Switch back: Using the pulmonary autograft to replace the aortic valve after arterial switch operation

Abstract

Aortic valve insufficiency has been described to occur after the arterial switch operation. Valve insufficiency is mild in most cases. In some patients valve repair or root reconstruction may solve the problem, but in others the valve will have to be replaced. Inasmuch as the number of patients surviving the arterial switch operation is growing, valve insufficiency may be seen more often. In infants the ideal way to replace the aortic valve is by using a pulmonary autograft. Our experience with aortic valve replacement using a pulmonary autograft (former aortic valve) in one infant with a history of arterial switch operation is described. Clinical summary. A little girl, 3 years 4 months old, was referred to us from another institution. At the age of 2 days an arterial switch operation was performed for simple transposition of the great arteries. The coronary anatomy was normal (1LCx-2R, Leiden classification). 1 The aorta was anterior to the pulmonary artery. Both semilunar valves were tricuspid and normal. The coronary arteries were excised together with U-shaped aortic wall buttons and implanted in the pulmonary artery base by means of the trapdoor technique. The neopulmonary root was reconstructed with a pantaloon-shaped patch of autologous pericardium. A Lecompte maneuver was part of the procedure. The postoperative course was complicated by ischemia, frequent ventricular extrasystoles, and periods of ventricular fibrillation. Left hemidiaphragmatic paresis necessitated later diaphragmatic plication. After an extended period of intensive care, she gradually recovered and finally was discharged from the hospital. Progressive dilatation of the aortic root with valvular insufficiency was observed during follow-up. Insufficiency was considered to be significant (2/4) when she was 1 year old. The left ventricle was dilated. Her condition deteriorated gradually, leading to fatigue on slight exertion.