Neoaortic Regurgitation Research Articles

The coronary reimplantation after neoaortic reconstruction technique can make a difference in arterial switch operation

BackgroundThe aim of this study was to determine if there was a difference between coronary reimplantation after neoaortic reconstruction and open coronary reimplantation technique in arterial switch operation (ASO).MethodsA total of 236 patients who underwent ASO from March 1994 to August 2018 were enrolled in this study. Multivariate analysis was performed for postoperative early mortality. Patients were divided into the open coronary reimplantation and coronary reimplantation after neoaortic reconstruction groups. The 30-day mortality, intraoperative and postoperative coronary artery (CA) revisions, CA–related late morbidity and mortality, and early and late neoaortic valve regurgitations after ASO were compared between the two groups.ResultsOverall postoperative early mortality was 7.2% (17/236). Patients who underwent open coronary reimplantation had higher early mortality as compared with those who underwent coronary reimplantation after neoaortic reconstruction. Risk factors for postoperative early mortality from multivariate analysis were cardiopulmonary bypass time and open coronary reimplantation. There was a higher incidence of CA–related late mortality or morbidity in the open coronary reimplantation group. The open coronary reimplantation group had a higher incidence of intraoperative or postoperative CA revision. There were no differences in the incidence of mild or more neoaortic valve regurgitation at discharge or in the 5-year freedom from mild or more neoaortic valve regurgitation.ConclusionsCA reimplantation after neoaortic reconstruction yields better results in mortality and intraoperative or postoperative CA–related problems in ASO without increasing postoperative neoaortic valve regurgitation.

Pregnancy Outcomes in Women After the Arterial Switch Operation

Pregnancy outcomes after the arterial switch operation (ASO) are rare. We sought to determine outcomes of ASO survivors who underwent pregnancy. Female patients who had an ASO and underwent pregnancy were identified from the congenital heart disease pregnancy clinic at The Royal Melbourne Hospital. All follow-up data were collected retrospectively by medical record review. Eleven (11) women were identified as having undergone medical care during pregnancy, from the adult congenital database, at The Royal Melbourne Hospital. There were 17 successful pregnancies, and nine women have been followed post pregnancy. Of the 17 successful deliveries, eight were delivered by Caesarean section, seven were vaginal deliveries and two were instrumented vaginal deliveries. Of the eight Caesarean sections, five were emergency and three were elective. The indications for emergency Caesarean section were obstructed labour (n = 2), abnormal cardiotocography (n = 1), obstructed labour and abnormal cardiotocography (n = 1) and congestive cardiac failure (n = 1). There was one neonatal complication (respiratory distress requiring intubation) in a child born at 31 weeks. There were maternal obstetric complications in 10 patients. There were two maternal cardiac complications during pregnancy (heart failure and rapid atrial fibrillation/flutter). There was no change in left ventricular function post-pregnancy. There was progression of severity of neo-aortic valve regurgitation in two patients post pregnancy (trivial to mild and moderate-severe to severe respectively). Pregnancy post ASO appears to be safe in the majority of women. Maternal cardiac complications are uncommon in patients without residual significant haemodynamic lesions, although maternal obstetric complications may be common.

Outcome of 40 consecutive cases of modified Ross procedure using novel Dacron valved conduit.

The Ross procedure is an established option for aortic valve disease in children. Due to limited availability of pulmonary homograft, we devised a novel technique for right ventricular outflow tract (RVOT) reconstruction by preparing indigenous Dacron valved conduit. Forty consecutive cases of modified Ross procedure done at our center (2013-2018) were analyzed. Thirty-seven patients (95%) were followed up with median duration of 2.5 (0.08-5.5) years. Median age was 12 (5-39) years. Nineteen (47.5%) patients had rheumatic aortic valve disease, while 19 (47.5%) had congenital aortic valve disease. Aortic root replacement with pulmonary autograft was performed in all patients. Dacron conduit for RVOT reconstruction was used with on table sewn bileaflet valve using Dacron patch (n = 22), expanded polytetrafluoroethylene (ePTFE) membrane (n = 10), bioprosthetic valve (n = 4), and pericardium (n = 4). Additional surgical procedures included mitral valve repair (n = 10), septal myectomy (n = 2), ascending aorta replacement (n = 1), ruptured sinus of valsalva (RSOV) repair (n = 1), and ventricular septal defect (VSD) closure (n = 1). There was one in-hospital mortality while one late death occurred at 3.5years postoperatively. The neo-aortic valve regurgitation on echocardiographic evaluation at last follow-up was trivial (n = 28), mild (n = 7), and moderate (n = 2). Mild RVOT obstruction was present in 8 patients while 18 patients had mild pulmonary regurgitation. No patient required reintervention during follow-up. Our early results of modified Ross procedure are encouraging, however, long-term follow-up is required.

