Atrial Switch Operation Research Articles

Abstract 1965: Global Longitudinal Strain and Strain Rate Imaging for Assessment of Systemic Right Ventricular Function

Background - We determined the usefulness of novel 2-dimensional strain indices, based on speckle tracking imaging, for assessment of systemic right ventricular (RV) function after atrial switch operation for transposition of the great arteries. Methods - Twenty-six patients, aged 21.0±3.6 years at 19.9±3.2 years after atrial switch operation, and 27 age-matched controls were studied. Two-dimensional imaging at the 4 chamber view was obtained with tracing of the entire RV endocardial border. The RV global longitudinal strain (GLS) and GLS rate were derived using an automated software (EchoPAC, GE Medical) (fig ), and correlated with tissue Doppler-derived RV isovolumic acceleration (IVA), and, in patient cohort, with cardiac magnetic resonance-derived RV ejection fraction. Results - Intraobserver and interobserver variability for measurement of GLS from 20 studies were 0.06±1.93% and 0.24±1.77% respectively. Compared with controls, patients had lower RV GLS (17.1±1.9% vs 26.3 ±2.9%, p<0.001), reduced GLS rate (0.78 ±0.11/s vs 1.33 ±0.23/s, p <0.001), lower RV IVA (1.10 ±0.36 m/s 2 vs 1.56 ±0.53 m/s 2 , p=0.001), and increased RV myocardial performance index (0.52±0.09 vs 0.38 ±0.09, p=0.001). Both RV GLS and GLS rate correlated positively with RV IVA (r=0.43, p<0.001 and r=0.46, p<0.001, respectively), and negatively with RV myocardial performance index (r=−0.65, p<0.001 and r=−0.57, p<0.001 respectively). In patients, GLS rate correlated positively with RV ejection fraction (r=0.62, p=0.001). Conclusion - Two-dimensional RV GLS and GLS rate are novel indices potentially useful for assessment of systemic RV function.

Recanalization of systemic venous baffles by radiofrequency perforation and stent implantation

Complete transposition of the great arteries has been historically managed by the Mustard (atrial switch) operation. This procedure is associated with longterm complications such as baffle occlusion, which also precludes the insertion of a permanent transvenous pacemaker. Transcatheter techniques have allowed the successful angioplasty and stenting of stenotic baffles but complete occlusions continue to pose a therapeutic challenge. We report the use of a novel technique, a radiofrequency perforation wire for the management of complete occlusion of systemic venous baffles post-Mustard operation.

Brain natriuretic peptide as a biomarker of systemic right ventricular function in patients with transposition of great arteries after atrial switch operation

Background Assessment of systemic right ventricular (RV) function is inherently difficult. In adults, plasma brain natriuretic peptide (BNP) level has been shown to reflect systemic ventricular dysfunction. We sought to test the hypothesis that plasma BNP is a biomarker of systemic RV function in patients after atrial switch operation. Methods We determined the RV function in 44 patients, 35 after Senning and 9 after Mustard operation, aged 19.7 ± 4.0 years, by tissue Doppler echocardiography and determination of myocardial performance index (MPI). The results were compared to the left ventricular function of 14 age-matched controls. Their plasma BNP levels were correlated with indices of systemic ventricular function. Results Compared with controls, the patients had greater MPI ( p < 0.001), lower systemic ventricular free wall-annular early diastolic ( p < 0.001), late diastolic ( p < 0.001), and systolic velocities ( p = 0.001), lower septal-annular early diastolic ( p < 0.001), late diastolic ( p < 0.001), and systolic velocities ( p < 0.001), and higher BNP levels ( p = 0.03). Plasma BNP levels correlated positively with MPI ( r = 0.43, p = 0.001) and negatively with the free wall- and septal-annular myocardial velocities ( r = − 0.32 to − 0.47, p < 0.05). The area under the receiver operating characteristic curve for BNP to detect ventricular dysfunction (MPI > 0.45) in patients was 0.67 ( p = 0.04). A BNP level of 36 pg/ml had a sensitivity of 55%, specificity of 86%, positive predictive value 80%, negative predictive value of 64%, and an accuracy of 70% for detecting systemic ventricular dysfunction. Conclusions Plasma BNP has modest accuracy in the detection of systemic RV dysfunction in patients after atrial switch operation.

