Arterial Switch Procedure For Transposition Research Articles

Pregnancy Outcomes in Women After Arterial Switch Operation for Transposition of the Great Arteries: Results From ROPAC (Registry of Pregnancy and Cardiac Disease) of the European Society of Cardiology EURObservational Research Programme.

BackgroundIn the past 3 decades, the arterial switch procedure has replaced the atrial switch procedure as treatment of choice for transposition of the great arteries. Although survival is superior after the arterial switch procedure, data on pregnancy outcomes are scarce and transposition of the great arteries after arterial switch is not yet included in the modified World Health Organization classification of maternal cardiovascular risk.Methods and ResultsThe ROPAC (Registry of Pregnancy and Cardiac disease) is an international prospective registry of pregnant women with cardiac disease, part of the European Society of Cardiology EURObservational Research Programme. Pregnancy outcomes in all women after an arterial switch procedure for transposition of the great arteries are described. The primary end point was a major adverse cardiovascular event, defined as combined end point of maternal death, supraventricular or ventricular arrhythmias requiring treatment, heart failure, aortic dissection, endocarditis, ischemic coronary events, and thromboembolic events. Altogether, 41 pregnant women (mean age, 26.7±3.9 years) were included, and there was no maternal mortality. A major adverse cardiovascular event occurred in 2 women (4.9%): heart failure in one (2.4%) and ventricular tachycardia in another (2.4%). One woman experienced fetal loss, whereas no neonatal mortality was observed.ConclusionsWomen after an arterial switch procedure for transposition of the great arteries tolerate pregnancy well, with a favorable maternal and fetal outcome. During counseling, most women should be reassured that the risk of pregnancy is low. Classification as modified World Health Organization risk class II seems appropriate.

Update on the Management of Adults With Arterial Switch Procedure for Transposition of the Great Arteries.

The arterial switch operation (ASO) is now the most frequently performed surgical correction in individuals with dextro-transposition of the great arteries (D-TGA). Patients who undergo this procedure as neonates have overall good clinical outcomes yet continued clinical follow-up is important to evaluate for postoperative complications. In this group, the highest mortality is in the immediate postoperative period and is generally associated with reimplantation of the coronary arteries. As these patients live into adulthood, longitudinal follow-up for other ASO complications including neo-pulmonary stenosis, right ventricular outflow tract (RVOT) obstruction, or neo-aortic root dilation and resulting aortic insufficiency should be performed. In adults, extra care should be taken to identify and treat traditional cardiovascular risk factors as individuals with coronary obstruction may not present with typical anginal symptoms. Management of these patients should be performed in collaboration with an adult congenital heart center of excellence. This population offers a unique opportunity to provide timely feedback to adult congenital heart community of providers regarding late outcomes from surgical intervention and in the next decade will hopefully demonstrate a model for clinical feedback cycles in lifelong congenital care.

Long-Term Outcome of Direct Neopulmonary Artery Reconstruction During the Arterial Switch Procedure

Neopulmonary stenosis at anastomosis site is one of the most frequent complications after the arterial switch procedure for transposition of the great arteries. The surgical technique is a crucial factor associated with the frequency of stenotic complications. We present the outcomes of direct neopulmonary anastomosis during the arterial switch procedure in patients with simple transposition. This research was to assess the efficacy of this surgical technique based on the incidence of postprocedural supravalvular neopulmonary stenosis (SVPS). Among 545 patients operated on in our department between 1992 and 2009, the 346 consecutive survivors who had undergone simple transposition in the first month of life were included in this analysis. Switch procedures were performed with direct neopulmonary artery anastomosis in 318 patients (92%); in the remaining 28 (8%), the risk of coronary artery compression required the use of a pericardial patch for pulmonary reconstruction. Neopulmonary stenosis occurred in 9 patients (2.6%): 5 had undergone direct neopulmonary reconstruction, and 4 had been treated with a patch. Balloon angioplasty of SVPS was performed twice in 1 patient. No patients required reoperation to treat neopulmonary stenosis. In multivariate analysis (logistic regression), patch reconstruction (odds ratio, 27.5; p=0.001) and nonfacing commissures (odds ratio, 11.1; p=0.004) were correlated significantly with the incidence of SVPS. Direct neopulmonary artery anastomosis during arterial switch is an interesting alternative to patch reconstructions and ensures a good postoperative result with low rates of complications and SVPS.

