Atrial Switch Operation Research Articles

Catheter Ablation of Atrial Fibrillation in Transposition of the Great Arteries Treated With Mustard Atrial Baffle

The survival of patients with D-transposition of the great arteries (D-TGA) has dramatically improved with corrective surgical procedures, including the atrial and arterial switch operations. In the current era, the majority of the adult patients typically have undergone atrial switch operations, either a Senning or a Mustard procedure. Late complications include baffle obstruction, systemic ventricular failure, systemic atrioventricular valve regurgitation, and rhythm disturbances. The most common atrial arrhythmia in this population is intra-atrial reentrant tachycardia (IART), which has been associated with development of heart failure and death.1–4 Proarrhythmic factors include atrial enlargement from tricuspid regurgitation and systemic right ventricular failure, as well as suture lines. As this population ages, chronic hemodynamic stress may result in atrial fibrillation as well. We present the first report of catheter ablation for treatment of atrial fibrillation in a patient with D-TGA treated with prior Mustard repair. ### Case Report A 41-year-old man with D-TGA status post Mustard repair presented with longstanding, recurrent atrial arrhythmias. He originally underwent balloon atrial septostomy 2 days after birth and a subsequent atrial switch procedure using the Mustard technique at 2 years of age.5 He did well until age 32, at which time he had recurrent symptomatic IART. EP study was performed. Cavotricuspid isthmus (CTI)-dependent flutter was induced and confirmed by entrainment mapping. Lines of ablation were drawn across the systemic venous baffle portion of the “medial” CTI and the pulmonary venous “lateral” CTI using a retrograde, aortic approach. Flutter terminated with ablation and could not be reinduced. Bidirectional block was demonstrated across the CTI. He remained arrhythmia-free for 2 years, then presented again at age 34 with exertional intolerance and fatigue due to partial obstruction of the pulmonary venous baffle. He underwent patch augmentation of the stenotic …

Bipolar Ablation of Ventricular Tachycardia in a Patient After Atrial Switch Operation for Dextro-Transposition of the Great Arteries

A 39-year-old man with atrial switch repair (Mustard baffle) and transpulmonary resection of infundibular muscle for dextro-transposition of the great arteries and subpulmonary stenosis was referred for ablation of a drug-refractory monomorphic ventricular tachycardia (VT). Before the ablation, the patient underwent multidetector CT to detect anomalous coronary anatomy (Figure 1A–1C) and contrast-enhanced MRI (CE-MRI) to determine the extent of scar after surgical resection. CE-MRI showed late enhancement in the basal interventricular septum extending toward aortic sinus 2 (origin of the circumflex artery) (Figure 1D and 1E). During the ablation procedure, both multidetector CT and CE-MRI-derived images were integrated with the electroanatomical maps. VT was induced, and diastolic activity could be recorded at the aortic sinus 2 and at the opposing site in the right ventricle (RV). There was no capture when high-output pacing at these sites was performed to entrain the VT. Irrigated-tip radiofrequency (RF) delivery resulted in slowing of the VT when applied from the aortic sinus site (up to 40 W; flow rate, 20 mL/min) and consecutive late termination when RF was delivered from the RV site (up to 50 W; flow rate, 30 mL/min). Figure 1. MDCT and CE-MRI images. A , The RV is connected to the AO. The LAD and the RCA have a common ostium in sinus 1, whereas the CX has a separate ostium in sinus 2. B , The PVs are connected to the RA, and the VCS to the Mustard baffle, directing blood to the LV. C , The poststenotic dilation of the PT is clearly visible. The infundibular septum is indicated by white arrowheads. D and E , The 3D reconstruction of the CE-MRI-derived scar, with red indicating core scar and yellow, border zone scar. Note the potential anatomic isthmus bordered by aortic sinus 2 and a scar in …

Mid-term results of bidirectional cavopulmonary anastomosis and hemi-Mustard procedure in anatomical correction of congenitally corrected transposition of the great arteries

