Vulnerability of coronary arteries in surgery for transposition of the great arteries

A detailed anatomic study of 82 hearts from patients operated upon for complete or congenitally corrected transposition of the great arteries revealed 12 instances of intraoperative injury to a major coronary artery. Because the coronary arterial anatomy is so variable in transposition of the great arteries, there is a significant risk of injury to them during operation. This is especially so if epicardial adhesions and scarring from previous operations obscure the surface anatomy of the heart. The most common site of injury was adjacent to incisions in the anterior surface of the right-sided ventricle, particularly in congenitally corrected transposition. Without a meticulous examination, these complications of cardiac surgery may be easily overlooked even when the hearts are examined at autopsy.     

Minimally invasive cardiac surgery for transposition of the great arteries in neonates

We evaluated our results of arterial switch operation (Jatene) for complete transposition of the great arteries between May 2003 and October 2005 particularly concerning various operation-related durations. Twenty neonates were studied. The mean age and body weight were 11.6 +/- 2.7 (range 5 to approximately 15) days and 3.0 +/- 0.4 kg, respectively. Duration of anesthesia, operation, extracorporeal circulation (ECC), and aortic cross-clamp were 199.4 +/- 30.1, 162.7 +/- 29.9, 91.6 +/- 8.8 and 59.8 +/- 8.1 minutes, respectively. Time differences between anesthesia and operation, operation and ECC, ECC and aortic cross-clamp were calculated, and their correlations with the duration of anesthesia were investigated. The items, whose coefficient of correlation with anesthetic time was greater than 0.6 were operation time, ECC time, aortic cross-clamp time, operation time minus ECC time, and operation time after ECC come-off. Furthermore, the operation time after ECC come-off was strongly correlated with plasma lactate concentrations and intraoperative bleeding. In conclusion, the time required for hemostasis and closure of the chest should be as short as possible. Therefore secure anastomoses with least hemorrhage possible is important.     

Review: surgery for transposition of the great arteries in the first year of life.

Elective intracardiac repair by the Mustard operation is recommented in patients with transposition of the great arteries and intact ventricular septum in the first year of life (Fig. 1). In patients with associated ventricular septal defect in the first three months of life, early banding followed by early debanding before the first year of life is recommended. When the left ventricular outflow tract obstruction is discrete at valvular or subvalvular level, Mustard operation, closure of the ventricular septal defect and direct relief of out-flow obstruction is acceptable, but in patients with an unfavorable left ventricular outflow tract anatomy, a preliminary shunt followed by a Rastelli operation after the age of four years will probably result in a greater salvage. The utilization of surface induced profound hypothermia and circulatory arrest allows for more precise and rapid surgery and is shown to be a definite advantage in the very young infant.     

Correction of the transposition of the great arteries.

Inversion of the atrial flow in transposition of the great arteries is achieved in the following way: the remaining atrial septum is detached from behind, leaving it as a flap between both AV-valves. The incision is continued into the coronary sinus and the Vena magna cordis to the base of the left atrial appendage along the mitral ring. The resulting flap from the split coronary sinus is sutured to the left atrial wall in front of the left side pulmonary veins, thus forming a septum dorsal to the caval veins, diverting the left pulmonary venous blood to the right side. The atrial septal flap is reattached in front of the caval vein orifices. In 50 cases a small Dacron patch was used to complete the midportion of the new septum. Six patients died and so far we have encountered one superior Vena cava stenosis and one pulmonary vein stenosis. In 16 patients completion of the midportion of the new atrial septum was done with a partially excised flap from the right atrial wall still attached to the Vena cava inferior. This method resulted in 3 operative deaths. In 42 of 58 survivors the ECG has been repeatedly controlled 3 months to 6 years postoperatively. Thirty-six of the 42 patients have sinus rhythm, 4 vary between nodal and sinus-rhythm and 2 have a total AV-dissociation.     

Senning's procedure for transposition of the great arteries

The outlook for children with transposition of the great arteries (TGA) improved dramatically with the advent of the atrial repair. This procedure, first successfully performed by Ake Senning, followed years of unsuccessful attempts at correction by a number of surgeons using a variety of techniques. Senning's procedure expanded on the concept experimentally proposed by Albert of redirecting venous return at the atrial level to achieve physiological correction. The Senning procedure was largely abandoned when Mustard's technique was introduced in 1964, but has enjoyed a resurgence as a number of its potential advantages became more fully appreciated. Today, patients with TGA are increasingly undergoing repair by the arterial switch technique. Not all patients, however, are suitable candidates for this approach, and its success will be measured against the ingenious procedure described by Senning more than a quarter of a century ago.     

Surgical management of transposition of the great arteries.

Sixty-two patients with transposition of the great arteries, ranging in age from one week to thirty-five years, underwent total corrective surgery during a seven year period at Stanford University Hospital. Reported herein are the first pateint to undergo complete correction at out hospital and every subsequent patient until October 1974. Eleven patients died, an overall hospital mortality of 18 per cent. Two of thirty-two patients with transposition of the great arteries and intact ventricular septum died, one of pulmonary hypertension at seven days of age. Nine of thirty patients with transposition of the great arteries and ventricular septal defect with or without pulmonary stenosis died. Cause of death usually was high pulmonary vascular resistance. The Donovan-Rastelli procedure was performed in ten patients, with three deaths, but all patients survived when the inserted right ventricular outflow contained a xenograft aortic valve. Transposition of the great arteries in the first weeks of life must be considered on the individual merits of each case, but the combined medical and surgical approach must be both expedient and thorough if the patient is to survive.     