Late-Onset Pulmonary Arterial Hypertension After a Successful Atrial or Arterial Switch Procedure for Transposition of the Great Arteries

Common complications after surgery for transposition of the great arteries (TGA) include systemic ventricular dysfunction and arrhythmia after atrial baffle repair (AB) and outflow tract stenosis or regurgitation after the arterial switch (AS). Severe pulmonary hypertension (PHT) is a rarely reported problem after AB and AS. In this study we sought to evaluate the frequency of late onset severe PHT following surgical repair for TGA. We report 3 cases, 2 after AB and 1 after AS, describe the frequency of this complication and treatment response, by comparing the response to pulmonary vasodilators in this group of patients to that of idiopathic or connective tissue disease (CTD) related PHT. We currently follow 85 patients >or=17 years of age with repaired TGA; 77 after AB and 8 after AS. 3.5% of our adult congenital heart disease patients with TGA have developed late severe PHT. None of these patients demonstrated clinical improvement with Bosentan at 6 months, however 2 of 3 were stabilised with the addition of Sildenafil to initial therapy. The third patient died 4 months after the diagnosis of severe PHT, whilst waiting for heart-lung transplantation, despite Bosentan, Sildenafil and inotropic support. By contrast, of 37 patients with idiopathic or CTD related PHT commenced on Bosentan as initial therapy, 32 (86.5%) demonstrated a clinical response at 6 months; the other patients had Sildenafil as added therapy after 6 months. Our data suggest that patients with TGA and late onset PHT are less likely to achieve a clinical response on pulmonary vasodilator monotherapy (P = 0.006). Whilst more investigation is needed, our experience suggests an aggressive clinical course, often requiring combination PHT treatment.

The Arterial Switch Procedure for Transposition of the Great Arteries

Transposition of the great arteries is the most common congenital heart defect among the birth defects that present with cyanosis during the early neonatal period. Infants with this cardiac birth defect, in which the aorta originates from the right ventricle and the pulmonary artery originates from the left ventricle, usually do not survive without surgical intervention in the first few days of life. The arterial switch procedure, performed via a median sternotomy incision during cardiopulmonary bypass, restores the aorta and pulmonary artery to their normal anatomic positions.

Invited commentary

This is an important article [1Kampmann C. Kuroczynski W. Trübel H. Knuf M. Schneider M. Heinemann M.K. Late results after PTCA for coronary stenosis after the arterial switch procedure for transposition of the great arteries.Ann Thorac Surg. 2005; 80: 1641-1646Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar]. Many centers have reported early or late stenoses of coronary arteries after the arterial switch operation for transposition of the vessels, both early and late. The varying incidences of coronary stenoses are probably related to the surgical techniques used. On many occasions the stenosis is asymptomatic and is discovered at re-catheterization for evolving problems in the right ventricular outflow tract and left ventricular outflow tract defined by follow-up echocardiography. The collated experience from three hospitals over the short and intermediate term after balloon angioplasty of stenotic coronary arteries is very encouraging. They have shown that balloon dilatation for this condition in young children is feasible and fairly reproducible, and more importantly, over a period of 3 to 5 years, the dilated coronaries have remained widely patent. The authors have carefully described the technique they use and have really laid down a blueprint for the management of this particular problem after the arterial switch operation, which has been a concern to many centers. As yet, there cannot be full confidence that coronary stenosis after the arterial switch operation is lastingly corrected by balloon dilatation. We would hope that this same group will review their 7 patients in a further 5 years and provide a follow-up communication to this journal. One would also hope that this particular article will stimulate the publishing of other articles describing the experiences from other centers for handling post-arterial switch coronary stenosis.

