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 a complex transposition of the great arteries in dextrocardia.

A very rare case of a newborn with dextrocardia, complete transposition of the great arteries {S,D,D}, ventricular septal defect, aortic arch hypoplasia, juxtaposition of the morphologically right atrial appendage and superoinferior ventricles is herein presented. He successfully underwent arterial switch operation, ventricular septal defect closure and aortic arch reconstruction with end to end extended direct anastomosis.     

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.     

The atrial baffle operation for transposition of the great arteries. A review of 591 reported cases

A survey of the literature on 591 atrial baffle operations for transposition of the great arteries was undertaken, and it was found that the underlying anatomical type strongly influences the results of operation. The overall mortality when an atrial septal defect was present alone was less than 20%. In the presence of a ventricular septal defect and pulmonary stenosis, the prognosis was less favorable. The most immediate postoperative complication was dysrhythmia, followed by ventilation problems necessitating tracheostomy. Long-term complications occurred in 30% of the patients. These included venous obstruction from the baffle itself, dysrhythmia, and tricuspid insufficiency. The 1-month mortality rate with the atrial baffle operation was 23%; at 5 years it was 38%. The long-term results suggest that a new approach should be considered in the surgical management of transposition. The goal remains direct anatomical repair.     

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 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 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.     

Long-term outlook after atrial correction of transposition of great arteries

Late results were reviewed in 220 survivors after atrial correction of transposition of the great arteries who were operated between 1964 and 1985. Senning's procedure and its various modifications have been used; all patients who survived 30 days after correction were included in this analysis. Average follow-up for the whole group was 10.3 years; 113 patients were observed for 10 years, 26 patients for 15 years, and 8 patients for 20 years. The actuarial survival rate for the whole group was 89% at 10 years, 87% at 15 years, 82% at 20 years. It was higher in simple than in complex transposition (92% versus 84% at 10 years). Sudden deaths (8 patients) and late heart failure (6 patients) were the principal causes of death, predominantly in the complex transposition group (10/13 deaths). Late survival was more common in the latter part of the study, with 95% of patients operated on after 1978 surviving 9 years as opposed to 84% of patients operated on earlier. Late reoperation was necessary in 18 patients (8%), with 12 reoperations occurring within 2 years after correction. Cumulative reoperation rate reached 11.7% after 10 years. Reoperations were more common in complex than in simple transposition (14% versus 6%, p less than 0.05). Late arrhythmias can occur after atrial correction, and the cumulative incidence of pacemaker implantations was 8% at 10 years. Most of the survivors are functionally free of symptoms (83% of the simple and 75% of the complex transposition group). Significant tricuspid valve incompetence was encountered in only three patients, with two valve reconstructions being possible. In summary, long-term outlook for survivors of atrial correction for transposition of the great arteries remains encouraging, although complex transposition does seem to engender more late problems. Atrial correction is still warranted in simple transposition, but close cardiological surveillance is necessary.     

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.     

Long-term coronary artery outcome after arterial switch operation for transposition of the great arteries

Objective: To analyse the long-term patency of coronary arteries after neonatal arterial switch operation (ASO). Methods: A retrospective study of the operative reports, follow-up and postoperative catheterisation data of 119 patients, who underwent the great arteries (TGA) repair since 1991, has been carried out. Patient population: Among the 133 survivors of the 137 ASOs performed between 1991 and 2007, 119 patients have been studied by routine control cardiac catheterisation and form the study population. Median time between repair and the coronary angiography was 2.9 ± 1.9 years. A comparison between the eight patients (6.7% out of the entire study population), known to have postoperative coronary obstructions (group I) and the rest of the cohort with angiographic normal coronary vessels (group II) was performed by univariate analysis of variance and logistic regression models. One patient had surgical plasty of the left coronary main stem with subsequent percutaneous angioplasty, three patients had primary coronary stent implantation and four patients had no further intervention at all. In group I, all but one patient denied symptoms of chest pain and echocardiography failed to show any difference between the two groups in terms of left ventricular systolic function (ejection fraction group I 61 ± 2% vs 62 ± 6% of group II, p = 1.0). Results: The association of coronary obstruction with complex native coronary anatomy (Yacoub type B to E) was evident at both univariate (62% of group I vs 22% of group II, p = 0.04) and logistic regression (p = 0.007, odds ratio (OR) 8.1) models. The type of coronary reimplantation (i.e., coronary buttons on punch vs trap-door techniques) was similar between the two groups (punch reimplantation in 25% of patients of group I vs 31% of group II, p = 0.1) as was the relative position of the great vessels (aorta anterior in 100% of patients of group I vs 96% of group II; univariate, p = 0.1). Conclusions: The late outcome in terms of survival and functional status after ASO is excellent. Nevertheless, the risk of a clinically silent late coronary artery obstruction of the reimplanted coronary arteries warrants a prolonged follow-up protocol involving invasive angiographic assessment.     