心房及大动脉双调转术治疗先天性矫正型大动脉转位

目的 总结先天性矫正型大动脉转位心房及大动脉双调转术治疗的初步经验.方法 先天性矫正型大动脉转位行心房及大动脉双调转手术17例.8例行Senning+大动脉调转术,年龄11个月～11岁,中位年龄3.7岁,其中7例合并肺动脉高压,1例合并肺动脉瓣下狭窄,3例曾行肺动脉环缩术-左心室锻炼.9例行Senning+ Rastelli手术,年龄5～24 岁,中位年龄9.0岁,其中5例行室缺扩大术.结果 Senning+大动脉调转手术组主动脉阻断183～282 min,术后呼吸机辅助14～984 h,引流208～1496 ml.术后完全性房室传导阻滞1例,安装永久性心脏起搏器后病愈出院;右侧膈肌麻痹1例,行膈肌折叠术后病愈出院.Senning+ Rastelli手术组主动脉阻断132～380 min,术后呼吸机辅助18～276 h,引流108～1780 ml,术后ECMO辅助循环1例,因低心排综合征死亡1例.结论 对于年龄较大的先天性矫正型大动脉转位病儿,心房及大动脉双调转术近期治疗效果满意.     

The Senning operation for transposition of the great arteries

The original Senning technique of interatrial transposition of venous return was selectively employed for physiological correction in 24 patients with transposition of the great arteries (TGA) ranging in age from 74 days to 26 months (median 7 months). Twenty-three had intact ventricular septum and one had a large ventricular septal defect and diaphragmatic subpulmonary stenosis. There were no hospital or late deaths, and at follow-up examination 1.5 to 12 months postoperatively, each patient was asymptomatic, in normal sinus rhythm, and had no clinical evidence of caval or pulmonary venous obstruction. Nine patients underwent cardiac catheterization and angiocardiographic studies between 1.3 and 9 months postoperatively which demonstrated widely patent venous pathways and effective "left" and "right" atrial contraction. This experience lends support to the continued use of the Senning technique for interatrial transposition of venous return.     

Modified Senning operation for treatment of transposition of the great arteries.

Since February, 1978, 42 infants ranging in age from 15 days to 16 months (mean age 6 months) and weighing between 2.0 and 9.0 kg (mean weight 5.8 kg) underwent a modified Senning I operation. Eleven (26%) underwent operation during the first 3 months of life. Twenty-nine patients had dextro-transposition of the great arteries (d-TGA) and an intact ventricular septum (Group I), and 13 patients had d-TGA and a large ventricular septal defect (VSD) (Group 2). In addition to the Senning I procedure, 13 patients had transatrial closure of their VSD, eight had ligation of a patient ductus arterioses, two had removal of a pulmonary artery band, and four had trans-pulmonary artery resection of short-segment subpulmonary stenosis. Modification of the original Senning operation included (1) patch augmentation (pericardium or Gore-Tex) of the atrial septal flap and (2) pericardial patch enlargement of the pulmonary venous pathway. One patient in Group 1 (3%) and two patients in Group 2 (15%) died after operation. A 2-week-old infant (Group 1) was treated with prostaglandin E1 (PGE) for 2 weeks before operation. The other hospital deaths (Group 2) occurred in a 2-month-old infant with advanced ischemic damage to the right ventricle and a 4-month-old child with multiple VSDs and Grade IV pulmonary vascular disease. No caval gradients were found after modification of the right atrial incision. Two patients died later from pulmonary venous obstruction, one during attempted recatheterization and the other after repair of the pulmonary venous obstruction. One patient had transient complete heart block, and four were discharged in junctional rhythm. Thirty-four patients (87%) were in regular sinus rhythm when released from the hospital. Postoperative catheterizations in eight patients showed no significant gradients in six and severe pulmonary venous obstruction in two (late deaths). More late postoperative results are required, including postoperative catheterization and electrophysiological studies, before the relative merits of the Senning versus the Mustard operation can be assessed.     

The Blalock-Hanlon procedure. Simple transposition of the great arteries.

Between 1959 and 1975 at St. Louis University Medical Center, 71 patients underwent surgery with the Blalock-Hanlon technique. Thirty-nine had simple transposition of the great vessels. The mean age at the time of operation was 3.4 weeks. Sixty-four percent were less than 1 month of age. Eighty-five percent survived the operation. In 11 the Blalock-Hanlon procedure was performed after failure of ballon septostomy. Arterial saturation was increased from a mean of 47% to 73%. There were three late deaths prior to Mustard repair (intra-atrial baffle procedure). Sixteeen patients underwent Mustard repair at a mean age of 4 years and a mean follow-up of 2 1/2 years. There were three deaths after surgery and three late deaths after the Mustard procedure. The Blalock-Hanlon procedure achieves prolonged palliation, avoiding an emergency Mustard procedure in infancy with its risk of late vena caval obstruction.