Arterial switch operation for transposition of the great arteries with situs inversus and mirror image dextrocardia

We report a successful arterial switch operation for complete transposition of great arteries with atrial and visceral situs inversus totalis and mirror image dextrocardia in a 12-day-old infant girl. The aorta was located left side-by-side to the pulmonary trunk with a single coronary artery (mirror image of 1RLCx). After French maneuver, the posterior circumference of the neo-aorta was reconstructed. Then the coronary button was transplanted into the neo-aorta with a trap door technique carefully avoiding any twist and over-stretch. The neo-pulmonary trunk was reconstructed with an autologous pericardial patch and sutured to the longitudinal incision made into the left central pulmonary artery. The baby was discharged from hospital and has been doing well without any morbidity relating myocardial ischemia.     

Arterial switch operation for simple transposition of the great arteries in infancy

Five infants (22-42 days of life) underwent arterial switch operation for simple transposition of the great arteries under deep hypothermic cardio-pulmonary bypass. Three babies required prostaglandin E1 infusion to keep ductus arteriosus opened widely before surgery. Balloon atrioseptostomy was necessary in 0-10 days of life in all babies because of poor condition. Left to right ventricular peak pressure ratio ranged from 0.75 to 0.86, preoperatively. Four of the five survived the operation, and one died of coronary insufficiency because of kinking of the implanted coronary artery. Hypothermic circulatory arrest was used in three (38-41 minutes). Aortic cross clamp time was 70-100 minutes, and cold crystalloid cardioplegia was given only one time just after aortic clamp in 3 babies. Single dose of cardioplegia protected left ventricular muscle well in babies with transposition of the great arteries as same as multiple dose method used in those with ventricular septal defect.     

Arterial switch in simple and complex transposition of the great arteries

Arterial switch for repair of transposition of the great arteries was performed on 53 patients since October 1983. These patients were divided into three groups: group I, 25 infants with an intact ventricular septum who had primary repair in the first month of life (2 to 34 days of age, mean 9.7 +/- 6.6); group II, 13 patients with an intact ventricular septum who had anatomic repair after a preliminary procedure (pulmonary artery banding in 13, shunt in 10, atrial septectomy in 1); and group III, 15 infants with transposition of the great arteries and ventricular septal defect. In group III, six patients had Taussig-Bing abnormality, nine had previous pulmonary artery banding, three had coarctation of the aorta repaired earlier in life, and four were less than 2 weeks old. Overall early mortality was 9.4% (5/53: group I 8%, group II 7.6%, group III 13.3%). Two late deaths occurred in group II 10 and 12 weeks postoperatively after infection and high fever. A third late death 18 weeks postoperatively was due to aspiration in an infant with Goldenhar's syndrome. Mortality and morbidity decreased significantly after an initial learning period (no deaths from July 1985 to March 1987 overall, and none in the last 15 infants operated on in group I). The surviving 45 patients are doing well. All have normal sinus rhythm. Two had transient asymptomatic arrhythmias. Left and right ventricular function assessed by echocardiogram and postoperative cardiac catheterization were within normal ranges in all but two patients, one with pulmonary artery stenosis and one (Taussig-Bing abnormality with two large ventricular septal defects) with severe pulmonary vascular disease (9.6 units) observed before anatomic repair. The right ventricular pressure at catheterization ranged from 27 to 42 mm Hg in 12 patients and was 55 mm Hg in two. There was no aortic stenosis. Aortic insufficiency was trivial in three patients and mild in one. We conclude that excellent results can be obtained with arterial switch for transposition of the great arteries with or without ventricular septal defect, especially in neonates.     

Arterial switch operation for transposition of the great arteries: surgical techniques to avoid complications.

