Arterial switch operation: factors impacting survival in the current era

Background. The arterial switch procedure has become the preferred procedure for the transposition of the great arteries (TGA) and Taussig-Bing anomaly. This analysis is intended to identify potential factors affecting survival in the current era.

Methods. From 1986 to 1999, 201 consecutive patients underwent an arterial switch operation for TGA or Taussig-Bing anomaly. Multivariate analysis of perioperative variables was performed for operative morbidity/mortality. Patients were separated into two groups. Phase 1 (n = 29) included patients before mid-1989 who underwent an open coronary reimplantation technique. Phase 2 (n = 172) included the patients undergoing a technique of reimplanting coronary buttons after neoaortic reconstruction.

Results. The patient population included TGA with intact ventricular septum (58.7%, 118 of 201), with ventricular septal defect (31.3%, 61 of 201), and Taussig-Bing anomaly (10.0%, 22 of 201). Overall, early mortality was 9.5% (19 of 201) and there were five late deaths (2.7%). One-month, 1-year, and 5-year actuarial survival rates were 90.4%, 87.9%, and 87.9%, respectively. Reoperation rate for late pulmonary stenosis was 2.7% (5 of 182). The freedom from reoperation at 3 and 5 years was 97.5% and 93.3%, respectively. In the analysis by time period, the operative mortality declined from 27.6% (8 of 29) to 6.4% (11 of 172) (p = 0.002). Risk factors for operative death were coronary artery patterns (usual vs retropulmonary left coronary artery, p = 0.009) in phase 1 and preoperative instability in phase 2 (p = 0.002).

Conclusions. The arterial switch operation for TGA and Taussig-Bing anomaly has early low and late mortality and reoperation rates. Technical modifications in coronary reimplantation have minimized coronary artery pattern-related risks.     

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.     

Results of arterial switch operation for primary total correction of the Taussig-Bing anomaly

BACKGROUND: This study evaluates the results of the arterial switch operation for early total repair of double-outlet right ventricle with subpulmonary ventricular septal defect (the Taussig-Bing heart). METHODS: From 1986 through April 2003, 27 patients with Taussig-Bing anomaly underwent arterial switch operation. Twenty patients were neonates (n = 11) or infants younger than 3 months (n = 9). Obstruction of aortic arch (n = 19) or subaortic right ventricular outflow tract obstruction (n = 20) and unusual coronary artery patterns (n = 19) were common. Total correction as a single procedure was performed in 21 patients. Events are depicted by Kaplan-Meier curves. RESULTS: There was 1 patient hospital death at 2 months after repair. One patient died late that was not cardiac related. Survival was 92% +/- 6% at 8 months and remained constant thereafter. Four patients underwent reoperation (1 for residual aortic arch obstruction and 3 for subvalvular and valvular pulmonary stenosis). Freedom from reoperation decreased to stabilize at 83% +/- 8% after 2 years. The risk to have right ventricular outflow tract obstruction develop was 33% +/- 10% at 1 year, increasing slowly and leveling out at 57% +/- 12% at year 5 and thereafter. Statistical analysis revealed no significant risk factor for death or need for reoperation. CONCLUSIONS: The Taussig-Bing anomaly should be corrected in the neonatal period or in early infancy by arterial switch operation, closure of the ventricular septal defect, and simultaneous correction of associated cardiovascular anomalies as a one-stage procedure. Right ventricular outflow tract obstruction often complicates the postoperative course and is the main cause for reintervention.     

Novel use of reverse double switch operation in failed left ventricular recruitment pathway

In spite of great advances in staged left ventricle recruitment strategy, some patients do not achieve biventricular circulation nor are candidates for reversal to single-ventricle palliation. We present a case of a successful reverse double switch operation in a patient with failure of left ventricle recruitment and pulmonary hypertension. This strategy provided a one-and-a-half repair with a sub-pulmonary hypoplastic left ventricle that improved the patient’s clinical status, becoming a novel alternative in this particular subset of patients.     

Management of the ventricular septal defect during double switch operation for atrioventricular discordant connections

Management of the ventricular septal defect at the time of the double switch operation can be challenging and deserves careful attention to the anatomic details of ventricular septal defect location, alignment with the appropriate subtended ventricles and their respective atrioventricular valves, and the disposition of the specialized conduction tissue. These anatomic details can differ considerably from hearts with concordant atrioventricular alignments, and further variations of right-left geometry and septal alignment can be exhibited. A case is described that underscores some of the particular challenges associated with management of the ventricular septal defect during double switch operation for hearts with discordant atrioventricular connections and either transposition of the great arteries or double outlet right ventricle.     

Extension of coronary artery with double flap technique in a complicated arterial switch operation

The increased distance between the coronary ostium and the reimplantation site poses technical challenges in older patients with transposition of the great arteries (TGA) and complex coronary artery anomalies. In this report, we describe a technique for coronary artery reimplantation using a pedicle flap on the pulmonary artery (PA) to create a tunnel resulting in an extension of the coronary button.     