Diastolic Biventricular Impairment at Long-term Follow-up After Atrial Switch Operation for Complete Transposition of the Great Arteries: An Exercise Tissue Doppler Echocardiography Study

The aim of this study was to investigate regional myocardial function after atrial switch operation for transposition of the great arteries (TGA) using tissue Doppler echocardiography with strain rate (SR) imaging. In all, 24 patients with TGA aged 12 to 33 years and 10 control subjects underwent tissue Doppler echocardiography/SR imaging at rest and during bicycle exercise at 1 and 2 W/kg. Longitudinal function was quantified by strain, SR, and peak velocities measured in the free wall of the systemic ventricle, in septum and in the lateral wall of the subpulmonary ventricle. In patients with TGA, both ventricles showed reduced peak systolic SR values at rest. The increase in peak early diastolic velocity with exercise was reduced in the systemic ventricle (-47 +/- 23 mm/s at rest to -73 +/- 35 mm/s at 2 W/kg, P < .05) and absent in the subpulmonary ventricle (-78 +/- 38 mm/s at rest to -75 +/- 19 mm/s at 2 W/kg) of patients with TGA. Exercise tissue Doppler echocardiography/SR imaging identified severely reduced relaxation reserve of both ventricles as typical feature of myocardial dysfunction after atrial repair for TGA.

Pulmonary and aortic root translocation in the management of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction

The Nikaidoh procedure, as an alternative to the Rastelli operation for dealing with transposition of the great arteries (TGA) with ventricular septal defect (VSD) and pulmonary stenosis (PS), could obtain a superior anatomic result. 1,2 However, the extracardiac conduit is unable to grow and is inevitably calcified; thereafter, the patients required reoperation. We report our experience with a novel modification in which the native pulmonary valve was preserved to address these problems.

Arrhythmias in Adult Patients With Congenital Heart Disease

By the time patients with congenital heart disease (CHD) reach adolescence and early adulthood, rhythm status has often become an active issue, if not the central issue, in their cardiac management. For some, arrhythmias are intrinsic to the structural malformation itself, as is the case with Wolff-Parkinson-White syndrome in the setting of Ebstein’s anomaly, or atrioventricular (AV) block in the setting of “congenitally corrected” transposition of the great arteries (L-TGA). For most other CHD patients, arrhythmias represent an acquired condition related to the unique myocardial substrate created by surgical scars in conjunction with cyanosis and abnormal pressure/volume loads of long duration. This review will attempt to address the major rhythm difficulties faced by adults with CHD, concentrating on electrophysiological features that distinguish CHD from more conventional forms of adult heart disease. A listing of specific arrhythmias and commonly associated congenital defects is provided in Table 1 to serve as an outline for the discussion. View this table: TABLE 1. Specific Arrhythmias and Associated Defects in Adults With Congenital Heart Disease As of 2001, there were estimated to be 800 000 adults with CHD living in the United States,1 a number that has grown steadily as more survivors of childhood surgery reach maturity. Of these, roughly 45% are considered to have mild forms of CHD (eg, atrial septal defect, valvar pulmonary stenosis), 40% are classified as having moderate disease (eg, tetralogy of Fallot, Ebstein’s anomaly), and 15% are considered to have complex disease (eg, single ventricle, transposition of the great arteries). Although arrhythmias can develop within any of the 3 subgroups, the incidence is highest for patients in the moderate and severe categories. Tetralogy of Fallot is an instructive example of moderate CHD with a large arrhythmia burden. As many as one third of patients with repaired tetralogy develop symptomatic atrial tachycardias by …

