Update on Surgery for Complex Transposition of the Great Arteries: Focusing on Aortic Root Translocation

Transposition of the great arteries (TGA) is a congenital heart defect (CHD) characterized by discordance between the ventricles and great arteries. The arterial switch operation generally provides excellent early and long-term outcomes in cases in which both great arteries are well developed. Furthermore, various surgical techniques, including the Rastelli procedure, réparation à l'étage ventriculaire (REV) procedure, and pulmonary root translocation have been introduced to improve the outcomes in patients with complex TGA accompanied by significant left ventricular (LV) outflow tract obstruction. A common feature of these 3 techniques is the intraventricular tunneling of the LV to the aorta through the ventricular septal defect while maintaining the original position of the aortic root. Recently, aortic root translocation (ART), which reconstructs the biventricular outflow tracts by repositioning the aortic root toward the pulmonary side, has been reevaluated as an alternative to conventional techniques. Early experiences with ART have reported technical challenges, in addition to high surgical mortality and morbidity rates. Nevertheless, with an increase in surgical experience, early outcomes comparable to those of non-ART procedures have been reported, along with improved long-term results. A key principle of ART is to preserve the integrity of the aortic root geometry. Various modifications have been introduced to achieve this. As a potential solution, we propose an aortic root reconstruction technique, which we briefly introduce here. Furthermore, ART has been applied in patients with complex congenitally corrected TGA, and we anticipate that this technique will facilitate safer and more feasible biventricular repair in patients with complex CHDs.