From June 1984 to November 1990, 109 patients with transposition of the great arteries underwent arterial switch operation. There were 5 deaths, yielding a mortality rate of 4.6%. During this period, modifications of the surgical technique were devised to minimize intra- and postoperative problems, such as bleeding, kinking of the coronary arteries, aortic regurgitation and pulmonary stenosis. The surgical refinements that evolved include (1) a more distal division of the ascending aorta, (2) a punch technique for reimplantation of the coronary arteries in a medially rotated position, approximating the commissure, and superior to the upper border of the sinus of Valsalva, and (3) removal of left coronary ostia by incision down from the transected site to include a button of aortic wall, avoiding the free margin of the aorta and patch enlargement of the neopulmonary artery. Since instituting these refinements: (1) the time consumed for hemostasis after termination of the bypass considerably decreased from 111 +/- 59 to 87 +/- 51 minutes (p less than 0.05), (2) the incidence of kinking of the coronary arteries decreased from 29% (4/14) to 7% (6/88) (p less than 0.05), and (3) the occurrence of aortic insufficiency 1 year after correction was reduced from 36% (5/14) to 8% (5/66) (p less than 0.02). However, the occurrence of pulmonary stenosis with a pressure gradient greater than 30 mmHg did not decrease significantly despite aggressive modifications of surgical techniques, and its incidence in the most recent series of 32 patients was still a high 19%.     

Arterial switch operation for transposition of the great arteries without use of prosthetic material]

For transposition of the great arteries (TGA), arterial switch operation (ASO) is theoretically preferable to atrial switch operation, since the left ventricle is established as the systemic ventricle and sinus node function is maintained. However, ASO is a delicate operation requiring the transfer of the coronary arteries. Use of prosthetic material for reconstruction of the neo-pulmonary artery causes postoperative supra-valvular pulmonary arterial stenosis. Five neonates and young infants with TGA underwent ASO without the use of prosthetic material by the technique reported by Pacifico et al. Three patients with simple TGA ranged in age from 10 to 27 days, and in weight from 2.9 to 3.9 kg. Two patients with TGA and ventricular septal defect ranged in age from 41 to 63 days, and in weight from 2.8 to 4.2 kg. There were no deaths, either early or late, and all patients are well 7 to 21 months after surgery. Catheterization and Doppler echocardiographic studies performed in all patients showed that pressure gradient between the right ventricle and pulmonary artery decreased significantly during mean follow-up period of 14 months. These results suggest excellent growth of the pulmonary artery after surgery.     

Arterial switch operation using aortic homograft for transposition of the great arteries with pulmonary regurgitation

We report a case of a 15 month-old boy who underwent the arterial switch operation using cryopreserved aortic homograft for transposition of the great artries with pulmonary regurgitation, with coexisting right ventricular outflow tract obstruction precluding atrial switch operation. Follow-up echocardiography at 6 months showed trivial neoaortic valve regurgitation, no significant systemic outflow obstruction, with good cardiac function. In small children, the choice of material for left ventricular outflow tract reconstruction is one of the most crucial issues. Cryopreserved homograft has been one of the primary options for the aortic valve replacement in small children because of the ease of suturing and excellent hemostasis.     

单个瓣窦发出冠状动脉的大动脉调转术

目的 评估单个瓣窦发出冠状动脉(CA)的大动脉调转术(ASO)手术效果.方法 1999年3月至2006年6月共行单个瓣窦发出冠脉的ASO 31例.包括完全性大动脉错位(TGA)伴室间隔缺损(VSD)27例,室间隔完整(IVS)的TGA 4例.其中单根CA开口于右瓣窦4例;LCA和RCA分别开口于右瓣窦15例;LCA在壁内走行与RCA分别开口于右瓣窦4例;单根CA开口于左瓣窦8例.术中采用冠状动脉button用"开门"或向后翻转90°,加心包片或动脉壁扩大的方法移植于新的主动脉根部.结果 术后死亡8例,病死率25.8%.随访2～5 年,2例残余分流自愈,2例肺动脉残余梗阻(压差30、56 mm Hg),所有病婴均无明显心肌缺血改变.结论 冠状动脉畸形移植是一种切实可行和减少移植后冠状动脉扭曲和变形的方法,并能减少术后心肌缺血,提高手术成功率.     