The Senning or Mustard procedure combined with the arterial switch operation (ASO) (± VSD and no left ventricular (LV) outflow tract obstruction) or the Rastelli operation (VSD and LV outflow tract obstruction) has become the preferred strategy over conventional repair as it is thought to prevent long-term dysfunction of the right ventricle (RV). More recently, hemi-Mustard rerouting of blood from the inferior vena cava to the RV in combination with bidirectional cavopulmonary anastomosis (BCPA) has been adopted by some centres for potential benefits over the classic atrial switch procedure. The aim of this study was to analyse our experience with hemi-Mustard and BCPA as part of an anatomical repair of congenitally corrected transposition of the great arteries (CCTGA) in selected patients. Between 2004 and 2011, eight patients underwent hemi-Mustard/BCPA with the Rastelli operation (n = 6) or ASO (n = 2). The median age was 2.9 (range: 1.2-9.1) years. Positional anomalies were present in 75% of the patients. Both patients with ASO had dysplastic and insufficient tricuspid valves. In the Rastelli group, four patients had previously received shunts followed by BCPA in one patient. In the ASO group, both patients underwent pulmonary artery banding initially. There was one in-hospital death and no late mortality. Two patients received a pacemaker. One patient from the Rastelli group required conduit change 6 years later. At the mean follow-up of 4.5 years, six and one patients are in NYHA classes I and II, respectively; six patients showed good biventricular function, while one had LV dysfunction. Systemic venous obstruction and sinus node dysfunction were not observed, and BCPA was functioning well in all patients. Hemi-Mustard/BCPA is useful in anatomical repair of CCTGA in selected patients. When compared with the classic atrial switch operation, it is technically easier which makes it especially helpful in atrio-apical discordance; it unloads an RV with limited size or function, and avoids complications related to the upper limb of the classic atrial switch procedure. Mid-term results of this approach are favourable. Further follow-up is needed to prove long-term benefits.

Pulmonary Venous Obstruction in the Atrial Switch Operation: A Forgotten Complication

The reported case involved a 7-year-old girl with congenitally corrected transposition of the great arteries (ccTGA) and situs inversus who after surgical management experienced symptoms of dyspnea and left-sided obstructive heart disease. Her symptoms, chest X-ray, and cardiac catheterization demonstrated pulmonary venous obstruction, a known but rare complication associated with intra-atrial baffle obstruction. The incidence of the reported disorder, the follow-up assessment, and the current literature regarding complications of Senning/Mustard surgery are discussed in the context of patients with ccTGA.

In adults with atrial switch operation for transposition of the great arteries low physical activity relates to reduced exercise capacity and decreased perceived physical functioning

Objective Patients with Mustard/Senning repair for transposition of the great arteries (d-TGA) have an impaired exercise capacity, but information about physical activity levels is scarce. The aim of the study was to come to a better understanding of the interrelationships between determinants of exercise capacity, physical activity and self-perceived health status.Methods and results We studied 39 d-TGA patients who underwent echocardiography and exercise testing, and who completed questionnaires about physical activity and perceived health status. All results were compared with normal values. Stepwise multiple regression analysis was used to assess the determinants of peak VO2% and exercise duration. Peak VO2 averaged 64 ± 14.1% of the predicted normal values, which is significantly lower than expected (P< 0.0001). Physical activity measures as well as perceived general health were significantly lower compared to a reference population (P< 0.05). Peak heart rate and peak oxygen pulse explained together 90% of the variability in exercise duration (model F = 162.72; P < 0.0001). Type of surgery, total energy expenditure and right ventricular contractility were independent predictors of peak VO2% explaining 43% of the variability (model F=8.75; P=0.0002).Conclusions Impaired peak exercise performance in d-TGA patients results mainly from the inability to increase stroke volume and heart rate at higher exercise intensities. Senning repair and a well-preserved right ventricular function are related to a better peak VO2%. Furthermore, an active lifestyle has a positive effect on exercise capacity and perceived physical functioning. Therefore it might be indicated to encourage d-TGA patients to adopt a more physically active lifestyle.

Atrial Switch Operation in the Current Era

Although rarely performed today, atrial switch operations continue to have an important role in the management of some forms of congenital heart disease. In developing countries, delayed diagnosis and presentation of patients with transposition of the great arteries is not uncommon. For some patients who are referred for surgery beyond the newborn period, the atrial switch operations are still considered to be the best option. Also, as part of surgical repair of congenitally corrected transposition, an atrial switch operation is combined with arterial switch or the Rastelli procedure as an alternative to physiologic repair. In isolated ventricular inversion (atrioventricular discordance with ventriculoarterial concordance), the atrial switch operation alone leads to complete anatomical correction. Finally, management of late complications of atrial switch operations requires a thorough understanding of the procedures.

