Invited commentary

Abstract

From a broad perspective the arterial switch operation is among the most intellectually satisfying procedures commonly performed by congenital heart surgeons because it seems truly curative. Incorrectly connected structures are transformed into correctly connected structures by means of an elegant, conceptually simple procedure. On closer examination, as with most apparently simple procedures, the importance of the small details of the conduct of the operation becomes apparent, particularly in regard to the coronary artery transfer, late neoaortic valve function, and the degree of patency of the main and branch pulmonary arteries. In the evolution of the procedure, numerous technical modifications to address each of these aspects have been introduced with consequent ever-improving early and late results. One of the areas of greatest concern continues to be stenosis in the reconstructed neopulmonary artery, which has been observed in virtually every large series of arterial switch operations, with an incidence as high as 30%. Since the introduction of the arterial switch operation by Jatene and colleagues [1Jatene A.D. Fontes V.F. Paulista P.P. et al.Anatomic correction of transposition of the great vessels.J Thorac Cardiovasc Surg. 1976; 72: 364-370PubMed Google Scholar], and the addition of the Lecompte maneuver to place the pulmonary confluence anterior to the reconstructed aorta [2Lecompte Y. Zannini L. Hazan E. et al.Anatomic correction of transposition of the great arteries.J Thorac Cardiovasc Surg. 1981; 82: 629-631PubMed Google Scholar], a variety of techniques have been applied in an attempt to reduce the occurrence of supravalvar pulmonary stenosis, each based on a specific understanding of the cause of the stenosis. Commonly implicated factors in the development of stenosis include excessive tension on the suture line in the pulmonary artery and involution or shrinkage of the patches used to repair the defect left in the anterior great vessel trunk by removal of the coronary artery buttons. The study in the present issue by Ullman and colleagues [3Ullmann M.V. Gorenflo M. Bolenz C. et al.Late results after extended pulmonary artery reconstruction in the arterial switch operation.Ann Thorac Surg. 2006; 81: 2259-2266Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar] describes a novel approach to prevention of supravalvar pulmonary stenosis, addressing the dual issues of excessive suture line tension and patch shrinkage, with very impressive mid-term and late results [3Ullmann M.V. Gorenflo M. Bolenz C. et al.Late results after extended pulmonary artery reconstruction in the arterial switch operation.Ann Thorac Surg. 2006; 81: 2259-2266Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. Their technique, which is a literal extension of the two-patch technique introduced by Quaegebeur and colleagues [4Quaegebeur J.M. Rohmer J. Ottenkamp J. et al.The arterial switch operation. An eight-year experience.J Thorac Cardiovasc Surg. 1986; 92: 361-384PubMed Google Scholar], uses glutaraldehyde tanning to prevent shrinkage of the autologous pericardial patches used for pulmonary artery reconstruction. The novel feature of the present report is the use of an intentionally oversized triangular patch to repair the left neopulmonary sinus and simultaneously enlarge the posterior wall of the pulmonary bifurcation to minimize anastomotic traction. The technique is inventive, well described, and well illustrated, and the follow-up in the article is thorough. The fact that none of the patients described have yet required reintervention for supravalvar pulmonary stenosis is a testimony to the effectiveness of the technique, but as an endpoint must be said to be in part reflective of physician behavior, in addition to actual patient biology. Furthermore, although it is likely that most pulmonary stenosis after an arterial switch operation will occur early, ongoing assessment of this patient cohort will be required. The authors are to be congratulated for their success, but given the history of the arterial switch operation to date, it unlikely that this report represents the last word on the subject.