A review of the Yasui operation with long-term follow-up of a case

Abstract

Yasui operation combines Norwood arch reconstruction with Rastelli operation for interrupted or hypoplastic aorta with aortic valvar atresia or hypoplasia with ventricular septal and two adequately sized ventricles, establishing biventricular repair. We present a case of aortic atresia, mitral hypoplasia, and ventricular septal defect (VSD) treated by Yasui procedure, and its long-term (108 months) follow-up and brief review of literature. Review of literature was done using keywords to search on “PubMed” and “Google Scholar.”

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-021-01174-5.

Introduction

The spectrum of hypoplastic left heart syndrome (HLHS) is variable, depending on the degree of hypoplasia/atresia of the aortic and mitral valves leading to poor development of the left ventricle (LV) and aortic arch. Rarely, some of the variants include a combination of aortic atresia (AA), hypoplastic aorta, a large ventricular septal defect (VSD), and two well-developed ventricles [1]. In this small subset, biventricular repair (BVR) can be achieved via either two- or single-stage Yasui procedure. The Yasui operation was first reported in 1987 describing 2 infants with interrupted aortic arch and severe left ventricular outflow tract obstruction (LVOTO). The repair involves division of the patent ductus arteriosus (PDA), restoration of the aortic continuity using the proximal main pulmonary artery (MPA), and placement of a patch to tunnel LV blood through the VSD into the pulmonary artery (PA) and a valved conduit for right ventricle to pulmonary artery (RV-PA) continuity. Placement of a valved conduit necessitates its replacement with time [2].

Our case

A 46-day-old female term infant weighing 3.045 kg presented with cyanosis and respiratory distress. Transthoracic echocardiography showed AA, hypoplastic ascending aorta and arch, large sub-pulmonary VSD, and duct-dependent systemic circulation. Computed tomography (CT) angiography confirmed the echocardiographic findings and also classified the degree and extent of aortic hypoplasia (Fig. 1). In view of acceptable size and volume of LV and only mild mitral valve hypoplasia, a Yasui procedure was planned.

Fig. 1.

CT image showing RV (right ventricle), LV (left ventricle), v (VSD), m (main pulmonary artery), hpa (hypoplastic arch), dta (descending aorta)

Upon midline sternotomy, a short length of innominate artery with normal branching pattern was noted. Cardiopulmonary bypass (CPB) was commenced via an 8-Fr wire reinforced arterial cannula inserted into a 4-mm polytetrafluoroethylene (PTFE) graft stitched to the innominate artery and an 18-Fr angled metal tip venous cannula in the right atrial appendage (RAA). Gradual cooling to 16 °C was initiated. Ascending aorta was transected from proximal arch after closing off the distal end by a ligature. Cardioplegia-free cold blood was infused by direct cannulation of the transected proximal ascending aorta for continuous coronary perfusion of an empty beating heart. This was delivered via the cardioplegia delivery system, where pressure was kept around 30 mmHg. The part of the arch between the innominate artery and left common carotid artery (CCA) was clamped and selective cerebral perfusion started. Left CCA and left subclavian artery (SCA) were controlled with tourniquets. During this phase, radial arterial pressure was closely monitored and maintained to around 35 mmHg.

Descending thoracic aorta (DTA) just distal to coarctation segment was clamped. The patent ductus was transected and ductal tissue bearing aorta from DTA and undersurface of the arch were excised. After clearing the ductal tissue from the left pulmonary artery (LPA) end, it was repaired primarily. MPA was transected just proximal to its bifurcation and the bifurcation was translocated anterior to ascending aorta (LeCompte maneuver). The left lateral lip of the arch was partly anastomosed to the DTA leaving an area on the undersurface to receive in the neo-aortic stump later. Cardioplegia was now delivered to the cannula inserted into the proximal ascending aortic stump to achieve diastolic cardiac arrest. A vertical incision was made on the right lateral aspect of MPA and a corresponding incision was made on the left lateral aspect of the ascending aortic stump. A side-to-side anastomosis between the MPA and ascending aorta was performed using 7–0 polypropylene to create the neo-aortic stump. Circulatory arrest with regional cerebral perfusion was established and clamp between the left CCA and innominate artery shifted to the base of the innominate artery. Distal right CCA and right SCA controlled via tourniquets. The remaining portion of the undersurface of the arch also filleted open. Creation of neo-aortic arch was accomplished by anastomosing neo-aortic stump to the filleted open inferior part of arch and adjoining DTA (Fig. 2).

