Arterial Switch Operation For The Great Arteries Research Articles

Long-term impact of coronary artery transfer techniques during the arterial switch operation on neo-aortic root dilation

BackgroundAortic dilation (AD) remains one of the most common complications needing re-operation after ASO (arterial switch operation) in simple transposition of the great arteries (TGA). ObjectivesWe sought to clarify which coronary artery transfer techniques help to minimize postoperative neo-aortic root dilation after ASO for TGA. Methods117 patients were identified in the German National Register for Congenital Heart Defects presenting transposition of the great arteries with intact ventricular septum (TGA-IVS) with minimum 5-year follow-up who underwent ASO between 1986 and 2015 at 16 centers. Our study population was divided into two groups depending on the sinus tissue gain during coronary re-implantation. Group one (n = 72) included the tissue-gaining techniques slit, trap-door, J-/V-/U-incision, and pericardial augmentation. Group two (n = 45) included ‘punch’ as the no-tissue gaining technique. Transthoracic echocardiography data were analyzed retrospectively for development of neoaortic dilation defined by Z-score ≥ 2.0. As secondary endpoint was analyzed, the need for reintervention due to aortic pathology. ResultsMedian follow-up was 11 (5–29) years; cumulative follow-up was 853 patient-years for group one and 19 (5–34) years; cumulative follow-up was 853 patient-years for group two, comprising 1706 patient-years, p < 0.0001. We observed statistically significant higher Z-scores at the aortic valve annulus level in group one (p = 0.03). There was no statistically significant difference between both groups regarding re-operation. ConclusionNeo-aortic roots of patients who underwent sinus gain tissue coronary artery transfer techniques show higher Z-scores than the punch technique in long-term postoperative follow-up. Lifelong surveillance of patients after ASO seems necessary.

Comparison of Four-Dimensional Flow MRI, Two-Dimensional Phase-Contrast MRI and Echocardiography in Transposition of the Great Arteries.

Pulmonary artery (PA) stenosis is a common complication after the arterial switch operation (ASO) for transposition of the great arteries (TGA). Four-dimensional flow (4D flow) CMR provides the ability to quantify flow within an entire volume instead of a single plane. The aim of this study was to compare PA maximum velocities and stroke volumes between 4Dflow CMR, two-dimensional phase-contrast (2D PCMR) and echocardiography. A prospective study including TGA patients after ASO was performed between December 2018 and October 2020. All patients underwent echocardiography and CMR, including 2D PCMR and 4D flow CMR. Maximum velocities and stroke volumes were measured in the main, right, and left PA(MPA, LPA, and RPA, respectively). A total of 39 patients aged 20 ± 8years were included. Maximum velocities in the MPA, LPA, and RPA measured by 4D flow CMR were significantly higher compared to 2D PCMR (p < 0.001 for all). PA assessment by echocardiography was not possible in the majority of patients. 4D flow CMR maximum velocity measurements were consistently higher than those by 2D PCMR with a mean difference of 65cm/s for the MPA, and 77cm/s for both the RPA and LPA. Stroke volumes showed good agreement between 4D flow CMR and 2D PCMR. Maximum velocities in the PAs after ASO for TGA are consistently lower by 2D PCMR, while echocardiography only allows for PA assessment in a minority of cases. Stroke volumes showed good agreement between 4D flow CMR and 2D PCMR.

Abstract 14902: The Impact of Bicuspid Pulmonary Valve in Aortic Position After Arterial Switch for Transposition of the Great Arteries onNeoaortic Root and Neoaortic Valve Function; Propensity Score Matched Analysis

