What are the surgical options for DORV ?

There are two basic types of repair for DORV

• ANATOMIC repair, which restores a circulation with two ventricles
• UNIVENTRICULAR repair, in which only one ventricle is functional. I will explain this situation in the section on Fontan operation for Tricuspid Atresia.

When can an anatomic repair be performed ?

The only criterion for suitability for an anatomic repair is the presence of two well-developed ventricles that will be capable of tolerating the workload after repair. It requires fine judgement after thorough investigation to make this decision.

What are the types of anatomic repair ?

There are three techniques of anatomic repair

• Intra-Ventricular Repair
  This operation has been described earlier. A tunnel is created between the VSD and aorta, directing blood from the left ventricle across the VSD into the aorta. The major requirement for this is an adequate distance between the tricuspid and pulmonary valves. If this distance is very small, one of the other alternative must be employed.
• "REV" or Lecompte Operation
  In this operation, a tunnel is created in the same way as in the intra-ventricular repair. But the tunnel may block the pulmonary valve. So continuity is achieved by directly sewing the pulmonary artery to the right ventricle, bypassing the blocked pulmonary valve.
• Arterial Switch with Tunnel Procedure
  Here a tunnel is created inside the right ventricle, between the VSD and the Pulmonary Valve. Following this, an arterial switch operation (see the section on TGA for further details) is performed to restore normal circulation.

What are the difficulties in creating a tunnel ?

The surgeon aims to create a non-obstructive passage between the left ventricle and aorta. There may be hurdles at different levels.

• VSD size - If the VSD is very small, it may need to be enlarged at the time of surgery.
• Abnormal attachments of chordae tendineae - When the tricuspid valve chordae run across the path of the tunnel, it may be possible to divide them and re-attach them to the wall of the tunnel. If the mitral valve chordae are abnormal, an anatomic repair is better avoided because of the risk of mitral valve leak if the supporting tissue is damaged.
• Narrowing of the valves or great arteries - This may need to be relieved at the time of repair.

In summary then, a simple way to decide upon the choice of repair would be

• NORMAL tricuspid valve to pulmonary valve distance with
  a. Normal pulmonary valve - Intra-Ventricular Repair
  b. Narrow pulmonary valve - Intra-Ventricular Repair with Pulmonary Valve Enlargement
• DECREASED tricuspid valve to pulmonary valve distance with
  a. Normal pulmonary valve - Arterial Switch with Tunnel to Pulmonary Artery
  b. Narrow pulmonary valve - REV operation

What is the best age to repair DORV ?

 

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