Late Neo–Aortic Valve Regurgitation Long After Arterial Switch Operation

The purpose of this study is to assess risk factors of neo-aortic regurgitation (AR) after an arterial switch operation and outcomes of neo-aortic valve surgery. This is a retrospective study of 469 hospital survivors after arterial switch operation from 1982 to 2016. Preoperative diagnoses included 285 transpositions of the great arteries with intact septum, 140 transpositions with ventricular septal defect, and 44 double-outlet right ventricles. More than mild preoperative pulmonary regurgitation was found in 15 patients. Median age at the operation was 1.0 months (range, 0.1-81.5). Concomitant relief of left ventricular outflow tract obstruction was performed in 20 patients. Seventy-seven patients had more than mild neo-AR at hospital discharge. More than moderate neo-AR was found in 41 patients (8.6%) at a median follow-up of 19.0 years (range, 0.1-35.2). Multivariate analysis identified more than mild preoperative pulmonary regurgitation, concomitant relief of left ventricular outflow tract obstruction, and more than mild neo-AR at hospital discharge as risk factors for late neo-AR. Seventeen patients (3.6%) underwent neo-aortic valve surgeries, including 11 aortic valve replacements, 3 aortic valve plasties, 2 Konno procedures, and 1 aortic root replacement, with median age at the neo-aortic valve surgery of 16.5 years (range, 6.2-27.3). There were 2 late deaths and 5 reoperations to the neo-aortic valve in 4 patients. Concomitant relief of left ventricular outflow tract obstruction and preoperative more than mild pulmonary regurgitation increase the risk of neo-AR after the arterial switch operation. Reoperation for neo-AR can be done safely.

A better approach for left ventricular training in transposition of the great arteries and intact interventricular septum: Bidirectional cavopulmonary anastomosis and pulmonary artery banding.

Management of the patients with transposition of the great arteries and intact ventricular septum may be challenging beyond the newborn period. Herein, we would like to present our alternative strategy for training the left ventricle in these patients. Six patients with transposition of the great arteries and intact ventricular septum were evaluated in our clinic. Two of them were palliated with Glenn procedure and pulmonary banding as a definitive treatment strategy at other centers. Four patients were operated on and a bidirectional cavopulmonary anastomosis in combination with pulmonary artery banding was performed (stage-1: palliation and ventricular training) in our center. In four out of these six patients, arterial switch operation was performed with takedown and direct re-anastomosis of the superior vena cava to right atrium after an interstage period of 21-30months (stage-2: anatomical repair). Any mortality was not encountered. The left ventricular mass indices increased from 18-32to 44-74g/m2 in patients undergoing the anatomical repair. All of the patients were uneventfully discharged following the second stage. The mean follow-up period was 20months (9-32months) following stage 2. All of the patients are doing well with trivial neoaortic regurgitation and normal biventricular function. Bidirectional cavopulmonary anastomosis with pulmonary artery banding may be a promising left ventricle training approach in ventriculoarterial discordance when compared to the traditional pulmonary artery banding with concomitant systemic-to-pulmonary artery shunt procedures which still carry a significant interstage morbidity and mortality.

Aortic angle is associated with neo-aortic root dilatation and regurgitation following arterial switch operation

IntroductionNeo-aortic root dilatation and regurgitation are common progressive long-term complications of the arterial switch operation (ASO) for transposition of the great arteries (TGA) with increasing clinical burden. While several risk factors have been identified, most are constitutional. The acute aortic angle commonly seen after ASO might alter aortic dynamics and facilitate progression of the neo-aortic root dilatation and aortic regurgitation, but insufficient data is available. We intend to assess the effect of the aortic angle in the extent of neo-aortic root dilatation and presence of regurgitation. MethodsRetrospective analysis of TGA patients undergoing CMR after ASO at a single tertiary centre from November 2010 to July 2017. Results180 patients were analysed, 157 of which having adequate imaging of the aortic arch and root. Neo-aortic root Z score was normally distributed with 73% of patients having a Z score > 2. The aortic angle had a significant (p < 0,001) inverse relationship with the neo-aortic root Z score both in univariate and multivariate linear regression. Other significant associations were male gender and the concomitant presence of a VSD or a dysplastic neo-aortic valve. The presence of neo-aortic regurgitation was also inversely correlated with the aortic angle. The presence of a bicuspid neo-aortic valve was another significant association, further correlating with the more severe forms. ConclusionsAcute aortic angles associate more extensive neo-aortic root dilatation and higher incidence of regurgitation. We believe a surgical technique promoting less acute aortic angles has potential for ameliorating the long-term outcomes of TGA.