Objective: Neoaortic valve regurgitation which might be related to root dilatation is one of the major concerns following arterial switch operation (ASO) for transposition of the great arteries (TGA). This study investigated the effect of bicuspid neoaortic valve on neoaortic root morphology, function, and the long-term clinical outcomes after ASO for TGA using propensity score matching (PSM). Methods: From 1997 to 2018, 442 patients underwent ASO for TGA. Patients who underwent staged repair (n=15), were repaired at extremely old age (&gt; 1 year, n=9), and died before discharge (n=46), and were lack of echocardiographic data at discharge (n=20) were excluded. Among a total of 352 eligible patients, 18 patients (5.1%) had a BPV. After PSM (1:4), 15 patients with BPV and 60 corresponding patients with tricuspid pulmonary valve were enrolled for analysis. Results: Baseline characteristics in both groups were similar. The median duration of follow-up was 9.9 years (4 months ~ 22.3 years). There was one late death. Freedom from reoperation at 10 years was 93.3 ± 6.4 % in bicuspid group and 88.7 ± 4.4 % in tricuspid group ( p =0.84). Reoperation for aortic valve or aortic root was rarely required during follow-up. Indexed dimension (z-score) of neoaortic annulus was not increased in both groups ( p =0.57) (Figure 1A), although there was a little increasing tendency in z-score of neoaortic sinus without intergroup difference ( p =0.69) (Figure 1B). Deterioration in neoaortic valve function was more prominent in bicuspid group (common odds ratio; 1.40 in bicuspid group [ p &lt;0.01], and 1.12 in tricuspid group [ p =0.03], p =0.03) (Figure 1C). Conclusions: Arterial switch operation could be a safe option in selected patients with TGA associated with BPV without increasing the risk of reoperation. Deterioration of aortic valve function was more prominent in bicuspid group, which suggests that the neoaortic valve function would be deteriorated mainly by valve itself not root pathology.

Abstract 14443: Aortic Root Rotational Position Associates With Aortic Valve Incompetence and Aortic Dilation After Arterial Switch Operation for Transposition of the Great Arteries

Introduction: Variation in aortic root (AoR) rotational position affects flow dynamics in normal patients. Complications of arterial switch operation (ASO) for transposition of the great arteries (TGA) include aortic dilation and neo-aortic regurgitation (AR). We sought to assess the association of neo-AoR rotational position with neo-AoR and ascending aorta (AA) dilation and neo-AR in TGA after ASO. Methods: Patients after ASO for TGA who underwent cardiac magnetic resonance (CMR) from 2005-2020 were retrospectively reviewed. Neo-AoR rotational angle, indexed (to height) neo-AoR and AA dimensions, indexed left ventricular end diastolic volume (LVEDVi), and neo-aortic regurgitant fraction (RF) were obtained from CMR. Multivariable regression analysis for neo-AoR and AA dilation, RF, and LVEDVi were performed. Results: A total of 36 patients (78% male) were included. Median age at ASO was 5 days (3, 7) and at CMR was 17.1 years (12.3, 21.9). Rotational angle was 25% counterclockwise (&lt;-9°), 25% central (-9 to +14°), and 50% clockwise (&gt;+15°). There was no material association of neo-AoR and AA size with sex, age, and coronary artery anatomy. A quadratic term for neo-AoR rotational angle - increasing extremes of counterclockwise and clockwise angles - was significantly associated with neo-AoR dilation (p=0.03), AA dilation (p&lt;0.02), and LVEDVi (p&lt;0.01) (Figure 1) and remained significant in multivariable model of neo-AoR dilation (p&lt;0.02), AA dilation (p&lt;0.01), and LVEDVi (p&lt;0.02). Rotational angle was negatively associated with neo-aortic RF (p&lt;0.05) and remained significant in multivariable model (p&lt;0.02). Conclusions: In conclusion, both clockwise and counterclockwise neo-AoR rotational position in TGA after ASO are associated with neo-AoR and AA dilation and LVEDVi. Counterclockwise rotational angle was associated with RF. Neo-AoR rotational position likely affects valve function and hemodynamics, leading to risk of neo-AR and aortic dilation.

Pediatric coronary artery surgery. A new area in cardiac surgery?