Intermediate-term results of the Senning or Mustard procedures combined with the Rastelli operation for patients with discordant atrioventricular connections associated with discordant ventriculoarterial connections or double outlet right ventricle

In patients with discordant atrioventricular and ventriculoarterial connections, anatomic repair restores the morphologically left ventricle to its role in supporting the systemic circulation. In this study, we have evaluated the outcomes in the intermediate term for this complex surgical procedure. Between December 1984 and October 2003, 4 patients underwent an atrial switch operation concomitantly with a Rastelli operation, and 2 patients underwent an atrial switch operation and a patch-plasty of the pulmonary outflow tract for anatomic repair at a mean age of 3.3 plus or minus 2.1 years. All patients had intracardiac rerouting, connecting the morphologically left ventricle to the aorta. There were no hospital deaths. In 5 patients, reoperation was needed, either for baffle complications, exchange of the conduit, repair of a residual ventricular septal defect, or relief of obstruction within the left ventricular outflow tract. Death occurred in 1 patient, from cardiac failure 6 months after correction. Mean follow-up time was 6.5 plus or minus 6.4 years, with a range from 6 months to 17 years. At follow-up, 1 patient presented with moderate tricuspid insufficiency, and 1 patient with mild obstruction of the pulmonary venous pathway. The remaining 3 patients showed good left and right ventricular function, and no, or mild tricuspid and mitral insufficiency. Anatomic repair can be performed with low hospital mortality. Restoration of the morphologically left ventricle into the systemic circulation in patients with discordant atrioventricular and ventriculoarterial connections is a demanding approach, associated with various reoperations over time. Despite this, the approach seems to be an appropriate solution for selected patients, since the majority of the patients show good left and right ventricular function, and no, or mild tricuspid and mitral insufficiency up to 17 years after correction.