Long-term Management of the Arterial Switch Patient.

This review paper describes the management of patients with dextro-transposition of the great arteries (D-TGA) with a focus on the complications seen and the appropriate care required to identify and prevent adverse events. D-TGA is a form of cyanotic congenital heart disease (CHD) representing ~ 3% of all CHD and almost 20% of all cyanotic CHD. Since the late 1980s, standard of care is to repair these patients with an arterial switch operation (ASO) as opposed to a Mustard/Senning operation. The long-term survival and complication rates are superior in the ASO. Long-term follow-up is recommended for all D-TGA patients and includes management with adult congenital heart disease specialists and the use of echocardiography and advanced imaging with CT or MRI. The most common complications seen are pulmonary stenosis, coronary artery stenosis, and neo-aortic regurgitation. Careful evaluation of new symptoms or declining function is essential in preventing and treating these long-term sequelae.

Mid- and Longterm Neo-Aortic Valve Regurgitation after Jatene Surgery: Prevalence and Risk Factors.

BackgroundJatene surgery became the surgical procedure of choice to repair transposition of the great arteries (TGA) in neonates and infants. Late complications, mainly related to the pulmonary outflow tract and coronary arteries, are well known. The behavior of the neo-aortic valve is a cause of concern because of its potential for requiring late reoperation.ObjectivesTo assess the prevalence and risk factors of neo-aortic valve regurgitation in 127 patients in the late postoperative period of the Jatene surgery.MethodsOf the 328 survivors of the Jatene surgery at the Biocor Institute from October 1997 to June 2015, all patients undergoing postoperative follow-up were contacted via telephone, 127 being eligible for the study. The patients were divided into two groups, simple TGA and complex TGA groups, with follow-up means of 6.4 ± 4.7 years and 9.26 ± 4.22 years, respectively. Echocardiography was performed with adjusted measurements (Z-score) of the neo-aortic annulus, sinus of Valsalva, sinotubular region and ascending aorta, as well as quantification of the neo-aortic valve regurgitation grade.ResultsThe incidence of mild neo-aortic valve regurgitation was 29% in a follow-up of 7.4 ± 4.7 years. Moderate regurgitation was identified in 24 patients with age mean (± standard-deviation) of 9.81 ± 4.21 years, 19 of whom (79%) in the complex TGA group. Those patients had a higher aortic annulus Z-score. The reoperation rate due to neo-aortic regurgitation associated with aortic dilation was 1.5%, all patients in the complex TGA group.ConclusionThis study shows that, despite the low incidence of reoperation after Jatene surgery due to neo-aorta dilation and neo-aortic valve regurgitation, that is a time-dependent phenomenon, which requires strict vigilance of the patients. In this study, one of the major risk factors for neo-aortic valve regurgitation was the preoperative pulmonary artery diameter (p < 0.001).

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.