Fig. 2.

Line diagram representation of anastomosis

A longitudinal right ventriculotomy was performed 5 mm below the pulmonary annulus. The LV was baffled to the neo-aorta using a Dacron (BARD Peripheral Vascular Inc., AZ, USA) prosthetic patch through the ventriculotomy. Full-body circulation was reestablished followed by rewarming. Continuity between the right ventricle (RV) and pulmonary bifurcation was established using a 12-mm bovine valved conduit (Contegra; Medtronic Inc., Minneapolis, USA), on a perfused empty beating heart. After full rewarming, CPB was weaned off on 0.2 mcg/kg/min of levosimendan after loading on pump with 12 mcg/kg over 20 min, 0.1 mcg/kg/min of adrenaline, and 100 mg/h of calcium gluconate infusion. Modified ultrafiltration was used to extract 300 ml of fluid thereafter. Total bypass time was 247 min with regional cerebral perfusion time of 76 min. The sternum was electively kept open and delayed closure performed 64-h post-surgery. She was extubated on the 5th post-operative day and oral feeds were established by a long nipple bottle for cleft palate. She was discharged on the 14th postoperative day. Echo before discharge showed no residual VSD, no significant left ventricular outflow tract (LVOT) or right ventricular outflow tract (RVOT) obstructions, and good flow in arch. Patient was kept on low-dose aspirin for 6 weeks.

Follow-up

The child was on regular follow-up with serial echocardiography. At 9 months of age, she underwent cleft lip and cleft palate surgery with infective endocarditis prophylaxis. She remained asymptomatic during her entire follow-up. Her cardiac magnetic resonance imaging (MRI) (Fig. 3) and echo findings during follow-up have been tabulated (Table 1).

Fig. 3.

Postoperative MRI image after 3.5 years showing a (aortic portion), p (pulmonary portion), c (conduit), arch (aortic arch)

Table 1.

Follow-up data showing echo and c-MRI findings. Child remained asymptomatic during each follow-up

FU #	Months Post-op	ECHO findings	MRI finding	Advice/intervention
1, 2, 3	1, 6, 12	No residual VSD, good flow across the arch, good biventricular function. No significant LVOTO/RVOTO	Not done	Regular follow-up At 9 months age repair of cleft lip and palate
4	26	No LVOTO/no aortic regurgitation, RVOT gradient 20 mmHg, moderate conduit regurgitation, good biventricular function		Cardiac MRI (c–MRI) planned
5	42		RVEF 38% Conduit RF 26% RVEDVI 85.4 ml/m2 RVESVI 32.3 ml/m2	Follow-up after 6 months
6	50	No LVOTO/no aortic regurgitation RVOT gradient 20 mmHg, moderate conduit regurgitation, mild turbulence in left PA (PG 20 mmHg) Good biventricular function. Basal RVIDd 17 mm (z-score + 0.65)		Repeat c-MRI after 6 months
7	65		RVEF 44% Conduit RF 23.92% RVEDVI 122.2 ml/m2 RVESVI 31.4 ml/m2 Left PA origin stenosis	Follow-up after 6 months
8	76	No LVOTO/no aortic regurgitation RVOT gradient 20 mmHg, severe conduit regurgitation, turbulence in left PA (PG 40 mmHg) Good biventricular function, basal RVIDd 18 mm (z-score + 3.7) Good biventricular function	RVEF 43% Conduit RF 32% RVEDVI 171 ml/m2 RVESVI 40.1 ml Left PA origin stenosis	Conduit replacement with left PA plasty
Conduit change with LPA plasty at age 7 years
9	83	No neo-conduit regurgitation PA confluence gradient of 30 mmHg Good biventricular function		Follow-up after 3 months
10	87	PA confluence gradient of 45 mmHg Good biventricular function		Follow-up after 6 months
11	93	No conduit regurgitation Confluence gradient of 50 mmHg (confluence to right PA origin site) Right PA origin 9 mm Right PA (distal) 9 mm Left PA 9 mm (LPA good flow) TAPSE 1 cm RVIDd 26 mm (dilated)		Follow-up after 6 months and introduced the possibility of right PA balloon dilation and/or stenting
12	108	In view of COVID, telephonic follow-up done. Patient had no new symptom, leading a good academic and physically active life		Re-enforced the need for early RPA intervention