Issue Highlights

HomeCirculationVol. 114, No. 18Issue Highlights Free AccessIn BriefPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessIn BriefPDF/EPUBIssue Highlights Originally published31 Oct 2006https://doi.org/10.1161/circ.114.18.1897Circulation. 2006;114:1897PRESENCE OF A VENTRICULAR SEPTAL DEFECT AND THE MUSTARD OPERATION ARE RISK FACTORS FOR LATE MORTALITY AFTER THE ATRIAL SWITCH OPERATION: THIRTY YEARS OF FOLLOW-UP IN 417 PATIENTS AT A SINGLE CENTER, by Lange et al.Many patients with transposition of the great vessels are surviving for decades after surgical repair. For decades, the surgical approach to transposition of the great vessels had been an atrial switch (Senning or Mustard) procedure. Currently, an arterial switch is the standard preferred procedure. The late results of procedures that are not in vogue today, however, are of importance in caring for the growing population of adults with repaired congenital cardiac defects. This study by Lange et al, from a single center, reviews 329 patients after a Senning Procedure and 88 after a Mustard operation with mean follow-up of 19 years. This historic collective of the atrial switch operations, especially those that require ventricular septal defect closure, provides the clinician with information about how to advise and follow this patient population. See p 1905.PERIPHERAL ARTERIAL DISEASE IN PATIENTS WITH END-STAGE RENAL DISEASE: OBSERVATIONS FROM THE DIALYSIS OUTCOMES AND PRACTICE PATTERNS STUDY (DOPPS), by Rajagopalan et al.Patients with end-stage renal disease and patients with peripheral arterial disease are both at high risk for cardiovascular morbidity and mortality. In Rajagopalan and colleagues examined a large international cohort of hemodialysis patients to understand the prevalence and prognosis of peripheral arterial disease in hemodialysis patients. Although they observed significant international variation, the investigators report a poor prognosis in the 25% of patients with peripheral arterial disease. Their research revealed an approximately 40% increased risk of cardiac and all-cause mortality and a doubling of cardiovascular events in hemodialysis patients, who already experience significant risk because of their end-stage kidney disease. The present study provides support for efforts to understand how to prevent the progression of chronic kidney disease and the development of peripheral arterial disease complications. See p 1914.INDUCTION OF ORAL TOLERANCE TO OXIDIZED LOW-DENSITY LIPOPROTEIN AMELIORATES ATHEROSCLEROSIS, by van Puijvelde et al.andSHORT-TERM TREATMENT WITH ANTI-CD3 ANTIBODY REDUCES THE DEVELOPMENT AND PROGRESSION OF ATHEROSCLEROSIS IN MICE, by Steffens et al.The notion that atherosclerosis is, in part, an inflammatory disease is now well established. Moreover, we now have considerable data concerning both the antigens generated during atherosclerosis and the cell types involved. The emergence of these data has prompted speculation that immune modulation may prove to be an effective strategy to ameliorate atherosclerosis. In this issue of Circulation, we have 2 landmark studies that have employed distinct methods of immune modulation to attenuate atherosclerosis in animal models. One of these investigations even suggests the possibility of developing “vaccination” strategies that could be utilized to prevent human disease. The impact of these studies is discussed in the accompanying editorial. See pp 1968 and 1977 (editorial on p 1901).Visit http://circ.ahajournals.org:Images in Cardiovascular MedicinePercutaneous Transcatheter Balloon Valvuloplasty for Bioprosthetic Tricuspid Valve Stenosis. See p e558. Download figureDownload PowerPointA 21-Year-Old College Student With Chest Distress and ECG Mimicking Dextrocardia. See p e560.Extensive Invasive Cardiothoracic Aspergillosis. See p e562.Book ReviewObesity and Cardiovascular Disease. See p e564.CorrespondenceSee p e565. Previous Back to top Next FiguresReferencesRelatedDetails October 31, 2006Vol 114, Issue 18 Advertisement Article InformationMetrics https://doi.org/10.1161/circ.114.18.1897 Originally publishedOctober 31, 2006 PDF download Advertisement

Presence of a Ventricular Septal Defect and the Mustard Operation Are Risk Factors for Late Mortality After the Atrial Switch Operation

Survival and functional status of patients with transposition of the great arteries treated by atrial switch are reported to be reasonably good within the first 15 postoperative years. However, in some patients, the function of the systemic right ventricle deteriorates, leading to significant morbidity or even to late mortality. This study seeks to identify risk factors for late death. Records of 329 patients after the Senning operation and 88 after the Mustard operation at a single center were retrospectively reviewed for demographic, anatomic, and echocardiographic predictors and outcomes. Mean follow-up interval was 19.1+/-6.5 years and was 95% complete. Survival 25 years after the Mustard procedure was 75.9+/-4.8% and after the Senning procedure was 90.9+/-2.3% (P=0.002). Mustard patients died more often of arrhythmia than Senning patients (P<0.001) and needed more baffle-related reoperations (P<0.0001). Ventricular septal defect closure at the time of the atrial switch operation (hazard rate=2.3; 95% confidence interval, 1.1 to 4.7; P=0.025) and the Mustard operation (hazard rate=2.0; 95% confidence interval, 1.01 to 3.8; P=0.045) emerged as independent risk factors for late mortality in multivariate analysis. At follow-up, 85.8% of the patients led a normal life with full-time work, and 11.8% were able to do part-time work. Only 2.4% experienced noticeable limitation of activities. Our patient data reveal satisfactory results at long term in this historic collective. Patients who had undergone ventricular septal defect closure at the time of the atrial switch operation and those who had undergone a Mustard operation are at higher risk for late death. Close follow-up, especially of these subgroups, is warranted.