Introduction and aim: Pediatric coronary artery surgery for congenital heart disease has become increasingly important in newborns and infants. It is life-saving in unsuccessful coronary transfer surgery, injury of coronary artery during surgery, in pediatric coronary artery bypass surgery (PCABS) due to acquired Kawasaki disease. Method: We review the current surgical role of congenital and acquired coronary artery diseases in newborns and infants. Results: The 7 main challenges are: 1) anomalous origin of the left coronary artery from the pulmonary artery; 2) different variations of the origins of the coronary arteries in transposition of the great arteries (TGA); 3) acute and late coronary events in the arterial switch operation for TGA; 4) complications after coronary transfer procedures: Ross-, Nikaidoh operation; 5) inadvertent coronary artery injury during heart surgery; 6) Kawasaki disease; 7) coronary artery procedures in premature infants. Direct coronary reimplantation in most, surgical angioplastic procedures in selected patients is the first choice; however, PCABS with internal thoracic artery (ITA) grafts can be life-saving in emergency or severe myocardial hypoperfusion conditions. Since the patency of saphenous vein grafts is poorer than that of ITA grafts, their use should be avoided in growing children. The procedures can be performed safely in neonates and infants, using high-power magnifying glasses or a surgical microscope. Conclusion: Pediatric coronary artery surgery technique is now established as the standard safety surgical choice, as a new area in cardiac surgery. Congenital heart surgeons after proper training are able to use coronary transfer and bypass surgery safely even in premature babies. Orv Hetil. 2019; 160(49): 1935-1940.

P2742Right ventricular stroke volume during dobutamine stress magnetic resonance compared to lung perfusion and peak oxygen uptake after arterial switch operation for transposition of the great arteries

Abstract Objectives Abnormal pulmonary perfusion due to stenosis of the central pulmonary arteries is common after neonatal arterial switch operation (ASO) for transposition of the great arteries (TGA). We conducted a monocentric prospective study in young adults after neonatal ASO for TGA to evaluate the effects of abnormal pulmonary perfusion on the increase of the right ventricular stroke volume (RVSV) during dobutamine stress magnetic resonance (DSMR) and on cardiopulmonary exercise capacity. Methods 68 unselected patients (age 18–29 years) underwent CMR at rest and under dobutamine stress (10 to 40 μg/kg/min). RVSV, pulmonary blood flow distribution (PBFD) and peak flow velocity were derived from phase contrast mapping in the main, right and left pulmonary artery (PA) at rest and each stress level. A cardiopulmonary exercise test (CPET) was performed at the same day. All patients reached maximal exercise effort according to heart rate and respiratory exchange rate. Results PBFD at rest: 9/68 patients (13%, ASO-S) had abnormal pulmonary perfusion at rest, defined as PBFD &gt;2:1 (right/left or left/right) and/or relevant stenosis of the main PA (Vmax &gt;2.5 m/s). 59/68 patients (87%, ASO-N) had normal pulmonary perfusion. PBFD under DSMR: (1) In the whole patient group, there was no increase of PBFD under stress compared to PBFD at rest. On an individual patient level, no relevant worsening of abnormal PBFD was found. (2) Under low dose dobutamine, ASO-S had a significantly lower RVSV-increase (RVSVstress/RVSVrest) compared to ASO-N (see figure). However, under high dose dobutamine, this effect was no longer significant (see figure). (3) The RVSV-increase under low and high dose dobutamine did not correlate with peak oxygen uptake during CPET, neither in the total group nor in the subgroups (see table). Peak oxygen uptake was not significantly different between ASO-N and ASO-S (p=0,72). RVSV-increase compared to CPET peak VO2% ASO-total ASO-S ASO-N RVSV-increase/peak VO2% RVSV-increase/peak VO2% RVSV-increase/peak VO2% low dose dobu high dose dobu low dose dobu high dose dobu low dose dobu high dose dobu Pearson correlation coefficient −0.02 −0.05 0.01 −0.22 −0.05 −0.04 p-value 0.90 0.71 0.98 0.56 0.71 0.78 Figure 1 Conclusion (1) Patients with relevant stenosis of main PA and/or abnormal peripheral blood flow distribution (ASO-S) exhibit a reduced RVSV-increase under low dose dobutamine compared to patients without stenosis (ASO-N). This effect was not present under high dose dobutamine stress. (2) These findings did not correlate with peak oxygen uptake during CPET, an objective parameter of cardiopulmonary exercise capacity. (3) Therefore, a conservative proceeding rather than surgery or catheter intervention should be considered, especially in asymptomatic adult patients. Acknowledgement/Funding Supported by Kinderherzen, Fördergemeinschaft Deutsche Kinderherzzentren e.V.