Outcomes of the Arterial Switch Operation in Children Less Than 2.5 Kilograms

Children with body weight less than 2.5kg who undergo the arterial switch operation (ASO) represent a challenging group. We sought to determine outcomes of patients with weight less than 2.5 kg at ASO at a single institution. All patients who underwent an ASO with biventricular repair and weighed less than 2.5 kg at time of surgery were identified from the hospital database and reviewed retrospectively. From 1983 to 2014, 870 patients underwent an ASO with biventricular repair at our institution. At the time of ASO, 31 patients (3.6%, 31 of 870) weighed lessthan 2.5 kg (mean 2.1; median 2.1; range, 1.1 to 2.4).Twenty-nine patients underwent an ASO for d-transposition of the great arteries, and 2 patients had an ASO for Taussig-Bing anomaly. Mean age at operation was 16 days (median 11; range, 3 to 66). There were 6hospital deaths (19%, 6 of 31) among patients weighing less than 2.5 kg compared with a hospital mortality of 1.9% (16of839) among patients weighing more than 2.5kg (p<0.0001). Mortality for children weighing 2.0 kg or less was 50% (5 of 10) compared with a mortality of 2.8% (1 of 21) for children weighing more than 2.0 kg but less than 2.5 kg. Four patients (13%, 4 of 31) required reoperation during hospital admission. Follow-up was available for 24 survivors (96%, 24 of 25). Mean follow-up was 13.2 years (median 11.9; range, 6 months to 25years). There were no late deaths. Two patients (8%, 2of 24) required late reoperation. No patient had more than mild neoaortic valve regurgitation, and all survivors were in New York Heart Association class I at last follow-up. Early mortality for children weighing less than 2.5 kg undergoing the ASO remains high; however, most of the mortality occurred in children weighing 2.0 kg or less. Long-term outcomes for survivors are excellent.

Outcomes of the Arterial Switch Operation in Patients With Concomitant Aortic Arch Obstruction as a Single Stage Repair

Purpose: We sought to determine outcomes of patients who underwent arterial switch operation (ASO) with concomitant aortic arch obstruction (AAO) repair as a single stage procedure. Methodology: All patients who underwent an ASO since 2008 were identified from a single institution's database and reviewed retrospectively. Aortic arch obstruction was defined as coarctation of the aorta, hypoplastic aortic arch or interrupted aortic arch. Results: From 1983 to 2008, 666 patients underwent an ASO for biventricular repair at our institution. Sixty-three (9.5%, 63/666) patients who underwent ASO had AAO. Thirty-five (55%, 35/63) patients had AAO repair at time of ASO as part of a single stage repair. Of these 35, twenty-one (60%, 21/35) had transposition of the great arteries and 14 (40%, 14/35) had Taussig-Bing anomaly. There were 2 (5.7%, 2/35) hospital deaths in these patients compared to an overall hospital mortality of 2.9% (19/666). No patients required reoperation during hospital admission. Follow-up was available for 32 (97%, 32/33) survivors. Mean follow-up was 11.2 years (range 7 months to 31 years). There were no late deaths. Three (9.4%, 3/32) patients required 4 late reoperations. Two (6.3%, 2/32) patients had moderate neo-aortic valve regurgitation (AR) at last follow-up. Two (6.3%, 2/32) patients required neo-aortic root valve replacement for severe AR. All survivors were in New York Heart Association Class I at last follow-up. Conclusion: Patients who go undergo ASO with associated AAO as a single stage repair have good early outcomes. Excellent survival and a low reoperation rate continues into adolescence and young adulthood. Close follow-up of neo-aortic valvular regurgitation is warranted.

Cardiovascular Magnetic Resonance Findings Late After the Arterial Switch Operation.

Despite its robust diagnostic capabilities in adolescents and adult patients after the arterial switch operation, little information is available on the cardiovascular magnetic resonance findings in this population. The cardiovascular magnetic resonance findings of 220 consecutive patients evaluated in our center were retrospectively reviewed (median age at cardiovascular magnetic resonance, 15.4 years; 66.8% male sex). Compared with published normal values, left and right ventricular end-diastolic volume z scores were mildly enlarged (0.48±1.76 and 0.33±1.5; P=0.0003 and 0.0038, respectively), with 26% of patients having left ventricular dilatation and 20% having right ventricular dilatation. Left ventricular dysfunction was present in 21.5% of patients (mild in most), and only 5.1% of patients had mild right ventricular dysfunction. Myocardial scar was found in 1.8% of patients. Dilatation of the neoaortic root was common (76%), and root z score increased at an average rate of 0.03 points per year. By multivariable analysis, neoaortic root dilatation was associated with worse neoaortic valve regurgitation (OR, 5.29; P=0.0016). The diameters of the thoracic aorta distal to the root were near-normal in most patients, whereas the neomain pulmonary artery was typically oval shaped with decreased anteroposterior and normal lateral diameters. Although the majority of arterial switch operation patients have normal ventricular size and function and myocardial scar is rare, an important minority exhibits ventricular enlargement or dysfunction. Neoaortic root dilatation, which is present in most patients and progresses over time, is strongly associated with significant neoaortic valve regurgitation. The findings of this study provide reference values against which arterial switch operation patients can be compared with their peers.

