Improvement in long-term survival after hospital discharge but not in freedom from reoperation after the change from atrial to arterial switch for transposition of the great arteries

Abstract

To compare survival, freedom from reoperation, and functional status between atrial switch and arterial switch operations for transposition of the great arteries. Data from 88, 329, and 512 patients who underwent Mustard, Senning, and arterial switch operations between 1974 and 2006 were analyzed. In-hospital mortalities were 8.0% for Mustard, 4.6% for Senning, and 6.4% for arterial switch. Presence of ventricular septal defect (hazard ratio 3.3, P < .001) was the only risk factor for in-hospital mortality in multivariate analysis. Follow-up for Mustard was 22.6 +/- 8.1 years, for Senning was 18.2 +/- 5.7 years, and for arterial switch was 9.5 +/- 5.7 years. Highest survival at 20 years was after arterial switch (96.6% +/- 1.3%), followed by Senning (92.6% +/- 1.5%) and Mustard (82.4% +/- 4.3%). Transposition with ventricular septal defect (hazard ratio 3.1, P < .001), transposition with ventricular septal defect and left ventricular outflow tract obstruction (hazard ratio 3.0, P = .029), and Mustard operation (hazard ratio 2.1, P = .011) emerged as risk factors for late death, with arterial switch a protective factor (hazard ratio 0.3, P = .010). Highest freedom from reoperation at 20 years was after Senning (88.7% +/- 1.9%), followed by arterial switch (75.0% +/- 6.4%) and Mustard (70.6% +/- 5.4%). Presence of complex transposition (hazard ratio 2.1, P < .001), previous palliative operation (hazard ratio 1.8, P = .016), surgery between 1985 and 1995 (hazard ratio 2.6, P = .002), surgery after 1995 (hazard ratio 3.5, P < .001), and Mustard operation (hazard ratio 3.3, P < .001) emerged as risk factors for reoperation. Change from atrial to arterial switch led to improved long-term survival after hospital discharge but not to lower incidence of reoperation. Survival and freedom from reoperation are determined by morphology.