Transposition of Great Arteries Is Associated With Increased Carotid Artery Stiffness

Transposition of great arteries is the consequence of abnormal aorticopulmonary septation. Animal embryonic data indicate that septation and elastogenesis are related events, but human and clinical data are not available. We tested the hypothesis that large artery elastic function was impaired in patients with transposition of great arteries. We studied 34 patients aged 9 to 19 years, 12+/-3 years after atrial switch operation; 14 patients aged 7 to 9 years, 8+/-1 years after arterial switch operation; and 108 healthy control subjects matched for age. Carotid artery diastolic diameter and pulsatile distension were determined by echo wall-tracking; carotid blood pressure was measured by tonometry. Systolic pressure was higher and diastolic pressure was lower in patients than in controls. Patients with atrial and arterial switch repair were compared with their respective controls by 2-factor ANOVA. For patients with atrial switch repair versus control, stiffness index beta was 4.9+/-1.5 versus 3.1+/-1.0 (P<0.001); for patients witch arterial switch versus control, stiffness index beta was 3.8+/-1.1 versus 2.1+/-0.6 (P<0.001). Similar differences were observed for carotid compliance, distensibility, and incremental elastic modulus as well. The interaction term was not significant for any of the elastic variables, indicating that carotid stiffening was a characteristic of the condition and not the consequence of different hemodynamics. Carotid artery is markedly stiffer in patients, suggesting that impaired elastogenesis may constitute part of the congenital abnormality. Since carotid artery stiffness has been established as an independent cardiovascular risk factor, this condition may have consequences in the clinical management of these patients.

Arterial switch operation using aortic homograft for transposition of the great arteries with pulmonary regurgitation

We report a case of a 15 month-old boy who underwent the arterial switch operation using cryopreserved aortic homograft for transposition of the great arteries with pulmonary regurgitation, with coexisting right ventricular outflow tract obstruction precluding atrial switch operation. Follow-up echocardiography at 6 months showed trivial neoaortic valve regurgitation, no significant systemic outflow obstruction, with good cardiac function. In small children, the choice of material for left ventricular outflow tract reconstruction is one of the most crucial issues. Cryopreserved homograft has been one of the primary options for the aortic valve replacement in small children because of the ease of suturing and excellent hemostasis.

Combined atrial arterial switch operation (double switch) for hearts with Shone syndrome and pulmonary hypertension

DOI:€10.1016/j.jtcvs.2005.09.028 J Thorac Cardiovasc Surg 2006;131:471-473 Brawn A.R. Hosseinpour, M. Amanullah, I.R. Ramnarine, O. Stumper, D.J. Barron and W.J.syndrome and pulmonary hypertension Combined atrial arterial switch operation (double switch) for hearts with Shonehttp://jtcs.ctsnetjournals.org/cgi/content/full/131/2/471 located on the World Wide Web at: The online version of this article, along with updated information and services, is

Evaluation of Right Ventricular Performance Long After the Atrial Switch Operation for Transposition of the Great Arteries Using the Doppler Tei Index

Right ventricular (RV) dysfunction may occur in patients after the atrial switch operation for d-transposition of the great arteries (d-TGA) and can be an important complication. Noninvasive assessment of RV function using echocardiography is necessary for following up these patients. We evaluated RV function using the Doppler Tei index (RV Tei index). The RV Tei index measures the ratio of total time intervals in isovolumetric contraction and relaxation to the ejection time. The subjects consisted of 33 patients who had undergone the atrial switch operation for d-TGA (the atrial switch group) (mean age, 21 +/- 4 years), 10 patients with pulmonary artery stenosis after the arterial switch operation for d-TGA (the arterial switch group) (mean age, 17 +/- 1 years), and 10 patients with a normally structured heart as a control group (mean age, 26 +/- 7 years). The RV Tei index (0.65 +/- 0.16) was significantly higher in the atrial switch group than in the arterial switch group (0.29 +/- 0.07) and the control group (0.29 +/- 0.01) (p < 0.05). The fractional area change of the RV obtained from the four-chamber view in the atrial switch group showed a significant negative correlation with the RV Tei index (r = -0.58, p < 0.01). The RV Tei index increased with increasing severity of the NYHA functional class. In the moderate/severe tricuspid regurgitation group, it was significantly higher than in patients with none/trivial tricuspid regurgitation. We conclude that the RV Tei index is useful for evaluating RV junction long after the atrial switch operation for d-TGA.

