Palliative arterial switch and pulmonary banding for complex intra cardiac repair in transposition of the great arteries

Abstract

Transposition of the great arteries (TGA) associated with ventricular septal defect (VSD) could present an intracardiac anatomy making the neonatal repair very challenging: multiple/apical VSD, straddling, tortuous intraventricular tunnel repair. To delay the repair, the isolated pulmonary artery banding (PAB) has the disadvantage to endanger the future aortic valve and to create a double obstacle in the frequent association with aortic annulus and arch hypoplasia. We propose a 2-step strategy with an initial palliative arterial switch operation (ASO) associated with PAB (± aortic arch repair) and, later, an intracardiac repair with debanding. The Aim of this retrospective study is to compare this strategy to a classic isolated PAB. Among the 715 neonatal TGA admitted in our institution between 2007 and 2018, 10 complex TGA benefited either from a palliative ASO with PAB (group A, n = 5) or a PAB (group B, n = 5). At palliation, the duration of inotropic support and the length of stay in intensive care unit were significantly shorter in group A (respectively 4.75 ± 1.7 and 5.5 [4.25–6.75] days versus 13 ± 6.9 and 16 [10.5–30] days in group B; P = 0,029 and P = 0,008). At complete repair, age and weight were significantly higher in group A ( P = 0,018) and the aortic cross-clamping and bypass times were shorter ( P = 0,018). No patient required a delayed sternal closure in group A. Mean length of stay in intensive care unit and hospital duration were respectively of 2 ± 1 days and 5.6 ± 1.53 days in group A versus 21.4 ± 16.9 days and 24.5 ± 19.9 days in the group B ( P = 0.018 and P = 0.029), showing reduced morbidity. Differing the neonatal repair for TGA is exceptional. When we should consider it due to particular intracardiac anatomy, it seems legitimate to practice a palliative ASO rather than the classic isolated PAB.