Myocardial blood flow and cardiac sympathetic innervation in young adults late after arterial switch operation for transposition of the great arteries

BackgroundThe arterial switch operation (ASO) for repair of transposition of the great arteries (TGA) requires transection of the great arterial trunks and re-implantation of the coronary arteries into the neoaortic root resulting in cardiac sympathetic denervation which may affect myocardial blood flow (MBF) regulation. The aims of the present study were to evaluate sympathetic (re-)innervation in young adults after ASO and its impact on MBF. MethodsTwelve patients (age 22.5 ± 2.6 years) after ASO for TGA in the neonatal period and ten healthy controls (age 22.0 ± 1.7 years) were included. Positron emission tomography (PET) was used for measuring cardiac sympathetic innervation with [11C]meta-hydroxyephedrine (mHED) and MBF with [15O]H2O PET at rest, during adenosine stimulation, and during sympathetic stimulation with cold pressor test. Cold pressor-induced MBF response capacity was calculated as maximal global MBF over peak rate-pressure product multiplied by 10′000. ResultsGlobal [11C]mHED uptake was significantly lower in patients compared to controls (7.0 ± 2.3 versus 11.8 ± 2.1%/min, p < 0.001). Global MBF was lower in patients compared to controls at rest and during adenosine-induced hyperemia (0.66 ± 0.08 versus 0.82 ± 0.15 ml/min/g, p = 0.005; 2.23 ± 1.19 versus 3.36 ± 1.04 ml/min/g, p = 0.030, respectively). Interestingly, MBF during cold pressor test did not differ between patients and controls (0.99 ± 0.20 versus 1.07 ± 0.16 ml/min/g, p = 0.330). However, cold pressor-induced MBF response capacity was significantly lower for patients as compared to controls (1.09 ± 0.35 versus 1.44 ± 0.39 ml/g/10,000 mmHg, p = 0.040). ConclusionsWith only partial sympathetic re-innervation of the coronary arteries, maximal dilator capacity of the coronary microvasculature and cold pressor-induced MBF response capacity remain substantially impaired in young adults after ASO compared to healthy controls.

Long-Term Results of Bay Window Technique for Coronary Translocation in the Arterial Switch Operation.

Accurate coronary translocation is very important for a successful arterial switch operation (ASO) for transposition of the great arteries (TGA) and to provide good long-term outcomes. We have previously reported the "bay window" technique as a useful option for coronary translocation with excellent midterm results. However, the long-term results of this technique and the morphological changes in the coronary channel have not yet been reported. Between September 2001 and December 2012, 33 patients with TGA underwent coronary translocation using the bay window technique concomitantly with ASO. The diagnoses were TGA with intact ventricular septum in 21, TGA with ventricular septal defect in 7, and Taussig-Bing anomaly in 5. The median age of the patients at operation was 12 days, and their median body weight was 2.93 kg. Coronary artery patterns were as follows: Shaher and Puddu's type 1 in 23, single coronary artery in 4, intramural type in 1, and others in 5. The median follow-up period was 4.5 years. There were no operative deaths, but there was one late death because of sepsis 13 months after ASO. Coronary artery evaluation with angiography, computed tomography, or myocardial scintigraphy was performed in 22 patients. There was no abnormal coronary morphology or perfusion. Coronary channel dilatation was not observed. Three patients underwent reoperation for pulmonary stenosis. The bay window technique provides excellent long-term results in ASO for TGA. Three-dimensional computed tomography revealed no aneurysmal changes in the bay window channel at nine-year follow-up examination.