Arterial switch operation with in situ coronary reallocation for transposition of great arteries with single coronary artery.

OBJECTIVES: Transposition of great arteries (TGA) with single coronary artery pattern is one of the high-risk groups for arterial switch operation (ASO). Any traction or kinking during coronary transfer can lead to a fatal outcome. With increase in experience, surgical results improved, but it did not completely eliminate the risks of coronary translocation. Many techniques have been described for transfer of single coronary and each one has its own merits and problems. We here in describe a new technique of in situ coronary reallocation during ASO for TGA with single coronary and also report the early and mid-term results with this new technique. METHODS: From September 1988 to June 2002, five consecutive cases of TGA with single coronary artery were operated employing this new technique. Their age ranged from 16 days to 9 months. ASO was done by transecting the great arteries just above the commissures. For coronary reallocation, hockey stick-shaped incisions were made in the facing sinuses of the proximal aorta and the pulmonary artery. These flaps were sutured in such a way that the coronary ostium was committed to the neo-aorta with the rest of surgical procedure done in the usual manner. RESULTS: All five patients had ASO. Additionally, four patients had closure of an associated ventricular septal defect and one patient had repair of the coarctation of the aorta. There was no in hospital mortality. All patients had follow-up echocardiograms at regular intervals, which showed no significant right or left ventricular outflow obstruction, no regional wall motion abnormalities and no neo-aortic or neo-pulmonary regurgitation. Three of five patients had cardiac catheterization and angiocardiography, which showed normal coronary arteries with no obstructive lesions and no neo-aortic regurgitation. Their follow up ranged from 5 to 50 months and there was no late mortality. CONCLUSIONS: This new coronary reallocation technique avoids problems related to coronary translocation such as traction and kinking. It spares the need for dissection of proximal coronary artery and its branches, and thereby eliminates the risk of development of fibrosis and stenosis. The same technique can be used regardless of the sinus of origin of the coronary artery. It is a reliable and a reproducible technique. The early and mid-term results appear excellent in this series.     

大动脉转换术治疗新生儿完全性大动脉错位

目的 回顾总结完全性大动脉错位（D－TGA）的手术治疗。方法 1999年11月至2001年8月，采用大动脉转换术（Switch）手术方法纠治新生儿D－TGA 16例，其中室间隔完整型大动脉错位（D－GA／IVS）6例，大动脉错位伴室间隔缺损（D－TGA／VSD）10例。所有病例都在深低温低流量和深低温停循环下行Switch纠治术。结果 Switch手术治疗TGA共16例，其中TGA／IVS 6例，无死亡；TGA／VSD 10例，死亡2例，均为伴有冠状动脉畸形者。14例随访2－20个月，VSD残余漏1例，肺动脉轻度残余梗阻2例，14例心功能均良好。结论 Switch手术是D－TGA纠治的首选方法，但必须早期手术。     

Arterial switch operation for transposition of the great arteries, with special reference to left ventricular function

Between June 1984 and September 1987, 48 patients underwent Lecompte's modification of the arterial switch operation for transposition of the great arteries, including transposition with intact ventricular septum with preparatory pulmonary artery banding (n = 18), with patent ductus arteriosus (n = 11), with dynamic left ventricular outflow tract obstruction (n = 4), and transposition with ventricular septal defect (n = 15). Ages ranged from 12 days to 36 months (mean 8 months) and weights ranged from 2.7 to 12.8 kg (mean 5.7 kg). Two deaths occurred, yielding an operative mortality rate of 4.2%. Preparatory pulmonary artery banding resulted in an increase to 65 +/- 5 mm Hg in the left ventricular afterload. Linear regression of the optimum circumference of the band (Y, millimeters) against left ventricular end-diastolic volume (X, milliliters) yielded the following formula: Y = 0.23X + 19.7 (r = 0.885, p less than 0.001). Influence of left ventricular mass on cardiac function after anatomic correction was evaluated. The total amount of dopamine used after repair in patients in whom the left ventricular mass was less than 60% of normal was significantly larger than that in patients with a left ventricular mass greater than or equal to 60% of normal (p less than 0.002). The left ventricular end-diastolic volume in patients with a left ventricular mass less than 60% of normal increased significantly 2 months after operation (p less than 0.05), whereas it decreased in patients with a left ventricular mass greater than 60% of normal (p less than 0.01). We believe it is safe to perform this procedure in patients in whom the left ventricular mass is larger than 60% of normal. Most newborn infants with simple transposition can undergo correction between 10 and 20 days of life if the ductus arteriosus is kept patent with prostaglandin E1 and the left ventricle is thereby loaded. Preparatory pulmonary artery banding, when necessary, will be satisfactory if the left ventricular pressure is greater than 65 mm Hg and/or the left ventricular/right ventricular pressure ratio is greater than 0.8.     

