Anatomic repair of transposition of great arteries with ventricular septal defect and aortic arch obstruction: One-stage versus two-stage procedure

Abstract

Between September 1, 1982, and March 1, 1992, 40 patients underwent anatomic repair of transposition of the great arteries, ventricular septal defect, and aortic arch obstruction. In group I, 26 patients (65%) underwent repair in a two-stage procedure, phases A and B. Phase A included repair of the aortic arch obstruction with (16 patients) or without (10 patients) pulmonary artery banding through a left thoracotomy (mean age 18.7 +/- 23.4 days). There were three deaths and three reoperations. Phase B included an arterial switch operation with closure of the ventricular septal defect (mean age 95.5 +/- 122 days). There were five early deaths and two late deaths. Eight patients required reoperation. Mean delay between phase A and phase B was 77.5 +/- 109 days. In group I, there were eight early and two late deaths, and 11 patients required reoperation. The mean stay in the intensive care unit was 24.7 +/- 20 days. Mean follow-up of 59.6 +/- 21.4 months was completed in all survivors. All but one were in New York Heart Association class I without medication. Actuarial survival rate and rate of freedom from reoperation at 5 years were 57.5% and 49.9%, respectively. In group II, 14 patients (35%) had a one-stage procedure through midsternotomy: an arterial switch operation with closure of the ventricular septal defect and repair of the aortic arch obstruction (mean age 10.2 +/- 5.5 days). There were two early deaths (14.2%) and one late death after reoperation for overlooked multiple ventricular septal defects. Two patients required reoperation. The mean stay in the intensive care unit was 11.7 +/- 2.5 days. Mean follow-up of 22.4 +/- 16.7 months was achieved in all survivors. They were all in New York Heart Association class I without medication. Actuarial survival rate and rate of freedom from reoperation at 3 years were 78.5% and 81.5%, respectively. The one-stage procedure allowed complete repair in neonates without the need for multiple operations. We believe that it may decrease early mortality rates (14.2% versus 30.7%), reduce the reoperation rate and cumulative stay in the intensive care unit (11.7 days versus 24.7 days, p = Not significant), and significantly decrease the overall rate of morbidity (p < 0.01). However, requirements for surgical intervention with a one-stage or a two-stage procedure must include accurate assessments of intracardiac and aortic arch anatomy.