Diffuse myocardial fibrosis in adolescents operated with arterial switch for transposition of the great arteries - A CMR study

Diffuse myocardial fibrosis in adolescents operated with arterial switch for transposition of the great arteries - A CMR study

Early and Midterm Results of the Arterial Switch Operation: A 9-Year, Single-Center Experience.

The arterial switch operation (ASO) has become the surgical approach of choice for transposition of the great arteries. The aim of this paper was to describe the outcomes in patients who underwent arterial switch operation and to analyze the predictors of in-hospital mortality and further need for reoperation at a single-center institution. We reviewed our 9-year experience with arterial switch operation (ASO) for transposition of the great arteries (TGA) or Taussig-Bing anomaly (TBA) to assess the early and midterm outcomes. Between January 2007 and May 2016, 34 consecutive patients who underwent ASO for TGA with IVS; and TGA with ventricular septal defect (VSD); and double outlet right ventricle (DORV) with subpulmonary VSD at our institution were included in this retrospective study. The same surgeons operated on all patients. Patients' charts, surgical reports, and echocardiograms were retrospectively reviewed. Median follow-up time ranged from 1 to 9 years, 54.2 (0.4-108) months. There were 2 (5%) in-hospital deaths. Late death occurred in 1 (2.9%) of 32 survivors. One patient (2.9%) required reintervention. The freedom from reintervention rate was 95.9 ± 1.8% at 9 years. Two patients (3.9%) developed moderate neoaortic regurgitation during the follow-up and one patient underwent reoperation mainly for neopulmonary artery stenosis. The analysis showed that weight, cross-clamp (CC) time, cardiopulmonary bypass (CPB) time, and age of operation are strong predictors for mortality. ASO remains the procedure of choice for the treatment of various forms of TGA with acceptable early and midterm outcome, and can also be performed with a low risk of early mortality and satisfactory midterm outcomes even in a small-volume center. Early and midterm survival is excellent after arterial switch operation.

Reoperation for right ventricular outflow tract obstruction after arterial switch operation for transposition of the great arteries and aortic arch obstruction.

Right ventricular outflow tract obstruction (RVOTO) is one of the reasons for late reinterventions after repair of transposition of the great arteries (TGA) with aortic arch obstruction (AAO). The aim of the present study was to identify predictors of reoperation for RVOTO in patients who underwent arterial switch operation (ASO) and arch repair for TGA or Taussig-Bing anomaly with AAO. Between 1977 and 2015, 45 patients [TGA/intact ventricular septum (IVS) 5, TGA/ventricular septal defect (VSD) 13, Taussig-Bing 27] with coarctation (21), arch hypoplasia (5), coarctation and hypoplasia (12) and aortic arch interruption (7) underwent ASO and arch repair. The median age at the ASO was 19 days (range, 1 day to 12.7 years). AAO was repaired concomitantly with ASO in 36 patients. Operation reports and 2D-echocardiographic data were retrospectively reviewed to determine the following parameters: position of the great arteries, coronary artery anatomy, and diameters of RVOT, aortic annulus, aortic sinotubular-junction, pulmonary annulus and transverse aortic arch previous to ASO. The median follow-up time was 6 years (range, 0-30 years). Four patients were lost to follow-up; reliable echo data were available in 24 subjects. Cox proportional hazard models were performed to examine predictors of reoperation for RVOTO. Thirty-day mortality rate after ASO was 13% (n = 6), and late mortality rate 9% (n = 4). Ten patients (TGA/VSD 2, Taussig-Bing 8) had 14 reoperations for RVOTO. One patient died after reoperation. Taussig-Bing anomaly was a significant predictor of reoperation for RVOTO [hazard ratio (HR) = 5.5, 95% confidence interval (CI) = 1.15-26.38, P = 0.033]. Higher preoperative aortic annulus Z-score significantly decreased the reoperation risk (HR = 0.6, 95% CI = 0.42-0.93, P = 0.020). In reoperated patients, the mean gradient across the RVOT reduced from 84 ± 12.2 mmHg prior to reoperation to 15.29 ± 13.70 mmHg at latest follow-up. Taussig-Bing anomaly and smaller preoperative aortic annulus diameter (Z-score) were significant predictors of reoperation for RVOTO in patients after ASO for TGA or Taussig-Bing anomaly with AAO. In Taussig-Bing hearts, the more complex anatomy often necessitates modifications of the operation technique, sometimes precluding RVOT relief at primary ASO. During follow-up, the possibility of recurrent RVOTO should always be considered in this specific patient population. Yet, in case of a reoperation for RVOTO, the surgical relief is in general effective.

