Nikaidoh Procedure

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Anatomy/Surgical technique

Nikaidoh Procedure illustration

The Nikaidoh procedure is an innovative surgical technique used for the repair of d-transposition of the great vessels and pulmonary stenosis. In addition, this technique can be applied to a number of other congenital heart lesions with common features of malposed great vessels and pulmonary outflow tract obstruction. D-transposition of the great vessels occurs when the right ventricle gives rise to the systemic artery (aorta) and the left ventricle gives rise to the pulmonary artery. This may occur as an isolated lesion or with other features such as ventricular septal defect and/or pulmonary stenosis, as well as other anatomic sub-variants. The arterial switch procedure is most commonly applied to variants with minimal abnormalities of the outflow valves and tracts. Ventricular septal defect is a common association (see Arterial Switch). When a large VSD occurs as well as pulmonary stenosis, the Rastelli procedure is frequently selected as the procedure of choice. The Rastelli procedure is considered a “ventricular-level switch,” with redirection of left ventricular outflow through a VSD to the anterior aorta. The pulmonary artery is then connected to the anterior right ventricle with a valved homograft or other suitable outflow conduit or patch (see Rastelli Operation).

With the Nikaidoh procedure, the pulmonary root is excised posteriorly to make room for translocation of the anterior aorta to a more posterior position over the left ventricle. The aorta is mobilized by removing the valve and aortic root completely from the right ventricle. The coronary arteries are mobilized from their epicardial connections, allowing posterior translocation of the aorta. Some variants of this operation involve reimplantation of one or both coronary arteries. The top of the ventricular septum is incised, allowing enlargement of the implant site for the aortic root. This allows for direct left ventricle- to-aortic geometry. The pulmonary artery is then connected to the right ventricle with a conduit or other reconstruction technique that may or may not involve use of a valve, depending on the specific needs of the patient.

The specific operation chosen for repair of d-trans- position of the great vessels depends on each patient’s specific anatomy. Many variations exist, making a case-by-case analysis of the optimal operation of choice necessary. The Nikaidoh procedure offers advantages over the Rastelli operation in some of these patients.

Postoperative considerations

All of the above operative techniques require cardiopulmonary bypass and aortic cross-clamping. In addition, all the procedures detailed here are major open-heart surgeries. Cross-clamp times are moderate to long, and suture lines are extensive. Transesophageal echo is performed as bypass circulation is weaned. Adequacy of outflow tract and septal reconstructions is assessed. Monitoring lines used frequently include arterial, central venous, and intracardiac lines as needed. Inotropic infusions might include epinephrine, milrinone, and/or other vasoactive infusions directed at maintaining satis- factory oxygen delivery to the systemic organs and cardiac output. In addition to traditional pulse oximetry, NIRS infrared probes are used in all patients to monitor these parameters. Pacing capabilities are also essential due to the frequent need for temporary pacing postoperatively.

Hospital stay required following surgery varies depending on many factors specific to each patient, but discharge is often accomplished in 7 to 10 days