LVOTO/RVOTO right/left ventricle outflow obstruction, RVEF/LVEF right/left ventricle ejection fraction, RF regurgitant fraction, RVESVI right ventricle end systolic volume index, RVIDd Right ventricle internal diameter in diastole, TAPSE tricuspid annular plane excursion

During her 6th year follow-up, her conduit regurgitation was documented to be severe along with LPA stenosis. MRI showed preserved RV ejection fraction with indexed RV end diastolic volume indicating need for conduit replacement. She underwent RV-PA conduit revision after 82 months of Yasui procedure. She was 15.2 kg at this procedure. RV-PA conduit was calcific and firmly adherent to the left half of the sternum but enough midline space was available as adjudged by MRI to achieve safe resternotomy. Due to previous LeCompte’s maneuver, a very short length of the ascending aorta was available for cannulation. Dissection of conduit was completed after commencing normothermic CPB. There was dystrophic calcification of the xenograft valve, which was explanted in toto. LPA was seen stenosed at its origin, possibly due to primary repair of the duct insertion site. In hindsight, it may have been avoided if the site had been patch augmented instead at the primary stage. LPA plasty was done by augmenting it with autologous pericardium. An 18-mm RV-PA bovine jugular valved conduit (Contegra; Medtronic Inc., Minneapolis, USA) was put in place. She was weaned off CPB without inotropes, extubated in the operating room, and was discharged on the 4th post-operative day with echo confirmation of adequate branch PA and conduit flow.

Review methodology

Keywords were used for search over PubMed and Google Scholar. A total of 28 articles were shortlisted where “Yasui operation” or an equivalent principle (LVOT bypass, Damus-Kaye-Stansel with arch augmentation and Rastelli, Norwood-Rastelli, etc.) was applied to manage a similar subset of conditions. Few authors of these articles had also included patients in whom other procedures were done but we teased out information specifically of those receiving Yasui operation and excluded the rest from analysis in this review. Articles were searched for number and type of Yasui (primary or staged; and the type of staging), rate of reoperations, overall survival, follow-up strength, and salient comments concluded by the authors pertaining to the selection criterion used for adopting the Yasui principle. These facts, where ever clearly discernable, have been mentioned. In the interest of space, articles reporting more than 10 cases of Yasui procedure have been tabulated individually in Table 2. A total of 256 Yasui cases were hence included in this review. Additionally, 21 papers, each with cases fewer than 10 in number, were found in the literature. Their tabulation and references have been mentioned in the supplementary table and reference list.

Table 2.