Great Vessel Root and Artery Dimensions in Transposition of the Great Arteries Repaired With Atrial Switch Operation

To describe great-vessel dimensions in patients with D-loop transposition of the great arteries (TGA) who have undergone atrial switch operation (ATSO). Patients who have undergone arterial switch operation for TGA have a high incidence of dilation of the neoaortic root. The incidence and degree of great artery dilation in patients who have undergone ATSO for TGA has not previously been described. A retrospective database review identified patients with TGA and intact ventricular septum who underwent ATSO at <1 year of age with cardiac magnetic resonance (CMR) within the previous 5 years (n = 39). A control group of patients referred for CMR with normal findings was identified for comparison (n = 40). Measurements of the annulus, root, sinotubular junction, and great vessels were performed, and interobserver/intraobserver variability was assessed. Median age of subjects at ATSO was 3 months (range 1-12) with median age at CMR of 29 years (range 18-40). For aortic measurements, mean z scores (± SDs) for patients relative to body surface area (BSA)-adjusted normal controls were as follows: annulus 1.41 (0.80), root 2.04 (1.48), sinotubular junction 2.16 (1.26), and great vessel 1.86 (1.53). For pulmonary measurements, similar values were as follows: annulus 1.82 (1.42), root 3.25 (2.01), sinotubular junction 2.47 (1.79), and great vessel 3.96 (3.08). In all cases, the p value was <0.001, and no confidence interval included the value 0. Adult patients with TGA repaired with ATSO in infancy have a greater incidence of dilation of both great vessels, particularly the pulmonary artery. These results may indicate abnormalities in the vascular structure of both great arteries in TGA that may predispose to progressive arterial dilation.

Modification of the arterial switch operation for transposition of the great arteries with complex coronary artery patterns

The arterial switch operation has evolved into the treatment of choice for most forms of transposition of the great arteries (TGA). Recently reported operative mortality of the procedure has fallen to the range of 1.1%-6.0%, even for complex forms of TGA. Despite advancement in the technical aspects of the procedure, certain anatomical variations of the coronary arteries, such as a single coronary orifice and/or intramural coronary artery, are still considered surgical risks in many centers. Optimizing the surgical technique for relocating these challenging variations of the coronary anatomy is key to improving the surgical outcomes for the procedure. In this review, the surgical modifications of the arterial switch operation for TGA associated with complex patterns of the coronary arteries are examined.

Time Course and Prognostic Value of Plasma B-type Natriuretic Peptide Concentration in Neonates Undergoing the Arterial Switch Operation

Plasma B-type natriuretic peptide (BNP) can predict postoperative complications after cardiac surgery in adults. Our aim was to investigate BNP kinetics and prognostic value in neonates undergoing the arterial switch operation (ASO) for transposition of the great arteries (TGA). We measured BNP concentrations in 30 neonates before, immediately after, and 6, 12, 24, and 48 h after ASO for TGA. Complicated postoperative evolution was defined as patients requiring mechanical ventilation or presenting low cardiac output syndrome for more than 72 h. We studied the ability of postoperative BNP concentrations to predict complicated evolution. Intubation duration, inotropic support duration, and intensive care unit stay were 68 (48-121) h, 78 (69-141) h, and 96 (76-149) h respectively. Patients with complicated evolution had higher 6 and 12-h BNP concentrations than patients with simple evolution (459 (210-897) vs 137 (67-248) ng/L and 547 (193-868) vs 185 (79-354) ng/L respectively; P < 0.05) and had longer intubation, inotropic support, and intensive care unit stay (96 (70-190) vs 50 (48-66) h, 100 (83-190) vs 70 (59-72) h, and 120 (90-240) vs 84 (72-96) h, P < 0.05). A 6-h BNP concentration >160 ng/L was able to predict complicated evolution with a sensitivity of 93% and a specificity of 67%. In neonates, BNP concentrations can predict adverse outcome in the postoperative period after ASO for TGA. This marker has potential clinical applications.