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.     

Long-term results after atrial correction of complete transposition of the great arteries

This study presents the late results for the first 104 consecutive patients surviving and atrial repair for transposition of the great arteries (TGA) between January 1971 and December 1978 (group 1). Mean follow-up was 12 years (range, 0.1 to 17.7 years). The actuarial survival rate at 18 years was 84.2% (70% confidence limits, 79% to 88%) for simple TGA and 93.7% (70% confidence limits, 84% to 97%) for complex TGA. Nine of the 11 deaths were sudden. Two (2.6%) of the 78 late survivors operated on for simple TGA are in New York Heart Association functional class III or IV versus 4 (26.7%) of the 15 survivors with complex TGA; the other patients are doing very well. To better assess long-term results, we report the findings for randomly obtained electrocardiograms, Holter monitor recordings, radionuclide angiographic studies, and cardiac catheterizations performed in 1987 in a larger group of 159 long-term survivors of atrial repair operated on at Ospedale Riuniti di Bergamo from January 1971 to December 1984 (group 2), which includes all of group 1. The findings confirm that the arterial switch repair is the procedure of choice for complex TGA and that there is a major incidence (approximately 10%) of systemic right ventricular dysfunction and rhythm disturbances after the atrial repair. On the other hand, our late survival rate at 18 years of 84% for simple TGA with 97.5% of the patients in functional class I is a result that should be kept in mind, especially in institutions where the arterial switch is a relatively new approach and presumably is a higher risk to cause early death.     

Coronary arterial size late after the atrial inversion procedure for transposition of the great arteries: implications for the arterial switch operation

BACKGROUND: Coronary flow reserve in the hypertrophied ventricle is reduced. One contributing factor may be the size of the proximal coronary arteries. In patients who undergo atrial inversion procedures for transposition of the great arteries, the left coronary artery supplies the pulmonary ventricle and may be smaller than the right coronary artery. We hypothesized that the dimensions of the coronary arteries may correlate with symptomatic status after atrial inversion and may be an important factor when these patients are considered for the arterial switch operation. METHODS: The proximal left and right coronary arteries were measured in 9 patients with transposition and failure of the systemic right ventricle after atrial inversion, 10 asymptomatic patients after atrial inversion, and 10 patients with normal hearts. The diameters of the coronary arteries were indexed to body surface area and compared. RESULTS: The absolute and indexed diameters of the right coronary artery were greater in symptomatic patients than in asymptomatic patients (indexed: 3.1 +/- 0.6 vs 2.4 +/- 0.4 mm/m(2), P <.001) or control patients (2.0 +/- 0.3, P <.001), and the absolute diameter of the left coronary artery was smaller (2.9 +/- 0. 7 vs 3.6 +/- 0.5 mm, P =.003 [asymptomatic], 3.6 +/- 0.5 mm, P =.01 [control]). In symptomatic patients, the absolute and indexed diameters of the left coronary artery were smaller than those of the right (indexed: 2.1 +/- 0.6 vs 3.1 +/- 0.6 mm/m(2), P <.001). By contrast, there was no difference in asymptomatic patients (2.2 +/- 0.5 vs 2.4 +/- 0.4 mm/m(2), P =.44), and the left coronary artery was larger in normal control patients (2.2 +/- 0.4 vs 2.0 +/- 0.3 mm/m(2), P <.001). CONCLUSIONS: Differences in the sizes of the proximal coronary arteries may be related to symptomatic status in patients with transposition of the great arteries who have undergone an atrial inversion procedure, as well as to the efficacy of ventricular retraining. When pulmonary artery banding and subsequent arterial switch are considered for patients with a Mustard or Senning procedure and a failing systemic right ventricle, the size of the proximal coronary arteries may be an important factor and should be evaluated with preoperative imaging studies.     

Clinical experience with atrial inversion using a Gore-Tex baffle in 52 cases of transposition of the great arteries

Atrial inversion was achieved by a modified Mustard operation in 334 patients with various types of transposition of the great arteries (TGA) between January, 1974, and January, 1983, in Hannover, West Germany. The overall mortality was 4.2% (N = 14). Between March, 1978, and January, 1983, 197 of the patients were operated on using a new design of a Gore-Tex prosthetic baffle. In February, 1982, a new step was integrated into our modification of the Mustard operation. It consisted of creating a pericardial flap that serves to enlarge the pulmonary venous atrium. This article describes the modified Mustard operations with Gore-Tex baffle used in 52 children with TGA between October, 1981, and January, 1983. Special attention is focused on operative techniques and on postoperative dysrhythmias and hemodynamics.