Arterial Switch Operation With Unidirectional Valved Patch Closure of Ventricular Septal Defect in Patients With Transposition of Great Arteries and Severe Pulmonary Hypertension

For patients with dextro-transposition of great arteries (d-TGAs), ventricular septal defect (VSD), and severe pulmonary arterial hypertension (PAH), the common surgical options are palliative arterial switch operation (ASO) or palliative atrial switch operation leaving the VSD open. We evaluated the role of ASO with VSD closure using a fenestrated unidirectional valved patch (UVP). Between July 2009 and February 2011, six patients with TGAs, VSD, and severe PAH (mean age 39.8 ± 47.4 months, median 21, range 8-132 months), weighing 10.7 ± 9.2 kg (median 8.6, range 4.3-29 kg), underwent ASO with VSD closure using our simple technique of UVP. Mean pulmonary artery systolic pressure before the operation was 106 ± 12.7 mm Hg (median 107.5, range 95-126 mm Hg) and pulmonary vascular resistance was 9.5 ± 4.22 units (median 9.5, range 6.6-17.1 Wood units). There were no deaths. All patients had a postoperative systemic arterial saturation of more than 95%, although there were frequent episodes of systemic desaturation due to right-to-left shunt across the valved VSD patch (as seen on transesophageal and transthoracic echocardiograms). Mean follow-up was 10 ± 7.6 months (median 7.5, range 1-22 months). At most recent follow-up, all patients had systemic arterial saturation of more than 95% and no right-to-left shunt through the VSD patch. In one patient, the follow-up cardiac catheterization showed a fall in pulmonary artery systolic pressure to 49 mm Hg. Arterial switch operation with UVP VSD closure is feasible with acceptable early results. It avoids complications of palliative atrial switch (arrhythmia and baffle obstruction) and partially or completely open VSD.

Total isovolumic time relates to exercise capacity in patients with transposition of the great arteries late after atrial switch procedures

Systemic right ventricular systolic dysfunction is common late after atrial switch surgery for transposition of the great arteries. Total isovolumic time is the time that the ventricle is neither ejecting nor filling and is calculated without relying on geometric assumptions. We assessed resting total isovolumic time in this population and its relationship to exercise capacity. A total of 40 adult patients with transposition of the great arteries after atrial switch - and 10 healthy controls - underwent transthoracic echocardiography and cardiopulmonary exercise testing from January, 2006 to January, 2009. Resting total isovolumic time was measured in seconds per minute: 60 minus total ejection time plus total filling time. The mean age was 31.6 plus or minus 7.6 years, and 38.0% were men. There were 16 patients (40%) who had more than or equal to moderate systolic dysfunction of the right ventricle. Intra- and inter-observer agreement was good for total isovolumic time, which was significantly prolonged in patients compared with controls (12.0 plus or minus 3.9 seconds per minute versus 6.0 plus or minus 1.8 seconds per minute, p-value less than 0.001) and correlated significantly with peak oxygen consumption (r equals minus 0.63, p-value less than 0.001). The correlation strengthened (r equals minus 0.73, p-value less than 0.001) after excluding seven patients with exercise-induced cyanosis. No relationship was found between exercise capacity and right ventricular ejection fraction or long-axis amplitude. Resting isovolumic time is prolonged after atrial switch for patients with transposition of the great arteries. It is highly reproducible and relates well to exercise capacity.

Life-threatening atrial tachycardia after the Senning operation in a patient with transposition of the great arteries

Atrial tachycardia (AT) is recognized as a risk factor of sudden death (SD) in patients with transposition of the great arteries (TGA) after atrial switch operation. A 20-year-old man with TGA who had undergone a Senning operation experienced a near-miss SD event 1 day after appearance of AT. He was successfully resuscitated by electrical defibrillation for documented ventricular fibrillation. An electrophysiological study showed three types of AT, and all of them were terminated by radiofrequency catheter ablation (RFCA). We consider that symptomatic AT against cardiac medications is indicated for RFCA therapy.