Arterial switch after failed atrial baffle procedures for transposition of the great arteries

BACKGROUND: Late failure of the systemic right ventricle after atrial baffle procedures in patients with transposition of the great arteries poses significant management problems. We reviewed our experience with staged conversion to arterial switch operation (ASO) in these patients. METHODS: Between 1984 and 1999, 11 patients underwent pulmonary artery band (PAB) to prepare the left ventricle for ASO conversion. One additional patient had subpulmonic stenosis and was naturally prepared. Mean age at the initial PAB was 12.2+/-7 years (range, 1.9 to 23 years). Four patients underwent reoperation to tighten the PAB before ASO. Mean interval from PAB to ASO was 1.3+/-0.9 years. RESULTS: There was no mortality from PAB. Six patients had ASO conversion and 2 died. Recent surgical modifications at the time of ASO were used to prevent neoaortic valve insufficiency and to cryoablate atrial reentry tachycardia. Four patients developed biventricular failure after PAB and had orthotopic cardiac transplantation (OCT) 14+/-10 months after PAB. The other 2 patients are still with PAB: 1 is awaiting ASO conversion and the other has insufficient left ventricular hypertrophy necessary for ASO conversion despite two preparatory PABs. CONCLUSIONS: A select group of patients with right ventricular failure after atrial baffle operations can undergo staged conversion to ASO with the opportunity for excellent long-term outcome. Surgical modifications at the time of ASO can address the problems of neoaortic insufficiency and persistent atrial arrhythmias. PAB may be a therapeutic endpoint in some patients not responding with adequate left ventricular hypertrophy. Those patients who develop biventricular failure after PAB will require cardiac transplantation.     

Late reoperations after neonatal arterial switch operation for transposition of the great arteries.

The arterial switch operation has become the treatment of choice for neonates with transposition of the great arteries. Currently, the early mortality rate is low as well as the need for early reoperation because of surgical failures; in our experience with 803 neonates, these risks were 3.8% and 1.5%, respectively. The late outcome in terms of survival and functional status is excellent. However, surgical repair is far from anatomical and potential late defects were identified as soon as this procedure was introduced: obstruction of the neo-pulmonary outflow tract, development of obstructions of the reimplanted coronary arteries, dysfunction of the neo-aortic valve, and progressive left ventricular dysfunction. Actually, late reoperations are required in 5-10% of patients (4.5% in our experience with a mean follow-up of 5.8 years). The more frequent indications for reoperation are coronary lesions and right ventricular outflow tract obstructions. Coronary obstructions are, in most cases, detected in patients without any clinical or echocardiographic evidence of myocardial ischaemia. Coronary lesions are progressive and repeated coronary evaluation at regular intervals is necessary. Reoperation is indicated when myocardial ischaemia, at rest or under stress, is demonstrated at myocardial imaging. Satisfactory results can be achieved by surgical coronary patch angioplasty; in selected cases, mammary bypass may be necessary. Right ventricular outflow tract obstruction is related either to inadequate growth of the pulmonary anastomotic site, or to inadequate growth of the whole new right ventricular outflow tract in patients with associated aortic arch obstruction. Reoperation is indicated when significant obstruction (gradient >50 mmHg) is detected at routine echo-Doppler evaluation. Although neo-aortic root dilation and minimal aortic valve insufficiency are common, reoperation for severe neo-aortic valve dysfunction is, to date, very rarely necessary. Whether this will remain the case in the decades to come requires further evaluation. Left ventricular function is maintained in the vast majority of patients. Reoperation may be indicated in some patients for other reasons: mitral valve malformation, tracheo-bronchial compression or pulmonary hypertension.     