Late Results After PTCA for Coronary Stenosis After the Arterial Switch Procedure for Transposition of the Great Arteries

The arterial switch operation has become the surgical approach of choice for d-transposition of the great arteries, but there is an increased awareness of adverse sequelae in some survivors. Long-term patency and normal function of the translocated coronary arteries must be achieved. It is reported that dependent of the prior coronary status, 3% to 11% of all survivors have proximal coronary stenosis or complete occlusion develop after arterial switch operations. However, treatment of these stenoses is still a matter of debate. Late results after percutaneous transluminal coronary angioplasty (PTCA) for coronary stenosis after the arterial switch operation for d-transposition of the great arteries are reported. Seven children after arterial switch operation for d-transposition of the great arteries who had subsequently undergone PTCA for coronary stenosis were angiographically re-evaluated 3 to 15 months after the initial PTCA and again after 3 to 5 years. All children survived the initial PTCA procedure. There were no late deaths. The degree of stenosis before PTCA ranged from 74% to 97%; immediately after PTCA from 5% to 10%; at 3 to 15 months after PTCA from zero to 6%; and at 3 to 5 years after PTCA from zero to 3%. Three to 5 years after PTCA all children showed normal development of the treated coronary artery. Primary PTCA of stenotic proximal coronary arteries after the arterial switch procedure for d-transposition of the great arteries seems to be an effective treatment with excellent long-term results.

Autologous patch angioplasty of the left main coronary artery in a pediatric patient: 7-year follow-up

We present a patient who developed ischemia after an arterial switch procedure for transposition of the great vessels secondary to left coronary artery stenosis. The excellent intermediate-term result of patch angioplasty of the left main coronary artery with the use of an internal thoracic artery patch is outlined.

Revial of rapid 2-stage arterial switch procedure for transposition of great arteries

Revial of rapid 2-stage arterial switch procedure for transposition of great arteries

Aortic root dilation and aortic regurgitation following the arterial switch procedure for transposition of the great arteries Colin J. McMahon, Grace C. Kung, Carrie A. Altman, Nancy A. Ayres, William J. Ravekes. Baylor College of Medicine/Texas Children's Hospital, Houston, TX

Aortic root dilation and aortic regurgitation following the arterial switch procedure for transposition of the great arteries Colin J. McMahon, Grace C. Kung, Carrie A. Altman, Nancy A. Ayres, William J. Ravekes. Baylor College of Medicine/Texas Children's Hospital, Houston, TX

BLOOD GLUCOSE LEVEL AND EARLY NEUROLOGIC RECOVERY AFTER CARDIAC SURGERY WITH CIRCULATORY ARREST IN INFANTS

Introduction: While high blood glucose levels can exacerbate cerebral ischemic damage in the normothermic mature brain, the relationship between glucose levels and neurologic outcome following deep hypothermic circulatory arrest (DHCA) is unknown for the immature brain of neonates and infants. Methods: Indicators of perioperative neurologic dysfunction were compared with serial serum glucose measurements drawn during a prospective, randomized, single-center trial of 171 infants undergoing the arterial switch procedure for transposition of the great arteries (Boston Circulatory Arrest Study) [1]. Infants in this study were assigned to a bypass strategy of predominant circulatory arrest (CA, n=87) vs. predominant low-flow bypass (LF, n=84). Perfusion methods and anesthetic management were rigorously standardized for all patients. Serum glucose levels were measured after induction of anesthesia, 5 minutes after the onset of bypass during cooling, at the onset of CA or LF, 5 minutes after resumption of bypass, at 32[degree sign]C (rectal) during rewarming, at 10 min after weaning from bypass, and 90 min after the end of CA. Linear regression analysis was used to examine the relationship between glucose level and perioperative neurologic outcomes assessed by ictal activity and reappearance of latency times on electroencephalography (EEG), creatine phosphokinase brain-isoenzyme (CK-BB) release, and blinded neurologic examination. Results: Higher glucose levels prior to CA were associated with increased CK-BB release in the first 6 hours after surgery (P<0.01), but had no relation to seizure activity. Longer duration of CA was associated with higher blood glucose levels at 32[degree sign] during rewarming (P<0.001), at 10 minutes after bypass (P<0.01) and 90 minutes after the end of CA (P=0.03). Glucose and EEG recovery times following CA were inversely related. Lower, but not hypoglycemic, glucose levels at 10 min after CPB and 90 min after CA were associated with increased EEG seizure activity in the initial 48 hrs postoperative (P<0.04). Conversely, intraoperative hyperglycemia was associated with shorter EEG recovery times and a low incidence of postoperative seizures. Pre- and post CA glucose levels were not associated with clinical siezures, nor abnormal neurologic examination or repeat EEG at time of discharge. (Figure 1)Figure 1Conclusions: The data reported here are observational and allow only conclusions related to associations between neurologic outcome and glucose level, nevertheless, the faster recovery of EEG latency with reduced ictal activity following CA suggests that high serum glucose may not be harmful during infant cardiac surgery with prolonged periods of cerebral ischemia. While in contrast to adult data, these findings are consistent with experimental data in immature animals undergoing cerebral ischemia.

