Abstract
In transposition of the great arteries (TGA), certain coronary patterns have been associated with major adverse events early after the arterial switch operation (ASO). We sought to determine the impact of preoperative echocardiographic (ECHO) diagnosis on the intra and postoperative morbidity. All patients with TGA born between June 2001 and June 2017 and who underwent ASO were reviewed. Data on presumed coronary anatomy (CA) preoperatively were obtained from the preoperative ECHO report. Intraoperative CA was categorized according to Yacoub classification. Major postoperative morbidity included at least one of the following: delayed sternal closure (DSC), prolonged (> 72 h) mechanical ventilation, reintubation, peritoneal dialysis (PD), ECMO, reoperation, and readmission within 30 days after surgery. 240 patients with median age of 5 days (range 1–614) and mean weight at surgery was 3.6 kg (1.8–8.4) were included. Preoperative ECHO assessment of CA was available in 228 patients. Intraoperatively, 181 patients (75%) were found to have type A, 25 patients had type B or C or intramural (B–C–IM; 10%), and 34 patients had type D or E (D–E; 14%). Patients with types B, C, and intramural coronary (B–C–IM) had increased risk for delayed sternum closure (9/25 vs. 20/181 in type A and 8/34 in type D–E; p = 0.04), peritoneal dialysis (4/25 vs. 8/181 and 1/34; p = 0.04), and ECMO (2/25 vs. 1/131 and 1/34; p = 0.02). Within the B–C–IM group, preoperative ECHO raised suspicion of type A in 13 patients (i.e., incorrect diagnosis, ID; 52%), whereas non-A CA was suspected in 12 patients (i.e., correct diagnosis, CD; 48%). With the exception of reoperation, which was seen only in the ID subgroup (4/12 vs. 0/10 in the CD subgroup; p = 0.04), the intraoperative (cardiopulmonary bypass time and cross-clamp time) and postoperative morbidity indices were comparable in both ID and CD subgroups (p > 0.1). Although there is a significant risk for early postoperative morbidity in TGA patients with single, interarterial, and intramural CA, there seems to be relatively limited influence of preoperative ECHO assessment of coronary anatomy on this morbidity burden.
Highlights
Transposition of the great arteries (TGA) is a congenital heart defect that, in terms of both diagnosis and surgical management, has undergone important advances with significant improvement in mortality and morbidity
Within the B–C–IM group, preoperative ECHO raised suspicion of type A in 13 patients, whereas non-A coronary anatomy (CA) was suspected in 12 patients
Remaining demographic variables were evenly distributed between the groups. This retrospective survey conducted on a large cohort of TGA patients with arterial switch operation (ASO) confirms the previously reported association of certain non-A types of coronary anatomy, i.e., single, interarterial, and intramural (IM) CA, with increased early postoperative morbidity
Summary
Transposition of the great arteries (TGA) is a congenital heart defect that, in terms of both diagnosis and surgical management, has undergone important advances with significant improvement in mortality and morbidity. To understand and improve outcome of TGA patients, several studies have investigated risk factors for postoperative mortality and morbidity. Recognized factors for mortality and morbidity include institutional and surgeon’s inexperience, prematurity, lower weight at ASO, presence of ventricular septal defect, and left ventricle outflow obstruction including arch anomaly [2,3,4,5,6,7,8,9]. One additional risk factor involves the surgical translocation of the coronary arteries [1]. Coronary ostium stenosis and even cardiac sudden death have been reported several years after surgery [10,11,12,13,14]
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