Late Outcome After Arterial Switch Operation for Transposition of the Great Arteries

Background Early and midterm results of the arterial switch operation (ASO) in transposition of the great arteries (TGA) are good, but late outcome data in large populations are still few. Methods and Results Twelve hundred patients had an ASO for TGA between 1982 and 1999, with prospective follow-up of 1095 survivors. Outcome measures included late death, reoperation, aortic insufficiency (AI), pulmonary stenosis (PS), and coronary anomaly. Median follow-up was 4.9 years (range 0.5 to 17 years). Late death occurred in 32 patients; survival was 88% at both 10 and 15 years. The hazard function for death declined rapidly, with no deaths after 5 years. Late mortality was correlated with reintervention and major events in the intensive care unit. Reoperation was performed in 103 patients, more often in complex TGA; the cause was mainly PS. Freedom from reintervention was 82% at 10 and 15 years, with a hazard function that declined rapidly but slowly increased after 3 years. At the last follow-up, PS was present in 3.9% of patients, and grade II or more AI was present in 3.2%, with a cumulative incidence of 9% at 15 years. Among the 278 patients who had a coronary arteriography, 8% had coronary lesions. Normal left ventricle and sinus rhythm were seen in 96.4% and 98.1%, respectively. Conclusions Fifteen years after ASO, late mortality was low, with no deaths after 5 years; reoperation, mainly owing to PS, occurred throughout the follow-up. AI and coronary obstruction are rare but warrant further follow-up. Good left ventricular function and sinus rhythm are maintained.

Arterial switch operation: factors impacting survival in the current era

Background. The arterial switch procedure has become the preferred procedure for the transposition of the great arteries (TGA) and Taussig-Bing anomaly. This analysis is intended to identify potential factors affecting survival in the current era.Methods. From 1986 to 1999, 201 consecutive patients underwent an arterial switch operation for TGA or Taussig-Bing anomaly. Multivariate analysis of perioperative variables was performed for operative morbidity/mortality. Patients were separated into two groups. Phase 1 (n = 29) included patients before mid-1989 who underwent an open coronary reimplantation technique. Phase 2 (n = 172) included the patients undergoing a technique of reimplanting coronary buttons after neoaortic reconstruction.Results. The patient population included TGA with intact ventricular septum (58.7%, 118 of 201), with ventricular septal defect (31.3%, 61 of 201), and Taussig-Bing anomaly (10.0%, 22 of 201). Overall, early mortality was 9.5% (19 of 201) and there were five late deaths (2.7%). One-month, 1-year, and 5-year actuarial survival rates were 90.4%, 87.9%, and 87.9%, respectively. Reoperation rate for late pulmonary stenosis was 2.7% (5 of 182). The freedom from reoperation at 3 and 5 years was 97.5% and 93.3%, respectively. In the analysis by time period, the operative mortality declined from 27.6% (8 of 29) to 6.4% (11 of 172) (p = 0.002). Risk factors for operative death were coronary artery patterns (usual vs retropulmonary left coronary artery, p = 0.009) in phase 1 and preoperative instability in phase 2 (p = 0.002).Conclusions. The arterial switch operation for TGA and Taussig-Bing anomaly has early low and late mortality and reoperation rates. Technical modifications in coronary reimplantation have minimized coronary artery pattern-related risks.