Persistent Institutional Difficulties in Surgery for Transposition of the Great Arteries in Guatemala: Analysis With the Aristotle Basic and Comprehensive Scores

Background. Neonates with complex congenital cardiac lesions are largely inadequately managed in Guatemala. Methods. Between 1997 and 2009, 79 patients who underwent operations for transposition of the great arteries were identified; 51 (63.3%) had an arterial switch operation (ASO) and 28 (36%) an atrial switch operation (ATSO). The Aristotle Basic Complexity score (ABC score) and the Aristotle Comprehensive Complexity score (ACC score) have been used to aid in the evaluation of quality of care associated with pediatric cardiac surgery by adjusting for operative complexity. Results. In-hospital mortality was 47% for the ASO and 25% for the ATSO group; 36.7% were beyond 1 month of age and many exhibited increased preoperative risk factors. The mean ABC score was 9.75 ± 0.89 and the ACC score was 12.12 ± 2.7, with a mean 2.36-point increase (P < .05). Comparing survivors and nonsurvivors with both scores, significant differences were identified (ABC: P < .04 and ACC: P < .02). Conclusion. During this 13-year period, a low volume of surgery for transposition of the great arteries (TGA) was performed at our institution with a relatively high surgical mortality. Many patients with TGA in Guatemala are either never referred for surgery or referred late. Strategies to improve outcomes for neonates with TGA in Guatemala must include increases in early diagnosis countrywide and prompt referral to our unit. Based on the larger number of neonates with TGA that would be referred to our center, we anticipate that this strategy should substantially improve surgical outcomes and favor overall team-related skills.

Electrophysiology Issues In Adult Congenital Heart Disease

Improved surgical outcomes in children have led to a growing population of adults with congenital heart disease. Rhythm disturbances in the adult congenital heart disease (ACHD) patient can be intrinsic to the anomaly or acquired after palliation. Tachyarrhythmias, either supraventricular or ventricular, and bradyarrhythmias, either sinus node dysfunction or atrioventricular block, may occur frequently. Technological advances in intervention and surgical approaches have led to prophylactic and therapeutic reduction in arrhythmias. In order of escalation, this article addresses medical management, catheter ablation, device therapy for antitachycardia pacing and defibrillation, and surgical intervention. There are now an estimated one million-plus ACHD patients living in the United States. An estimated 45% of those have simple defects (e.g., atrial septal defects), 40% have moderately complex defects (e.g., tetralogy of Fallot, or ToF), and 15% have severely complex defects (e.g., single ventricle anatomy or surgical palliations for transposition of the great arteries [TGA]). The moderate and severe categories have a high incidence of arrhythmia. Of older repaired ToF patients, 34% develop symptomatic atrial or supraventricular tachycardias, 8.5% develop high-grade ventricular tachycardia (VT), and there are an increasing number of implantable defibrillators due to a sudden-death estimate of 2% per decade. Thus, an estimated 50,000 adults with repaired ToF will require electrophysiology follow-up with 100 sudden deaths per year nationally. Roughly 3% of all congenital heart surgeries requiring cardiopulmonary bypass have post-operative AV block, and 1% will require permanent pacing. Older atriopulmonary Fontans have up to an estimated 50% incidence of atrial tachycardia within a decade of palliation due to suture lines and elevated atrial pressures. Patients who have undergone an atrial switch operation (e.g., Mustard or Senning operations) are rarely exclusively in sinus rhythm a decade after repair, thus posing problems for rhythm control and anticoagulation. Catheter ablation in congenital heart disease is often more challenging than structurally normal hearts because of abnormal anatomy (congenital and/or post-surgical) and thicker chamber walls due to unfavorable hemodynamics. In preparation, review of noninvasive imaging, previous catheterization angiography, and surgical palliation reports are paramount prior to a procedure. Fortunately, to meet the growing challenge, newer software with 3-D packages allow for improved mapping. In addition, advances with larger-tipped and irrigated-tip catheters allow for deeper, more effective lesions to be placed. Several advances in surgical approach have led to a reduction in arrhythmias. For example, the arterial switch operation for d-transposition of the great arteries instead of the aforementioned atrial switch operation eliminates the use of a systemic right ventricle that can later develop intra-atrial reentrant tachycardia and sinus node dysfunction. Other advances include paying careful attention to minimizing ventriculotomies in ToF and ventricular septal defect (VSD) repairs, earlier complete repairs, and valve sparing to reduce pulmonary insufficiency. Finally, completion of the extra-cardiac Fontan procedure (e.g., total cavopulmonary connection) for single ventricles avoids extensive suture lines in the right atrium, thereby reducing scarring and higher pressures that lead to IART and sinus node dysfunction. Extracardiac (EC) conduits and lateral tunnel (LT) Fontans are preferred today, and the Fontan conversion procedure (converting prior atriopulmonary Fontans to the EC or LT type) can be performed to reduce arrhythmia and thromboembolic events.

