Cirugía de reparación biventricular en pacientes con transposición de los grandes vasos, comunicación interventricular y estenosis pulmonar

espanolIntroduccion: La correccion biventricular de la transposicion de grandes vasos con comunicacion interventricular (CIV) y estenosis pulmonar incluye las cirugias de Rastelli, REV y Nikaidoh. Objetivos: Evaluar los resultados de las cirugias de correccion biventricular realizadas en nuestro hospital en los pacientes con transposicion de grandes vasos con CIV y estenosis pulmonar. Comparar las cirugias de Rastelli y Nikaidoh en terminos de morbi-mortalidad en el subgrupo de pacientes con CIV no relacionada con la aorta. Materiales y Metodos: Se incluyeron 76 pacientes (p) operados durante el periodo 1991-2015 en nuestro centro con tecnica de Rastelli (60p=78,9%), Nikaidoh(13p=17%) y REV(3p=4%). Resultados: En posquirurgico inmediato: 24p tuvieron disfuncion ventricular, 18p arritmias y 11p estenosis subaortica. Ninguno presento insuficiencia aortica significativa. En la evolucion, con un tiempo medio de seguimiento de 9,9 anos(SD+-6anos) desarrollaron disfuncion del conducto ventriculo derecho-arteria pulmonar(52p), obstruccion al tracto de salida ventricular izquierdo(14p), arritmias(12p) e insuficiencia aortica moderada(1p) La sobrevida alejada a 5 y 10 anos fue 96% y a 15 anos 92%. El 55% de los pacientes requirio reintervencion a 6,2anos (DS+-5), principalmente por disfuncion del conducto ventriculo derecho-arteria pulmonar (77%). Murieron 9p, 7 de ellos en el postquirurgico inmediato. La mortalidad se asocio a CIV no relacionada con la aorta (p=0,02) y a disfuncion ventricular (0.02), arritmias(p=0,01) y reoperaciones (P=0.0000) en el postquirurgico inmediato. En el grupo de pacientes con CIV no relacionada con la aorta, la cirugia de Rastelli presento mayor mortalidad (p=0,01), obstruccion subaortica en el postquirurgico inmediato (p=0,04) y alejado (p=0,01) que Nikaidoh. Conclusiones: Los pacientes con cirugia de Rastelli, Nikaidoh y REV tienen buena sobrevida alejada. Las reintervenciones son frecuentes (55%) principalmente por disfuncion del conducto ventriculo derecho-arteria pulmonar. En los pacientes con CIV no relacionada con la aorta, la cirugia de Nikaidoh surge como mejor opcion terapeutica que la de Rastelli. EnglishBackground: Biventricular repair of transposition of the great arteries with ventricular septal defect and pulmonary stenosis includes the Rastelli operation, the REV (reparation a l’etage ventriculaire) and the Nikaidoh procedure. The treatment of choice is still controversial due to the anatomic variability of this condition and to the suboptimal results of the different surgical techniques proposed. Objectives: To evaluate the results of biventricular repair procedures performed in our hospital in patients with transposition of the great arteries with ventricular septal defect and pulmonary stenosis. 2. To compare morbidity and mortality with the Rastelli operation and the Nikaidoh procedure in the subgroup of patients with non-committed ventricular septal defect. Methods: Between 1991 and 2015, 76 patients operated on in our center underwent the Rastelli operation [n=60 (78.9%)], the Nikaidoh procedure [n=13 (17%)] and the REV procedure [n=3 (4%)]. Results: In the immediate postoperative period, 24 patients presented ventricular dysfunction, 18 had arrhythmias and 11 developed subaortic stenosis. None of the patients presented signs of significant aortic regurgitation. During a mean follow-up of 9.9 years (± 6 years), 52 patients developed dysfunction of the right ventricle-to-pulmonary artery conduit, 14 patients presented left ventricular outflow tract obstruction, 12 patients had arrhythmias and 1 patient developed moderate aortic regurgitation. Long-term survival at 5 and 10 years was 96%, and 92% at 15 years. Fifty-five percent of the patients required reintervention at 6.2 years (±5), particularly due to dysfunction of the right ventricle-to-pulmonary artery conduit (77%). Nine patients died, 7 in the immediate postoperative period. Mortality was associated with non-committed ventricular septal defect (p=0.02), ventricular dysfunction (p=0.02), arrhythmias (p=0.01) and reoperations (p=0.0000) in the immediate postoperative period. In the group of patients with non-committed ventricular septal defect, the Rastelli operation was associated with higher mortality (p=0.01) and subaortic obstruction in the immediate and late postoperative periods (p=0.04 and p=0.01, respectively), compared with the Nikaidoh procedure. Conclusions: - Patients undergoing the Rastelli operation, the Nikaidoh procedure and the REV procedure have favorable long-term survival. - Reinterventions are common (55%), particularly due to dysfunction of the right ventricle-to-pulmonary artery conduit. - In patients with non-committed ventricular septal defect, the Nikaidoh procedure emerges as a better therapeutic option than the Rastelli operation.Key words: Heart Defects, Congenital - Cardiac Surgical Procedures/methods - Heart Septal Defects, Ventricular/surgery - Transposition of Great Vessels - Pulmonary Stenosis - Postoperative Period