Brief review of literature

Name of the study and year	Subset suitable for Yasui = (N) -Primary (n) -Staged (n) (Method of staging) -Interstage mortality -Additional procedures	Re-op/intermediate procedures/morbidities	-Death (causes) -Survival (% at years)	Available follow-up	Comments
Shihata M et al., 2014 [3]	-N = 44 (syndromic, 23; nonsyndromic, 21) -Staged = 44 (Norwood, 41; hybrid, 3) -Stage I Mortality, 9% -Interstage survival (syndromic, 46%; non-syndromic, 100%) Yasui completion, 24 pts. -VSD enlargement, 9	Interstage procedure: Surgical 23 (additional BTS) Cath procedure 5 (PA plasty and coarctation ballooning) Re-Int after 2nd stage: Conduit change, 11; patch PA plasty, 2; PA stent, 1; VSD enlargement, 2; pacemaker implantation, 1 Freedom from Re-Int post 2nd stage: 53% at 6 yr	Stage 1 survival to hospital discharge 91% Overall survival: Syndromic 43% Non-syndromic 86%	Maximum shown follow-up 12.5 years	-To qualify for Yasui, VSD size ≥ 5 mm -Staged approach associated with less myocardial trauma and shorter ischemia times in the neonatal period -Staged approach allows for growth and later reconsideration
Mallios D N et al., 2021 [4]	-N = 30 -Primary, 3 -Staged, 27 (Norwood) -Interstage mortality, 1 (needed shunt revision, LCOS) -Concomitant VSD enlargement, 2 (staged group) Unsuitable for 2nd stage (single-ventricle pathway), 4 Awaiting 2nd-stage surgery, 3	Re-surgery after total correction: Staged group: 1 (neo-AVR) Freedom from Re-Int at 10 yr (overall): LVOT: 91% RVOT: 71%	Mortality during 2nd stage = 1 (5%) (VSD was enlarged, baffle decreased RV volume, LCOS, ECMO) Overall mortality (5.2 yr): 2 (10.5%) (noncardiac cause) Need for pacemaker 0	Median 4.9 years Range 3.5 to 6.5 years	-Patients for Yasui repair had median AoV z-score,− 3.7 (− 4.5 to − 3.0), median size of VSD 5.1 mm (3.8 to 6 mm) -When the VSD is smaller and more remote, primary Ross-Konno procedure may be preferred, but associated with higher complication rate
Gruber P J et al., 2006 [5]	-N = 21 -Primary, 21	Re-op = 10 Conduit change, 5; baffle leak, 4; tricuspid valve replacement, 1 Cath lab Interventions = 11 Conduit dilatation, 6; ballooning of aortic arch, 4; pacemaker, 1	Mortality at discharge, 0 _	Available (16/21)
				Median, 34.2 months Range: 0.5 to 81.9 months	Aortic annular diameter ≤ 3 mm → consider Yasui
Kanter K R et al., 2012 [2]	-N = 21 -Primary, 6 -Staged, 15 (Norwood) -No interstage mortality Awaiting completion, 2 -VSD enlargement done in staged Yasui, 7 Neo-aortic valve replacement during 2nd stage, 1	Intermediate procedure 02 Glenn, 1 (later taken down at 2nd stage) BTS converted to Sano, 1 Balloon arch dilatation, 5 Re-op after total correction: 8 8 (conduit change, 6; LVOTO, 1; residual VSD, 1) No intergroup difference in actuarial freedom from re-op or death	Early mortality, 0 Late death, 3 Primary, 1 (brain bleed) Staged, 2 (sepsis, respiratory failure) Overall freedom from death 100% at 1 year 75 at 5 years (no intergroup difference)	Mean, 4.1 ± 2.9 years Range: 5 weeks to 9.5 years	LVOT diameter < 4 mm → favor Yasui LVOT diameter 4 to 4.5 mm → either Yasui or conventional repair (VSD closure, arch repair) LVOT > 4.5 mm → conventional repair
Ohye R G et al., 1999 [6]	-N = 20 -Primary, 11 -Staged, 8 (All Norwood) -No inter-stage mortality Awaiting completion, 1	Re-op (overall) Residual VSD closure, 1 PA augmentation, 1 Residual VSD + PA augmentation, 1 Conduit change, 3	Early mortality: Primary, 1 (LCOS) Staged, 1 (after Yasui completion) Late death: Primary, 2 (non-cardiac cause) Staged, 0 Actuarial survival at 5 yr: Primary 73% Staged 89%	Mean, 28 months Range, 1 to 85 months	Ao V z-score ≤ −2 → consider Yasui