Cardiac transplantation in adults with congenital heart disease

Objectives: Advances in surgical and medical management of congenital heart disease result in survival of an increasing number of grown-up congenital heart (GUCH) patients. As myocardial dysfunction can occur, some of them require heart transplantation (HTx). Methods and results: Fourteen GUCH patients (mean age 30.6, range 16–58 years) underwent HTx between April 1986 and June 2005 at our institution. The diagnoses were: single ventricle (n=4), d-TGA and previous atrial switch operation (n=2), l-TGA (n=1), Morbus Uhl (n=3), others with VSD and complex valve surgery. Refractory heart failure (NYHA IV) was present in all. Four patients received heart transplants after mechanical circulatory support (3 ECMO, 1 BVAD Berlin Heart). Nine patients had a mean of 2 previous cardiac operations. There was 1 early death due to infection. The Kaplan-Meier survival rate was 93% at 1 year, 84% at 5 and 84% at 10 years. No anatomic or surgical risk factor was predictive of death. Outcome was compared with matched (age, gender, time of HTx) controls consisting of 70 patients with dilated cardiomyopathy (DCM) and 28 with ischemic heart disease (IHD). Survival rates of the control groups did not differ significantly from those of GUCH (1 year, 5 years, 10 years: DCM 92%, 88%, 84%; IHD 9%, 89%, 75%). Conclusions: Successful HTx can be achieved in patients with GUCH disease, with an outcome similar to that of patients with acquired heart disease. Detailed assessment of cardiac anatomy and careful surgical planning are essential to obtain optimal results.

Early Results of Anatomic Repair in a Subgroup of Corrected Transposition

The atrial switch operation with the Rastelli procedure is becoming popular for treatment of the subgroup of corrected transposition of the great arteries with ventricular septal defect and pulmonary obstruction. This technique eliminates the problem of short- and long-term right ventricular failure, and decreases the incidence of iatrogenic atrioventricular heart block. Between April 2001 and November 2002, this technique was used in 3 patients aged 5 to 7 years. Two had a Senning operation and one had a Mustard operation. There was no operative death. The first patient needed re-operation to close the sternum. The last patient was re-explored for bleeding. All patients were in New York Heart Association functional class I at their last follow-up. The atrial switch plus Rastelli procedure is feasible in this subgroup of corrected transposition, but longer follow-up is necessary to determine whether this approach is indeed warranted.

Assessment of myocardial function of the systemic right ventricle in patients with D-transposition of the great arteries after atrial switch operation by tissue Doppler echocardiography

