Is the Lecompte technique the last word on transposition of the great arteries repair for all patients? A magnetic resonance imaging study including a spiral technique two decades postoperatively

Abstract

Objectives: To compare the Lecompte technique and the spiral anastomosis (complete anatomic correction) two decades after arterial switch operation (ASO).

Methods: Nine patients after primary ASO with Lecompte and 6 selected patients after spiral anastomosis were evaluated 20.8 ± 2.1 years after ASO versus matched controls. Blood flow dynamics and flow profiles (e.g. vorticity, helicity) in the great arteries were quantified from time-resolved 3D magnetic resonance imaging (MRI) phase contrast flow measurements (4D flow MR) in addition to a comprehensive anatomical and functional cardiovascular MRI analysis.

Results: Compared with spiral reconstruction, patients with Lecompte showed more vortex formation, supranatural helical blood flow (relative helicity in aorta: 0.036 vs 0.089; P < 0.01), a reduced indexed cross-sectional area of the left pulmonary artery (155 vs 85 mm²/m²; P < 0.001) and more semilunar valve dysfunctions (n = 5 vs 1). There was no difference in elastic aortic wall properties, ventricular function, myocardial perfusion and myocardial fibrosis between the two groups. Cross-sectional area of the aortic sinus was larger in patients than in controls (669 vs 411 mm²/m²; P < 0.01). In the spiral group, the pulmonary root was rotated after ASO more towards the normal left position (P < 0.01).

Conclusions: In this study, selected patients with spiral anastomoses showed, two decades after ASO, better physiologically adapted blood flow dynamics, and attained a closer to normal anatomical position of their great arteries, as well as less valve dysfunction. Considering the limitations related to the small number of patients and the novel MRI imaging techniques, these data may provoke reconsidering the optimal surgical approaches to transposition of the great arteries repair.

Keywords: Lecompte technique; Magnetic resonance imaging; Physiological spiral anastomosis; Transposition of great vessels.

Figure 1:

Morphology of the pulmonary arteries. Preoperative cinecardioangiogram (anterior–posterior projection) of a patient with simple D-TGA showing the centre points of the aortic (red dot) and pulmonary root (blue dot) (1). Anatomy of the great arteries 20 years after primary ASO, comparing the Lecompte technique (2) and the spiral anastomosis (3) and normal configured pulmonary arteries in a healthy control (4) illustrated by MRI (axial views) (upper row) and as a schematic drawing (lower row, red colour: aorta, blue colour: pulmonary artery). The steep aortic arch is illustrated by the smaller distance between the ascending and descending aorta in the Lecompte technique and the riding of the pulmonary bifurcation on the aorta. The post rotational more leftward position of the pulmonary root is shown in a patient with a spiral anastomosis (3a) and the corresponding schematic drawing (3b). A: aorta; P: pulmonary artery; D-TGA: dextro-transposition of the great arteries; ASO: arterial switch operation; MRI: magnetic resonance imaging.

Figure 2:

Pathlines in lateral (A + B) and anterior–posterior view (C) two decades after primary ASO with Lecompte, exemplifying vortex formation (arrows) in the great arteries (A: aorta ascending; B: pulmonary artery; C: aorta). The images display the typical steep angle of the aortic arch and the pulmonary bifurcation in front of the ascending aorta. (Full movie available for electronic download.) ASO: arterial switch operation.

Figure 3:

Colour-coded flow velocities in the great arteries displayed from different perspectives (superior view: 1a–3a; anterior view: 1b–3b). Pathlines were reconstructed from 4D flow data for patients after ASO with Lecompte (left), spiral anastomosis (middle) and a healthy volunteer (right). ASO: arterial switch operation.

Figure 4:

Boxplot illustrating the relative helicity difference of the thoracic aorta in TGA patients after Lecompte or spiral technique. The graph illustrates the higher standard deviation and mean value of helical flow within the thoracic aorta (*Mann–Whitney U-test). TGA: transposition of the great arteries.