Carrillo S A et al., 2015 [7]	-N = 18 -Primary, 15 -Staged, 3 (All Norwood)	Morbidity after primary Yasui: Pacemaker implantation, 2 Freedom from Re-op: Average interval to 1st Re-op, 12.5 ± 3 months Re-op in primary group: 10 Conduit change, 9 Arch revision, 1	Mortality in primary group, 2 (early, 1; late, 1) Operative mortality Primary, 6.7% Staged- NA Survival for primary Yasui was 85% at 5 years	Maximum discussed follow-up, 5 years	Ao V z-score < − 3 → consider Yasui
Nakano et al. 2014 [8]	-N = 17 -Primary, 6 -Staged, 11 (Hybrid, 8; Norwood, 3) -No inter-stage mortality	ECMO-1 (primary) 6 patients underwent 8 re-op, including 13 procedures (RVOT re-op, 8)	Operative death, 1 primary (acute MI) Actuarial survival (overall): 87.8 at 10 years	Mean, 7.6 to 9.2 years Range, 0.7 to 28.1 years	For LVOT diameter ≤ body wt + 1 mm → consider Yasui
Abarbanell G et al., 2018 [9]	-N = 17 -Primary, 3 -Staged, 14 (method of staging, NA)	Re-Int (overall): 64.7% LVOT intervention, 2 Recoarctation, 1 RVOT/PA intervention, 8 Conduit change, 6	Early death: 0 Late death: 5 Long-term survival data, NA	Mean = 4.5 years Range, 3.3 months to 10 years	Lower odds of re-op in patient with aortic root z-score < 2.5 with Yasui repair
Alsoufi B et al., 2016 [10]	-N = 17 -Primary, 3 -Staged, 14 (All Norwood)	Intermediate procedure after stage 1 Norwood, 1 Glenn (later taken down at 2nd stage) Re-op in LVOT bypass group: Conduit change, 5 PA plasty, 4 Residual VSD closure, 3 Tricuspid valve repair, 2 Sub-aortic obstruction repair, 1	Post-op ECMO, 4 (28%) after stage1 Norwood Death after Yasui, 4 1, abdominal surgery 1, needing AVR later 1, needing neo-AVR at the time of 2nd stage reoperation 1, persistent biventricular dysfunction after repair 10-year survival: 76%	Maximum discussed follow-up, 8 years	Yasui was offered in patients with: Ao V z-score < 4.1(4.5–3.4), Ao V annulus minus weight = 0.8 (0.4–1.2), Ao V indexed cross-sectional area 0.57 cm2/m2 (0.49–0.7)
Nathan M et al., 2006 [11]	-N = 17 -Primary, 17	Re-op = 9 conduit change, 7 LVOTO, 1 Residual VSD closure, 1	Early death, 03 (biventricular failure and septicemia) Freedom from death, 82 at 10 years	Median, 6 years Range: 1 to 17.7 years	Ao V z-score, − 3.87 → consider Yasui
Krishna Moorthy P S et al., 2007 [12]	-N = 16 -Primary, 16 -VSD enlargement, 8	Re-op: Ballooning of RV-PA conduit, 2 Ballooning of aortic arch, 1 RV-PA conduit replacement, 4 LVOT enlargement, 1	Early mortality (30 days), 3 (LCOS and PAH) Actuarial survival for primary Yasui was 53% at 5 years	Median, 32 months Range, 4 to 191 months	-VSD was enlarged when the location was not strictly sub-pulmonary and there was a muscle bar between the pulmonary valve and VSD margin -Delay in performing the initial repair may increase the mortality
Alsoufi B et al., 2010 [13]	-N = 14 -Primary, 13 -Staged, 1 (Norwood)	Re-op, 8 Conduit change, 6 Tricuspid valve repair, 1 Mitral valve repair, 1	Early mortality, 3 (21%) Late mortality, 1 (complication during conduit change) Survival, 79% at 5 years	Maximum discussed follow-up, 11 years	-In presence of concomitant mitral valve pathology, single ventricle repair serves better -Yasui as compared to Ross has lower early mortality, and hence must be preferred in cases with concomitant arch pathology
Hickey et al., 2010 [14]	-N = 13 -Primary, 9 -Staged, 4 (Norwood)	Re-op, 9 (conduit change, 9) −50% remained free of re-op at 7 years	Total death, 4 (details NA) Overall survival 69% at 10 years	Maximum discussed follow-up, 10 years	–