Intraoperative Ultrasonographic Troubleshooting After the Arterial Switch Operation

Background. Less than perfect coronary artery translocation accounts for the majority of perioperative deaths after the arterial switch procedure for transposition of the great arteries. Some types of coronary arterial anatomy are associated with a higher risk of death.Methods. Prospective epicardial ultrasound examination of all neonates with failing left ventricle or difficulty in weaning off cardiopulmonary bypass was performed after completion of the arterial switch operation during a 2-year period from March 1994 to February 1996. The aim was to identify any mechanical, and potentially remediable, factors accounting for ventricular failure.Results. Four neonates fulfilling the above criteria were identified during a 2-year period when epicardial echocardiography was routinely applied. In 2 patients coronary arterial problems in the form of kinking of the proximal left coronary artery (1 patient) and extrinsic compression of the artery by the neo-pulmonary trunk (1 patient) were identified and successfully corrected. In 2 other patients, supravalvar aortic stenosis was recognized, leading to prompt revision.Conclusions. Epicardial echocardiography has an important “troubleshooting” role in the subgroup of patients with a suboptimal hemodynamic result after the arterial switch operation. Patients with unusual coronary anatomy should routinely be candidates for such studies.(Ann Thorac Surg 1997;63:445–8)

Advances in surgical care of infants and children with congenital heart disease

Recent important technical developments in the field of surgery for congenital heart disease have included the Ross pulmonary autograft replacement of the aortic valve, video-assisted thoracoscopic surgery, and the double-switch and switch-Rastelli procedure for congenitally corrected transposition. Although the growth potential of the pulmonary autograft has been confirmed, an important incidence of late aortic regurgitation has been noted. Expanding indications for video-assisted thoracoscopic surgery have been described, including division of the vascular ring. Late hemodynamic assessment after the double-switch or switch-Rastelli procedure will encourage increased application of this repair. Both clinical and laboratory studies have focused on neurologic and developmental outcome after cardiac surgery. Perioperative seizures in young infants have been found to be associated with impaired psychomotor development at 1 year of age. In the area of perioperative management, the antifibrinolytic agents tranexamic acid, epsilon-aminocaproic acid, and aprotinin have been found to be useful in reducing postoperative hemorrhage. Nitric oxide is useful in reducing postoperative pulmonary hypertension. Late clinical follow-up studies of patients with single ventricle have revealed an important incidence of pulmonary arteriovenous malformations after a bidirectional Glenn shunt and atrial flutter after a Fontan procedure. Late assessment of patients after the arterial switch procedure for transposition has revealed preservation of ventricular function and an extremely low incidence of late arrhythmias.

Arterial switch: Translocation of the intramural coronary artery

Translocation of an intramural coronary artery is one of the most challenging problems in anatomic correction of transposition of the great arteries. Of 259 patients undergoing arterial switch procedure for transposition of the great arteries in our hospital, 12 (4.6%) were found to have intramural coronary arteries. The diagnosis was made intraoperatively in all patients. There were five different types of intramural coronary anatomy noted, with ostial stenosis present in half. The operative technique consisted of detachment of the posterior commissure of the aortic valve and unroofing of the intramural segment of the coronary artery by excision of a triangular portion of internal aortic wall. The coronary arteries were excised as a single disc, which was divided into two cuffs. The arterial switch was then performed in the usual fashion. The posterior commissure of the aortic valve was resuspended to the pericardial patch used to reconstruct the neopulmonary artery sinus. There were no operative or late deaths over a follow-up of 328 patient-months. Fostoperatively, no patient showed ischemic changes on electrocardiogram or abnormal wall motion on echocardiogram. We believe that intramural coronary arteries can be managed satisfactorily with this technique, and mat arterial switch will be possible in all cases.