The long-term follow-up of patients with D-transposition of the great arteries after atrial switch operation shows specific problems such as tricuspid valve insufficiency, rhythm disturbances and failure of the morphologic right ventricle in systemic position. Assessment of the myocardial contractility of the subaortic right ventricle by conventional echocardiography is limited. The usage of tissue Doppler echocardiography with strain combined with strain rate imaging provides a new approach for quantitative analysis of longitudinal myocardial function. The aim of this study was to assess patterns of wall motion and regional contractile function of the systemic right ventricle in patients after atrial switch operation for D-transposition of the great arteries and to compare them to those of normal subjects. Twenty-four patients with Dtransposition of the great arteries after atrial switch operation with a mean age of 21.3 (range, 13 to 31) years and a postoperative period of 16.9 years were examined and compared to 22 control individuals with a mean age of 21.5 (range, 3 to 43) years. Tissue Doppler studies were obtained from apical 4- chamber view to determine regional systolic (Syst(T)) and diastolic (E(T), A(T)) velocities as well as E(T)/A(T) ratio at the basal free wall. The presystolic isovolumic contraction peak was assessed and the ratio of the presystolic peak velocity to the isovolumic acceleration time as the IVA index was calculated. Strain and peak systolic and diastolic strain rates were assessed on basal, middle and apical segments of the right ventricular free wall. Data obtained from the morphologic right systemic ventricle in patients were compared to those derived from the left and the right ventricle in controls. The right ventricular free wall systolic velocities were significantly reduced in patients compared to velocities obtained from the normal right and left ventricle. On the other hand, the IVA index was only reduced in patients compared to the IVA index in the normal subpulmonary right ventricle. Compared to data obtained from the normal systemic left ventricle, the IVA index in patients was not significantly different. In contrast, strain and strain rate parameters in all analyzed segments mostly showed a highly significant reduction compared to normal right and left ventricular data. Tissue Doppler echocardiography is a promising tool for the evaluation of regional myocardial contractile function of the morphologic right systemic ventricle in patients following atrial switch operation for D-transposition of the great arteries. Presystolic, systolic and diastolic regional ventricular function was reduced in the systemic right ventricle. However, further comparative studies using other quantitative parameters of global and regional myocardial function derived from cardiac catheterization or MRI should be performed in order to evaluate the reliability of tissue Doppler echocardiography for the assessment of global right ventricular function in these patients.

CRT in right ventricule for a senning patient: a case report

This case report highlights the feasibility of CRT in sub-aortic right ventricle dysynchrony, induced by left ventricular pacing, in patients with atrial switch operation fro transposition of great arteries. Medical history This 32 years old patient, had a Senning operation (atrial switch) in childhood. Subsequent complete AV block required endocardial DDD pacing. Due to failing sub-aortic right ventricle, the patient developed progressive Heart failure, despite appropriate medical treatment. Systemic right ventricle dysynchrony was evaluated, before registering this patient on heart transplant program. Baseline data Functional status: NYHA class III Inter-ventricular, intra-ventricular and AV dysynchrony assessed by echo: View this table: Intra-ventricular asynchrony results from inter-ventricular septum delayed contraction. Intervention Based on these data, a new LV lead was implanted on the inter-ventricular septum. An epicardial lead was positioned on the lateral free wall of the sub-aortic RV. Leads were connected to a triple chamber PM. Post op results NYHA class I/II, increased Bblockers and reduced diuretics at 1 month. Correction of the dysynchrony assessed by echo: View this table: Evolution clinical and electromechanical stability at 3 months. Conclusion CRT is feasible and may improve patients with a sub-aortic right ventricle after Senning operation for transposition of great arteries. In these patients, left ventricular pacing may induce or reveal electro-mechanical dysynchrony. Septal pacing site might be preferable to apical site, as inter-ventricular septum proper motion is certainly hemodynamically crucial in these patients.

Noncultured cell transplantation in an ovine model of right ventricular preparation

Beyond the first 2 months of life, pulmonary artery banding is warranted before two-stage arterial switch operation. The aim of this study was to explore whether myogenic cell transplantation could contribute to right ventricular function during pulmonary artery constriction in an ovine model. Sixteen rams were assigned to one of the following groups: group 1, simple pulmonary artery banding (n = 5); group 2, pulmonary artery banding and cell implantation in the right ventricle (n = 7); and group 3, pulmonary artery banding and placebo injection in the right ventricle (n = 4). Hemodynamic assessment with pressure-volume loops was performed on days 0 and 60. The pulmonary artery banding and the injections were achieved through a left fourth intercostal thoracotomy. Autologous myogenic cell implantation was carried out with a noncultured cell preparation, as previously described by our group. Implanted sites were processed with monoclonal antibodies to a fast skeletal-specific isoform of myosin heavy chain (MY32). Skeletal myosin heavy chain expression was detected at 2 months after noncultured cell implantation in all grafted animals. Right ventricular training resulted in statistically significant increased signs of contractility in all three groups. There was no observed difference, however, between the cell therapy group and the other two groups with respect to signs of cardiac function. Successful engraftment of noncultured cells into right ventricular myocardium did not translate into a functional benefit that we could demonstrate in our ovine model. Cellular therapy thus is probably not useful to strengthen a left ventricle being retrained through pulmonary artery banding before arterial switch operation. However, cell transplantation may affect the outcome of right ventricular failure long term after atrial switch operation. Although preliminary, this investigation paves the way for further research into cellular cardiomyoplasty, right ventricular failure, and congenital heart disease.