AVR aortic valve replacement, ECMO extracorporeal membrane oxygenation, RVEDVI/LVEDVI right/left ventricle end diastolic volume index, LCOS low cardiac output syndrome, PAH pulmonary arterial hypertension, Ao V aortic valve, Re-op reoperations, Re-Int reinterventions

Discussion

Typically, HLHS presents with hypoplastic LV making it amenable only to single-ventricle palliations. Rarely does there exist a variant where the LV and mitral valve are sufficiently well developed (4–6%) to sustain a BVR [15]. These variants have similarity with patients of interrupted/hypoplastic aortic arch, a malaligned VSD, and hypoplastic aortic valve. Biventricular repair for such variants was originally performed by Yasui and colleagues in 1987. Repair that goes by his name is a combination of Norwood type neo-aortic and arch reconstruction with redirection of LV outflow through the VSD to both the semilunar valves and establishment of RV-PA continuity using a valved conduit [2].

Considerations while applying the Yasui principle

Important anatomical features to keep in mind while selecting patients for Yasui procedure are adequacy of biventricular volumes adjudged with the proposed VSD patch on echo, adequacy of LV inflow, VSD size and routability, degree of LVOT hypoplasia, and suitability of pulmonary valve. To determine the indication of Yasui operation in terms of the severity of LVOT obstruction, Kanter et al. [2] recommended the smallest diameter of LVOT to be < 4 mm in neonate. Similarly, Nakano et al. [8] have considered LVOT diameter to be < body weight in kg + 1 mm. Tomoyasu et al. [16] in their 7-staged Yasui procedure used RV end diastolic volume index more than 80% of normal as a criterion to select patients for Yasui completion surgery. A pathological pulmonary valve deemed unsuitable for use as a systemic valve or a remote unrouteable VSD would be a contraindication for Yasui repair. Cases with pulmonary valve contraindication and patent LVOT will need correction with VSD closure, LVOT resection, and arch repair with expectation of future need of re-surgery for LVOT obstruction. In patients with good functional pulmonary valve but remote unrouteable VSD or with recurrent complex LVOT obstruction, Ross-Konno becomes an essential tool but may be associated with higher mortality in the postoperative period [17]. Our case had aortic atresia, committable sub-pulmonary VSD, and a competent pulmonary valve; hence, none of the above considerations was applicable. Nakano et al. [8] considered that the weight of 4 kg and age of 3 month are sufficient to qualify for Yasui operation. The risk factors for failure of biventricular repair in multiple left heart obstructive lesions are presence of moderate to large VSD, uni-commissural aortic valves, hypoplastic mitral valve (z-score < − 2), and hypoplastic LV with low LV end diastolic volume (z-score < − 2) as mentioned by Schwartz and associates [18]. Our patient had aortic atresia with mitral valve z-score of − 2. On follow-up, her mitral z-score was found to be normal. Lastly, the Yasui principle can also be applied successfully in patients with progressive LVOT obstruction after primary conventional repair of arch obstruction and VSD closure [19].