Modification of the arterial switch operation for transposition of the great arteries with complex coronary artery patterns

The arterial switch operation has evolved into the treatment of choice for most forms of transposition of the great arteries (TGA). Recently reported operative mortality of the procedure has fallen to the range of 1.1%–6.0%, even for complex forms of TGA. Despite advancement in the technical aspects of the procedure, certain anatomical variations of the coronary arteries, such as a single coronary orifice and/or intramural coronary artery, are still considered surgical risks in many centers. Optimizing the surgical technique for relocating these challenging variations of the coronary anatomy is key to improving the surgical outcomes for the procedure. In this review, the surgical modifications of the arterial switch operation for TGA associated with complex patterns of the coronary arteries are examined. This review was submitted at the invitation of the editorial committee.     

Results of the double switch operation for congenitally corrected transposition of the great arteries.

OBJECTIVE: To determine the outcomes for a program that utilizes the double switch operation as the primary approach for congenitally corrected transposition. METHODS: The records of 46 consecutive patients from a single institution who had undergone a double switch operation from October 1993 to March 2002 were reviewed. The records of 24 patients who were evaluated during the same period and felt not to be candidates for the double switch operation or who are awaiting double switch after pulmonary artery banding were also reviewed. RESULTS: The median age at operation was 28 months (range 2 months to 16.3 years). Associated defects included ventricular septal defect 40, pulmonic stenosis 13 and pulmonary atresia 16. Twenty-six patients underwent an arterial switch operation combined with a Senning procedure while 20 patients underwent combined Rastelli and Senning procedures. Before the double switch, 12 patients had required pulmonary artery banding and 21 patients had systemic to pulmonary artery shunts. The median duration of stay in the intensive care unit was 3.5 days (range 2-60 days) and the median duration of total hospital stay was 8 days (range 5-60 days). There were no hospital deaths; one patient died 5 months after discharge due to an arrhythmogenic cardiac arrest during a median follow-up of 24 months [long-term survival 98% (95% CI 89-100%)]. CONCLUSIONS: The double switch operation may be performed with excellent hospital and long-term survival. The theoretical advantages of this procedure which enables the morphologic left ventricle and mitral valve to support a systemic pressure load must be established by careful follow-up of these patients.     

Arterial switch operation in transposition of great arteries and double-outlet right ventricle. Experience at the Brompton Hospital, London

Between 1981 and 1989 89 patients underwent anatomic correction of transposition of the great arteries with intact ventricular septum (n = 32), transposition with ventricular septum defect (n = 37) and double outlet right ventricle with subpulmonary ventricular septal defect (n = 20). The perioperative mortality was 17% (n = 15). The causes of death are discussed. The most common postoperative complication is right ventricular outflow tract-obstruction (RVOTO), accounting for two late deaths and necessitating reoperations in many patients. Besides RVOTO the mid-term results in arterial switch-operation are encouraging. Especially satisfactory are the absence of any problems with growth of the transferred coronary arteries, the function of the new aortic valve as well as the performance of the left ventricle. Of course, long-term experience is not yet available.     

Fenestrated arterial switch operation: surgical approach to an unusual transposition of the great arteries complex

Transposition of the great arteries with intact ventricular septum and aortopulmonary window is an extremely rare anatomic combination, having been reported just twice previously. Other authors performed a physiologic repair, because the combination was considered unsuitable for an anatomic repair. We describe the case of a 26-day-old baby with such anatomy who was successfully treated with an arterial switch operation. A 4 mm fenestration at atrial level was made for a smoother postoperative course.