Introduction

This issue of the pediatric cardiac surgery annual is one of our most ambitious ever. We have tried to assemble a diversity of information with the anticipation that we will be providing the reader with a collection of articles that will be a resource for several years to come. We are grateful to the numerous contributors for working with us to meet a very tight deadline and submitting such high-quality work within a restricted time frame. We remain indebted to Jill Shepherd at Elsevier for her outstanding editorial support and advice and are thankful to Amy Cline at OHSU for her efforts over 2 years to provide us with a consistent and outstanding administrative presence. We have divided this issue into several sections. The first addresses important innovations in our techniques of cardiopulmonary bypass and perioperative management. We are convinced that some of our improvement to outcomes in the future will occur as we further refine and understand the systems that we expose our patients to in and out of the operating room. In the section on Innovative and Complex procedures, we have assembled contributions from numerous outstanding contributors in our field that provide information for dealing with challenging defects or patient groups. For HLHS, we have concentrated on the evolving management strategy that uses avoidance of CPB for neonatal palliation by using various approaches to create control of pulmonary blood flow and security of systemic blood flow. We have also included two articles related to treatment of AV discordance because this defect underscores our need to train future surgeons in atrial switch operations—a procedure that many young surgeons have never seen. Evaluation of outcomes after congenital heart surgery is becoming increasingly important and will most likely become a major focus of how we evaluate our work in the future. Significant work is being performed to help us all understand the quality of our care for those patients who survive us, and surgeons are becoming increasingly aware that they are part of a much larger system of overall care for a patient with congenital heart disease. We have included two pro-con issues by surgical colleagues who were intrepid enough to try and defend a position. We are aware that it is by acknowledging these controversies that we can stimulate the imagination and the ability to create that has long been a hallmark of our profession in the hopes that we can provide solutions to current limitations. A short article on a modification of the Ross procedure designed to eliminate the possibility for autograft dilatation is appended to the debate on the Ross procedure to emphasize this. Finally, we have included the vast amount of information that was collected at the recent combined meeting of the Congenital Heart Surgeons Society (CHSS) and the European Association for Congenital Heart Surgery (EACHS) relating to practice patterns for a variety of important issues as indicated using an audience response system that can improve the reliability of the information by ensuring anonymity of response. In closing, we are grateful to Richard Jonas for inviting us to guest edit this edition. It provided us with the opportunity to select and present you with this information. Enjoy.

Atrioventricular discordance with ventriculoarterial concordance: A remaining indication for the atrial switch operation

Isolated ventricular inversion is a very rare anomaly in which there is atrioventricular (AV) discordance and ventriculararterial (VA) concordance (AVD-VAC). Thus although the aorta arises from the left ventricle and the pulmonary artery (PA) originates from the right ventricle, the systemic and pulmonary circulations are in parallel and not in series. The physiology is that of complete transposition of the great arteries (TGA), but an arterial switch is contraindicated because it would leave the morphologically right ventricle to support systemic circulation. Six different anatomic types of AVD-VAC have been identified (Figure 1). All such patients rely on adequate mixing of pulmonary and systemic circulation through either a patent ductus arteriosus or an intracardiac shunt to survive. These anomalies are one of the few indications for the atrial switch operation in the modern era. Herein we describe the anatomy, corrective operation, and long-term follow-up in these rare patients.