Nursing care of a child following an arterial switch procedure for transposition of the great arteries

The restoration of the left ventricle as the systemic pump and the lack of sinus node dysfunction (assessment with the Senning or Mustard procedure) have been suggested as the major advantages of the arterial switch procedure. Although the results are encouraging, children will require follow up to assess: long-term left ventricular function; coronary ostial growth; aortic and pulmonic anastomosis growth; long-term aortic valve (anatomical pulmonary valve) dysfunction. A learning curve is inherent to a new surgical procedure. During this learning period, both surgical technique and patient selection criteria improve, resulting in reduced morbidity and mortality. The arterial switch procedure for TGA is certainly not an exception. Expert nursing assessment and intervention during the postoperative period is imperative and may reflect on the long-term outcome of these children.

Report of neoaortic valve replacement in a ten-year-old girl after an arterial switch procedure for transposition

Report of neoaortic valve replacement in a ten-year-old girl after an arterial switch procedure for transposition

Left internal thoracic artery bypass graft in arterial switch with coronary transfer for transposition of the great arteries

The left internal thoracic artery was anastomosed to the circumflex coronary artery to treat myocardial ischemia during an arterial switch procedure for transposition of the great arteries in a 6-month-old infant. Follow-up angiography revealed complete patency of the anastomosis.

Surgical management of congenital heart defects: Current trends

Surgical treatment for congenital heart disease has become available over the last five decades. Palliative procedures have been designed to improve physiologic abnormalities, for example systemic artery (or venous) to pulmonary artery shunts of various types to increase the pulmonary blood flow, pulmonary artery constriction (banding) to decrease the pulmonary blood flow, and surgical or transcatheter atrial septostomy to augment intracardiac mixing. These can be performed with a low mortality. The majority of congenital heart defects can be corrected by open heart surgical techniques; some require prior palliation and others can be operated without prior palliative surgery. Recent surgical advances include early total surgical correction for tetralogy of Fallot, arterial switch procedure for transposition of the great arteries, Fontan operation and its modifications for tricuspid atresia and single ventricle, new operations for hypoplastic left heart syndrome, newer prosthetic valves, myocardial preservation and cardiac transplantation.

Current Technique of the Arterial Switch Procedure for Transposition of the Great Arteries

The arterial switch operation has recently become the preferred method of repair for patients with transposition of the great arteries in the majority of congenital heart centers. Concern regarding the late results in those patients undergoing atrial repairs has stimulated this major change in operative treatment. Although initially high, the current operative mortality has been reduced substantially to equal that of atrial repair in experienced institutions. The precise methods of coronary artery transfer, as well as aortic and pulmonary artery reconstruction have been refined to allow the routine performance of direct arterial repair within the first few weeks of life with low risk and excellent late survival. At the University of Michigan, a policy of arterial repair for all suitable infants with transposition of the great arteries with or without ventricular septal defect was adopted in July 1985. Although modifications in surgical technique have been made, the basic procedure has remained constant. This article reviews the current operative approach used in a consecutive series of 81 patients undergoing the arterial switch procedure.

Recent Advances in Cardiac Surgery

Virtually all forms of congenital heart disease can be repaired or significantly palliated. The risk of surgery in infancy continues to decline, and many lesions are being routinely repaired at an early age. This may permit an improved functional result later in life. Other recent advances include the arterial switch procedure for transposition of the great arteries, the palliative repair of hypoplastic left heart syndrome, and the increased application of the Fontan procedure in patients with only one effective ventricle. Combined with an ever-growing understanding of cardiopulmonary physiology, anatomy, and biochemistry, the future of congenital cardiac surgery is bright and exciting.