Long-term morbidity and quality of life after surgical repair of transposition of the great arteries: atrial versus arterial switch operation

Since a growing number of patients after surgical repair of transposition of the great arteries (TGA) survive until adulthood the focus of attention has shifted to the management of associated long-term morbidity and quality of life (QoL). Therefore, we reviewed all patients that underwent surgical repair of TGA at our institution and compared long-term results after atrial and arterial switch operation. Between 1973 and 2000, a total of 302 patients underwent either atrial switch operation (n=222) or arterial switch operation (n=80). Mean follow-up was 14.5±10.1 years. The arterial switch repair was associated with a higher early mortality whereas long-term survival was comparable between both groups. Postoperative arrhythmias including loss of sinus rhythm and pacemaker implantation occurred significantly more often after atrial switch repair. There was a trend towards a more favourable outcome of the arterial switch group concerning freedom from re-interventions, severe systemic ventricular dysfunction and need for heart failure medication. However, also the arterial switch operation was associated with an increased incidence of loss of sinus rhythm and neo-aortic valve regurgitation during late follow-up. Health related QoL according to the SF-36 questionnaire was not significantly different between both groups and comparable to a healthy population.

The Single Center Experience of Pacing Device Implantation in Patients with Complex Congenital Heart Disease

Aim: Transvenous cardiovascular implantable electronic devices (CIEDs) implantation in patients with complex congenital heart disease (CCHD) is challenging because of their complex anatomy. We report our experience of CIEDs implantation in CCHD patients. Methods: CCHD patients underwent the CIEDs implantation, were analyzed retrospectively. Results: We implanted CIEDs (pacemaker n=19, ICD n=5, CRT-D n=2) in consecutive 26 CCHD patients (mean 25 y.o.) from 1994 to 2011. The underlying heart diseases were tricuspid atresia (n=2) and single RV (n=1) both after Fontan operation, single LV (n=1) underwent the septation, truncus arteiosus communis underwent Rastelli (n=1), transposition of great ateries (TGA) (n=9) and corrected TGA (n=12; SLL n=9, IDD n=3). Twelve patients with TGA and corrected TGA underwent atrial switch (n=6) or double switch (n=6) operation. The pacing leads were successfully positioned with favorable sensing and pacing threshold in all patients, transvenously, without major complications. In 2 patients with cTGA, we successfully positioned the leads at the LV apex and in the coronary vein for the resynchronization of anatomical RV. The lead revision was required during the follow-up period, due to the lead dislodgement (n=2) and the lead fracture (n=2). Conclusion: Transvenous implantation of CIEDs was safely performed and feasible even in patients with CCHD and sometimes with atrio-ventricular discordance.

Prä- und Postoperative Bildgebung bei Patienten mit Transposition der großen Gefäße

Transposition of the great arteries (TGA) is a rare disease representing not more than 3-5% of all congenital heart diseases. TGA is a cardiac anomaly in which the aorta arises entirely or largely from the morphological right ventricle and the pulmonary artery from the morphological left ventricle. This is called a ventriculo-arterial discordant connection and when accompanied by an atrio-ventricular concordant connection it is called a complete or D-transposition (D-TGA). The terms congenitally corrected TGA (ccTGA) or L-TGA describe an atrio-ventricular discordant connection. In D-TGA survival can only be achieved if additional shunting is simultaneously present, which possibly has to be created post-natal by the so-called Rashkind maneuver.Nowadays, an early anatomic correction using the arterial switch operation is the treatment of choice. Up to the 1980s, an atrial switch operation according to Senning/Mustard was performed. Apart from echocardiography the imaging modality of choice is usually MRI to assess the complex postoperative anatomy, viability of the myocardium and to perform a volumetric and functional assessment, including MR flow measurements. Multidetector computed tomography (MDCT) is used if there are contraindications to MRI or if an assessment of cardiac and especially coronary anatomy is the main interest.

Ventricular Assist Device Placement in an Adult with D-transposition of the Great Arteries with Prior Mustard Operation

Adults with congenital heart defects and congestive heart failure are a challenging population because of their complex anatomy, prior surgical palliation, and hemodynamic status. We report one of the first cases of a ventricular assist device placement in a patient with decompensated heart failure and a history of D-transposition of the great vessels who had a prior atrial switch operation.