Staged vs primary

After anatomic evaluation, if the patient is deemed suitable for BVR, the choice between primary or staged repair must be made. Various modified surgical techniques can then be employed to achieve BVR like Damus-Kaye-Stansel, Norwood, or Yasui with use of homograft or autologous tissue, depending on anatomy faced [8]. Biventricular outcome can be achieved either in a staged manner wherein an initial Norwood palliation or Geissen hybrid procedure is followed by a biventricular completion utilizing baffling of the VSD to neo-aorta and RV to PA conduit or performing both in one stage. Single-stage biventricular repair gives the advantage of a patient getting into a normal series circulation early in life, as compared to the staged approach which involves continuation of parallel circulation with deoxygenated blood going in systemic circulation during the inter-stage period. Moreover, staged approach is associated with significant interim morbidity regardless of the method of stage 1 palliation (hybrid or Norwood). This interim physiology being better tolerated in biventricular scenarios vis-à-vis a typical hypoplastic left ventricle remains a point in contradiction with no literature precisely addressing this argument. The staged approach has an advantage of allowing for declaration of growth of borderline sized mitral valve, LV, and LVOT deferring the decision point of commitment to uni-ventricular vs biventricular pathway, as well as the type of biventricular repair to be applied. Single-stage repair has downsides in the form of prolonged surgical time, long aortic cross clamp time, bypass time, and risk of heart block. Since this involves correction in neonatal age, need for conduit replacement is early, as compared to staged biventricular repair [7]. Gruber et al. [5] reported 21 cases of neonatal primary repair with no early mortality and 1 late death. Nathan et al. [11] described 17 cases of primary neonatal repair for aortic atresia or with severe LVOT obstruction and reported 3 (18%) early mortalities with no late deaths. Their actuarial survival at 10 years was 82%. With these good results, they advocated for primary neonatal repair in this group of patients.

RV to PA continuity

RV to PA continuity can be achieved using either a valved homograft (aortic, pulmonary [11]), bovine jugular vein [13], expanded polytetrafluoroethylene (e-PTFE) valved conduit, Dacron valved conduit [8], or LeCompte maneuver (with or without a valve) [8]. A singular case of femoral vein homograft use in the Yasui procedure has also been reported. Yasui operation, by virtue of using a conduit for RV-PA continuity, mandates reoperations for conduit changes. Carrillo et al. [7] demonstrated that the freedom from reoperation was superior in the Yasui cohort as compared to staged BVR. The establishment of 2-ventricle circulation has important physiologic consequences and confers significant midterm benefits compared with a single-ventricle circulation. The average reoperation period after a Yasui operation was 13.5 ± 3 months. In our case, the bovine jugular vein conduit required the first change at 82 months. In our case, LeCompte maneuver to establish RV-PA continuity has been seen to reduce or delay risk of reoperation as also observed by Nakano et al. [8]. Performing the LeCompte maneuver is easily feasible during a primary Yasui unlike attempting the same after a Norwood stage 1. Though after a hybrid stage 1, it can still be performed along with bilateral branch pulmonary artery plasty.

Yasui takedown

Although RVOT obstructions have been commonly encountered in the follow-up after a Yasui procedure, obstruction in the neo-LVOT could be found only in a solitary case report in this review of literature. This was successfully managed by takedown of the Yasui and conversion to standard VSD closure, arch augmentation and reconnection of the PA to the confluence of branch pulmonary arteries [20].

Conclusion

To conclude, we suggest that in the presence of routable VSD with AA or severe LVOTO and two adequately sized ventricles, BVR is possible and desirable. Primary Yasui avoids a vulnerable period associated with the shunted single-ventricle physiology of the staged approach. It is safe in the intermediate and long term and requires regular follow-up.

Author contribution

1. Dr. Ajaykumar R Pandey: Collected and compiled all the necessary information, prepared the main manuscript and tables.

2. Dr. Sibashankar Kar: Assisted in manuscript preparation and helped with the figures especially the line diagram.

3. Dr. Neeraj Aggarwal: Helped with 2D ECHO follow up and contributed in editing the tables.

4. Dr. Salil Bhargava: Helped in procuring the apt CT and MRI images and their nomenclature.

5. Dr. Reena Khantwal Joshi: Assisted with overall editing and language correction.

6. Dr. Raja Joshi: Conceptualized the whole idea, helped in language correction, involved in regular follow-ups.

Funding

None.

Declarations

Ethics committee approval

Not applicable.

Informed consent

Well-informed consent was taken before procedure stating clearly about permission to publish.

Statement of human and animal rights

Not applicable.

Conflict of interest

The authors declare no competing interests.