Neo-coarctation after the arterial switch operation

Neo-coarctation following arterial switch operation (ASO) for transposition of the great arteries (TGA) is a complication that is not regularly described, but may occur. We describe five patients who developed a neo-coarctation after operation. They were diagnosed with TGA, either with or without ventricular septal defect without signs or symptoms of a coarctation. Except for one patient, all patients were reoperated for a neo-coarctation within one year after the ASO. Several explanations are discussed as a possible cause for this phenomenon.     

Results of arterial switch operation for transposition of great arteries with regard to coronary pattern

One of the factors determing the postoperative results of arterial switch operation (ASO) for complete transposition of great arteries (TGA) is coronary event (CE). We analyzed the risk factors of CE after ASO in patients whose coronary patterns excluding Shaher type 1. The subjects were 44 patients operated from 1994 to 2007. As for the coronary reconstructive technique, procedures by Mee or Aubert were conducted on patients with Shaher 5A intramural type. The conventional technique was conducted on other patients, with or without trapdoor technique. In all patients, the pulmonary artery was reconstructed mainly with autopericardium using Lecompt maneuver. The mean observation period was 4.0 +/- 3.1 years, and the number of patients showing CE was 14 (32%) at 1.6 years after surgery on the average. The risk factors of CE and the operative procedures were discussed.     

Double Switch术治疗先天性矫正性大动脉转位二例

目的 介绍解剖矫治先天性矫正性大动脉转位的手术特点。方法 2例矫正性大动脉转位患者,1例9个月,合并室间隔缺损、肺动脉高压,行Senning加动脉调转术;1例23岁,合并室间隔缺损、肺动脉狭窄、三尖瓣关闭不全,行Rastelli加Senning术。结果 2例患者全部成活,其中1例术前出现Ⅲ度房室传导阻滞,安装永久起搏器,术后超声检查心室功能正常,心内隧道和心外管道通畅。无三尖瓣反流。结论 Double Switch手术是一种理想的治疗先天性矫正性大动脉转位的方法。     

Long-term result of arterial switch operation for corrected transposition of the great arteries or double inlet left ventricle

The purpose of this study is to analyze the operative maneuver and long term outcome of the arterial switch operation (ASO) for congenitally corrected transposition of the great arteries (c-TGA) or double inlet left ventricle (DILV). Since October 1977, 221 patients had undergone ASO in National Cardiovascular Center, Japan. Of these, 8 patients underwent ASO as a part of double switch operation (DSO) for c-TGA, and 1 patient underwent ASO and ventricular septation for the DILV with a rudimentary right ventricle simultaneously. We retrospectively reviewed these 9 patients. Six patients had a past history of the pulmonary artery banding. Age at the time of ASO ranged from 6 months to 5 years (median 3 year). As a reconstruction of the pulmonary artery at the time of ASO, Lecompte maneuver was performed in 7 patients, and original Jatene procedure was performed in 2. Coronary transfer was done as usual in all patients. There was no early death, and 1 patient died 1 year after the operation due to chronic heart failure. Late complication related to the ASO was pulmonary artery stenosis (1 patient after DSO) and aortic regurgitation (1 patient after ventricular septation).     

Results of the Kirschner operation

Between 1964 and 1979, a total of 1,536 patients with carcinoma of the thoracic esophagus were treated at this center. Of these, 142 patients with unresectable tumor underwent the Kirschner operation for palliation. In this operation, esophageal obstruction is bypassed by subcutaneous or retrosternal gastric esophagoplasty, and the thoracic esophagus defunctionalized by a long Roux-en-Y jejunal loop to the abdominal esophagus. Dysphagia is thus relieved and aspiration of esophageal and gastric contents into the respiratory tract avoided. Any patient who was not discharged from the hospital for any reason and eventually died in the hospital is counted as a mortality. The hospital mortality for these 142 patients was 41.5% (59 patients). In recent years, there has been a reduction in mortality rate. The most common cause of death was progressive bronchopneumonia (72.9%). Leakage of anastomosis occurred in 67 patients (47.2%), but most healed on conservative treatment. The ability to eat normally was restored in 69% of survivors, and another 28% were able to tolerate a soft diet. Although temporary postoperative aspiration was occasionally encountered when the patient started oral feeding, once swallowing was established, tracheobronchial aspiration did not occur. The mean survival of the discharged patients was 5.0 months. Malignant cachexia from growth of the primary tumor accounted for 61.4% of late deaths; metastatic disease, 10.8%; and cardiopulmonary insufficiency, the remainder. One patient is alive more than 5 years after operation, and presumably was cured by postoperative radiotherapy.Although the mortality rate of the Kirschner operation is substantial, other forms of treatment also have significant mortality rates but with less palliative potential. Therefore, we would recommend this operation for the palliation of unresectable carcinoma of the esophagus.

