract, there are several surgical approaches to the repair of discordant ventriculo-arterial connections in the setting of concordant atrioventricular connections. Choosing the optimal technique demands not only knowledge of the different surgical procedures, but also the understanding of the particular anatomic features present in a specific patient. These requisites are then essential to plan the operation, to foresee some difficult situations, and to avoid post-operative complications. In this review, we assess all these surgical and anatomic aspects, focussing on their relative importance in clinical assessment.

Transposition of the great arteries

“…This impediment to the flow of blood can be caused by a wide spectrum of lesions, either at valvar or subvalvar level, and deviation of the muscular outlet septum is but one of them. Bulging of the septum, a fibrous shelf or fibromuscular tunnel, tissue tags, and anomalous attachment of the atrioventricular valvar tension apparatus can also be substrates for stenosis [ 10 ].…”

“…It shows the connection of the proximal great arteries to the distal end of the other great artery, as well as the transfer of coronary arteries to the new aorta. (adapted from [ 10 ]. Martins P, Tran V, Price G, Tsang V and Cook A, Cardiol Young 2008; 18:124–34, with permission from Cambridge University Press).…”

Midterm follow-up of arterial switch operation for transposition of the great arteries with intact ventricular septum and left-ventricular outflow tract obstruction☆

“…When the ventriculo-arterial connections are discordant, (transposition of great arteries, TGA), it is the channel between the left ventricle and the pulmonary trunk which is impeded, but by the same individual obstructive lesions [1]. Although anatomic LVOTO is more commonly seen in the presence of a ventricular septal defect (VSD), it is an infrequent association of TGA with intact ventricular septum (IVS) [2][3][4].…”

“…Valvar restriction is quite rare, and the valve can be dysplastic, bicuspid, and stenotic. The subvalvar lesions can be a fibrous shelf or fibromuscular tunnel, tissue tags, and anomalous attachment of the atrioventricular valvar tension apparatus [1].…”

“…In recent years, arterial switch operation (ASO) has become the most favoured surgical option [2,3], but its feasibility needs to be thoroughly assessed after evaluation of the coronary arterial patterns, along with the anatomic characteristics of the obstructed LVOT. Special attention should be given to the size of the ventriculo-arterial junction, the nature of the obstruction, and its potential respectability [1]. Presence of LVOTO was considered to be a contraindication for ASO in the past [5,6].…”