ABC | Volume 111, Nº1, July 2018

Original Article Martins et al Regurgitation aortic after Jatene Surgery Arq Bras Cardiol. 2018; 111(1):21-28 Methods From October 1997 to June 2015, 367 patients with TGA were submitted to the Jatene surgery at the Biocor Institute of Cardiovascular Diseases from Minas Gerais, 328 of whom survived and were discharged from the hospital. This observational study was performed from November 2015 to May 2016 at the Biocor Institute as part of a Master’s thesis. Of the 328 survivors, 251 were on regular outpatient follow‑up, and 127 participated in this study, being divided into two groups based on their anatomical characteristics. In the simple TGA group, 84 patients with TGA and intact ventricular septum were included. The complex TGA group included 43 patients with TGA and intermediate to large ventricular septal defect (VSD) and patients with double RV outflow tract without pulmonary stenosis (Taussig Bing), with or without obstruction of the aortic arch. Patients with the following characteristics were excluded from the study: children with a postoperative period shorter than 2 years (n = 18); patients submitted to ventricular preparation (n = 3); patients submitted to pulmonary artery reduction plasty (n = 27), a technique for patients with great disproportion in the sizes of the neo-aorta and neo-pulmonary artery, which began to be used at the Biocor Institute in 2006; and those who could not attend the consultations (n=76). Seventy-five patients were lost to follow-up and two had late death. Preoperative data collection The medical records were reviewed for collection of pre-, perioperative and immediate postoperative demographic data, such as anatomical characteristics of the defect, age in days and body surface at the time of surgical correction, adjusted pulmonary artery measurement, and presence of associated anomalies. Postoperative data collection During postoperative assessment, all patients underwent clinical examination by a pediatric cardiologist of the institution, with weight and height measurement to calculate body surface. Transthoracic echocardiography was performed with no cost to the patient. The Secretariats of Health of the respective municipalities were responsible for the patients’ transportation, and when that was not available, this study’s author responded to that need. This study was approved by the local Ethics Committee, in accordance with the Declaration of Helsinki, regarding research in human beings. All individuals or their legal guardians provided written consent for this study. Surgical technique The Jatene surgery technique used at the Biocor Institute was the same during the entire study period. Lecompte maneuver was used for almost all patients (96%) and coronary reimplantation was performed with the neo-aorta distended and always in the sinuses of Valsalva, never in the suture line (“trap door”). The approach to the VSD varied according to its anatomical location: via the right atrium, aorta or pulmonary artery. Pulmonary reconstruction was performed with autologous pericardium (two patches or monopatch). Methodology of the echocardiographic study The echocardiographic study was performed by the author, the pediatric echocardiographer at the Biocor Institute, with a Phillips HD11 device and four sequential measurements of the aorta, quantifying the neo-aortic valve regurgitation grade. Another equally trained echocardiographer performed the same exam, and the measurements were compared. There was no discrepancy between the echocardiographers regarding the measurements. Thus, no other checking was necessary, because the guidelines regarding measurements are very clear. 9 Serial measurements of the neo-aortic annulus, sinus of Valsalva, sinotubular region and ascending aorta were taken in the parasternal view of the long axis of the left ventricle and adjusted for body surface, following the American Society of Echocardiography (ASE) guidelines (Figure 1). In accordance with those guidelines, the aortic root was considered to extend from the implantation of the aortic leaflets in the LV outflow tract to the tubular portion of the aorta (sinotubular junction). 9 The aortic root is a geometrically complex structure that includes: (1) aortic valve annulus; (2) interleaflet triangles; (3) semilunar aortic leaflets and their attachments; (4) sinuses of Valsalva; (5) sinotubular junction. 10 The aortic measurements were taken at the following sites: (1) aortic valve annulus; (2) maximum diameter of the sinus of Valsalva; (3) sinotubular junction (usually a well-defined transition between the sinuses of Valsalva and the tubular portion of the ascending aorta); (4) maximum diameter of the proximal ascending aorta, recording the distance between the measurement site and the sinotubular junction. 9 The measurements of the aortic annulus, sinus of Valsalva, sinotubular region and ascending aorta were adjusted by using the Z-score. 11,12 Similarly, the measurements of the aortic annulus were taken in accordance with the ASE recommendations. 9 Thus, they were taken in the zoom mode, in mid systole, when the annulus is slightly larger and rounder than in diastole, between the hinging points of the aortic valve leaflets (usually between the hinging point of the right coronary leaflet and the border of the sinus at the side of the commissures between the left coronary leaflet and the noncoronary leaflet) in its internal border. In accordance with the ASE recommendations, all other aortic measurements were taken at the end of diastole, along a strictly perpendicular plane to the long axis of the aorta. 9 The neo-aortic valve regurgitation was assessed on color Doppler echocardiography and quantified as absent or trivial, mild, moderate and severe, depending on the relationship between the regurgitating jet and the LV outflow tract diameter. 13 If that relationship was smaller than 0.25, the regurgitation was quantified as mild; if between 0.25 and 0.5, moderate; and if higher than 0.5, severe. However, considering the possibility of underestimating the regurgitation grade in patients with aortic annulus dilation, the flow in the descending aorta was analyzed by use of Doppler echocardiography. In the presence of holodiastolic flow reversal in the descending aorta, regurgitation was considered moderate or severe. 14 The regurgitation grade was compared to the neo-aorta diameter in its respective measurements. 22