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Résumé Nous avons traité, entre 1974 et 1979, 1536 malades atteints de cancer de l'oesophage thoracique. Une opération palliative de KIRSCHNER a été réalisée pour 142 tumeurs non résécables. Dans cette opération, l'obstacle oesophagien est court-circuité par une gastroplastie sous-cutanée ou rétro-sternale, et une longue anse jéjunale en Roux-Y est anastomosée à l'oesophage abdominal. L'opération pallie la dysphagie et évite l'aspiration dans les voies respiratoires du contenu oesophagien et gastrique.Pour les 142 malades, la mortalité hospitalière (tous les malades morts pendant leur séjour à l'hÔpital, quelle qu'en soit la cause) a été de 41.5% (59 cas). Elle a été réduite au cours des dernières années. La cause de décès la plus fréquente a été la bronchopneumonie (72.9%), Un lachage de la suture est survenu chez 67 malades (47.2%) mais a, dans la majorité des cas, guéri par traitement conservateur. Parmi les survivants, 69% peuvent manger normalement et 28% de plus peuvent prendre un régime semi-liquide. Après l'opération, on observe parfois une aspiration trachéo-bronchique au moment où l'alimentation est reprise; mais, une fois le méchanisme de déglutition rétabli, cette complication ne se reproduit plus.La survie moyenne pour les malades sortis de l'hÔpital est de 5.0 mois. Les décès tardifs sont dus, dans 61.4% des cas à une cachexie maligne par croissance de la tumeur primitive, dans 10.8% à des métastases, et dans le reste à une insuffisance cardio-respiratoire. Un malade est en vie plus de 5 ans après l'opération, probablement guéri par la radiothérapie postopératoire.La mortalité de l'opération de KIRSCHNER n'est pas négligeable. Mais les autres thérapeutiques possibles ont également une mortalité lourde et leur capacité de palliation est beaucoup moins bonne. Nous recommandons donc cette opération palliative chez les malades atteints de cancer non résécable de l'oesophage.

     

Selective timing for the arterial switch operation

BACKGROUND: To determine outcomes for the arterial switch operation individualized according to the underlying anatomy and clinical status. METHODS: A retrospective review of a consecutive series of infants less than 90 days of age who underwent the arterial switch operation at a single institution. RESULTS: From July 1993-April 2001, 117 infants underwent an arterial switch operation before 90 days of age. Seventy-five patients (64%) had transposition of the great arteries with intact ventricular septum with the aim of operation before 14 days of age; however, 8 of these patients had delayed presentation (range 15-46 days). Thirty-five patients (30%) had transposition with a ventricular septal defect (30 patients) or double outlet right ventricle (5 patients) and normal arch anatomy and were repaired within the first 90 days of life depending on the severity of heart failure at a median of 12 days of age (range 3-83 days). Seven patients (6%) had associated aortic coarctation (5 patients) or interrupted aortic arch (2 patients). One patient died during hospitalization (0.85% hospital mortality) and one patient died from noncardiac causes during a median follow-up of 35 months (1.7% total mortality). Four patients required intervention during follow-up (3.4%) for new aortic coarctation (2 patients), supravalvar pulmonic stenosis (1 patient), or right hemi-diaphragm paralysis (1 patient). CONCLUSIONS: Individualized timing for the arterial switch operation within the first ninety days of life produces excellent survival rates for all types of transposition physiology with the expectation of a satisfactory course during follow-up.     

动脉转位术的临床应用

目的 总结动脉转位术(arterial switch operation，ASO)治疗完全型大动脉转位(transposition of the great arteries，TGA)和右心室双出口伴肺动脉瓣下室间隔缺损(VSD)的临床经验。方法 采用ASO治疗小儿先天性心脏病32例，其中TGA22例，伴室间隔完整型(intact ventricular septum，IVS)9例，伴VSDl3例；右心室双出口伴肺动脉瓣下VSD(Taussig—Bing)10例。结果TGA／IVS9例中死亡1例，TGA／VSD13例中死亡4例，Taussig-Bing10例死亡3例，总手术死亡率25％(8／32)。术后随访3个月～2年，所有患者紫绀消失，活动能力明显增强。1例Taussig—Bing术前二尖瓣轻-中度反流，术后仍为中度反流；2例TGA主动脉和肺动脉瓣上狭窄，压差40mmHg(1kPa=7．5mmHg)，1例肺动脉瓣下狭窄和残余VSD，3个月后再次手术治愈。结论 ASO已广泛应用于TGA的纠治，手术效果满意；应用于右心室双出口肺动脉瓣下VSD的早期纠治，不但可防止发生肺血管阻塞性病变，而且避免了心内修补左心室流出道梗阻的远期并发症。