Diastolic ventricular interaction in patients after atrial switch for transposition of the great arteries: A speckle tracking echocardiographic study

BackgroundWe tested the hypothesis that diastolic ventricular interaction occurs after atrial switch operation for transposition of the great arteries (TGA) and that subpulmonary LV diastolic function is influenced by septal geometry. MethodsTwenty-nine patients (male 19) after atrial switch operation for TGA aged 20.8±4.1years and 27 healthy controls were studied. Two-dimensional longitudinal systolic strain, systolic (SRs), early diastolic (SRe), and late diastolic (SRa) strain rates of both ventricles were determined using speckle tracking echocardiography. Early diastolic trans-atrioventricular velocity (E) and myocardial early diastolic myocardial velocity (e) at the ventricular free wall–annular junction were measured. Geometry of the morphologic left ventricle was quantified by the diastolic eccentricity index (EI). ResultsIn both systemic and subpulmonary ventricles, SRe and SRa were significantly lower and trans-atrioventricular E/e ratios higher in patients than controls (all p<0.001). In patients, RV SRe correlated with left ventricular (LV) SRe (r=0.49, p=0.008), and RV SRa correlated with LV SRa (r=0.46, p=0.01). Significant leftward shifting of the septum in patients was reflected by the greater LV EI (p<0.001). In patients, LV EI correlated with age- and sex-adjusted z score of LV end-diastolic volume. As a group, LV EI correlated negatively with LV SRe (r=−0.62, p<0.001) and LV SRa (r=−0.51, p<0.001), and positively with mitral E/e ratio (r=0.33, p=0.02). ConclusionsSystemic RV diastolic dysfunction occurs after atrial switch operation and correlates with subpulmonary LV diastolic dysfunction. The observed diastolic ventricular interaction may potentially be mediated through alteration of septal geometry.

Surgery for transposition of the great arteries, ventricular septal defect and left ventricular outflow tract obstruction: European Congenital Heart Surgeons Association multicentre study

Optimal surgical management for patients with transposition of the great arteries (TGA), ventricular septal defect (VSD) and left ventricular outflow obstruction (LVOTO) remains controversial. Although the Rastelli operation has been the most widely performed surgical procedure during the past decades, several studies have shown its suboptimal long-term prognosis. Other operations have been developed to improve results. This study was performed to compare the outcomes of the different surgical approaches for patients with TGA, VSD and LVOTO, as well as to determine risk factors for mortality and re-intervention. Records from 146 patients undergoing surgery from 1980 to 2008 from eight European hospitals were reviewed. Median age at operation was 21.5 months (range 0.2-165.1 months), and median weight was 10.0 kg (range 2.0-41.0 kg). Surgical procedures involved were the Rastelli procedure (82), arterial (24) and atrial (5) switch operation with relief of LVOTO, Réparation à l'Etage ventriculaire (REV) procedure (7) and the Metras modification (24), as well as the Nikaidoh procedure (4). The overall survival was 88%, 88% and 58% at 1, 10 and 20 years, respectively. The overall event-free survival was 80%, 45% and 26% at 1, 10 and 20 years, respectively. The REV procedure and the Metras modification were found to have the best long-term results in both survival and event-free survival rates. Multivariate analysis revealed year of operation, non-commitment of the VSD and prolonged cardiopulmonary bypass (CPB) time as risk factors for mortality while age at surgery, year of operation and type of corrective surgery were risk factors for re-intervention. Different surgical approaches have been developed for patients with TGA, VSD and LVOTO. The REV procedure and the Metras modification were observed to have favourable long-term results in survival and event-free survival rates. Aortic translocation techniques such as the Nikaidoh procedure seem promising, but further studies will be needed to confirm this in the long term.

An Alternative Technique for the Atrial Switch Operation for Transposition of the Great Arteries in an Unoperated Adult Patient

We report a 26-year-old patient with d-transposition of great arteries, intact ventricular septum, and an atrial septal defect. The relevant literature on late natural survivors with this condition is reviewed and the technical aspects of an alternative technique for accomplishing a successful atrial switch in this situation are discussed.

Invited Commentary

Invited Commentary

Long-term outcome after surgical repair of transposition of the great arteries: atrial versus arterial switch operation

Long-term outcome after surgical repair of transposition of the great arteries: atrial versus arterial switch operation