Dilatation and Dysfunction of the Neo-aortic Root and in 76 Patients After the Ross Procedure.

Pulmonary autograft replacement (Ross procedure) is used as an alternative to prosthetic aortic valve replacement patients with aortic valve disease. There are limited data on incidence and risk factors for dilatation and dysfunction of the neo-aortic after the Ross procedure. Ross procedure was performed in 100 patients at our institution between 1993 and 2011. In 76 patients, complete follow-up data were available. Their median age at surgery was 16 (0.4-58) years (76% males; 95% with congenital aortic valve disease). Median follow-up duration was 5.2years (0.3-16.0years). We analyzed their clinical and echocardiographic follow-up to identify possible risk factors for neo-aortic root dilatation and dysfunction. Ross procedure included reduction plasty of the native ascending aorta in 25% of patients. During follow-up, 21 patients (28%) developed neo-aortic root dilatation, 38 patients (50%) dilatation oft the native ascending aorta and 7 patients (9%) at least moderate neo-aortic regurgitation. Univariate risk factors for neo-aortic root dilatation were preoperative aortic regurgitation (p=0.04), concomitant reduction plasty of the ascending aorta (p=0.009) and a longer duration of follow-up (p=0.005). Younger age at surgery was associated with dilatation of the ascending aorta (p=0.03). Reoperation on the neo-aortic root because of severe dilatation was necessary in 6 patients (8%), where 2 patients had at least moderate neo-aortic root regurgitation. Neo-aortic root and aortic dilatation are common after the Ross procedure. This is often combined with neo-aortic valve dysfunction. Close follow-up of these patients is mandatory.

Long-Term Outcome of Arterial Switch Operation Conversion After Failed Senning/Mustard Procedure

We evaluated long-term outcomes of the arterial switch operation (ASO) conversion after a failed Senning/Mustard operation among patients with dextro-transposition of the great arteries. Between 1986 and 2006, 9 patients with dextro-transposition of the great arteries underwent ASO conversion at our institute. All patients had systemic right ventricle failure, 6 had supraventricular tachycardia, and 8 had moderate or severe tricuspid valve regurgitation. All patients had New York Heart Association classification II or III. The median age of patients at the ASO conversion operation was 7.4 years (range, 0.6 to 32.4 years). Pulmonary artery banding for left ventricle training was performed in 8 of the 9 patients before conversion. There was 1 early death from low-output syndrome at 5 days postoperatively and 1 late sudden death at 5 months. Median follow-up time was 23.1 years (range, 0.08 to 28.0 years). The actuarial survival rate was 76.1% at 20 years. Long-term survivors revealed good New York Heart Association classification (class I, 6 patients; class II, 1 patient), with less than mild tricuspid regurgitation and brain natriuretic peptide levels of 40.6± 16.2 pg/mL. Cardiac catheterization revealed significant improvements of right ventricle end-diastolic volume (decreased from 243.2% to 117.7% of normal), and right ventricle ejection fraction (increased from 0.42to 0.572; p < 0.05). Three patients underwent new pacemaker implantation for sick sinus syndrome, and moderate neoaortic valve regurgitation developed in 1patient. Excellent long-term outcomes can be achieved after ASO conversion; however, careful observation for new-onset sick sinus syndrome and aortic regurgitation is mandatory.

Neoaortic Valve Regurgitation After Arterial Switch: Ten Years Outcomes From A Single Center

Report results of neoaortic regurgitation (NAR) after arterial switch for patients with d-transposition of the great arteries (d-TGA) and corrected transposition of the great arteries. From 2003 to 2013, 583 patients who underwent arterial switch operation for d-TGA and 31 patients who underwent double switch (DS) for congenitally corrected transposition of the great arteries (cc-TGA) were included in this retrospective study. Since 2011, concomitant neoaortic sinotubular junction reconstruction was performed if aorta and pulmonary artery discrepancy was present in patients with d-TGA. The long-term survival rate was 92.5% (544/583) in patients with d-TGA and 74.2% (23/31) in patients with cc-TGA. More NAR developed in patients with cc-TGA than with d-TGA. Moreover, significant NAR (7.1% [38/539] versus 26.1% [(6/23], p= 0.010) and the aortic valve replacement (0.6% [3/539] versus 8.7% [2/23], p= 0.003) were less in the d-TGA group. Previous pulmonary artery banding and aortic and pulmonary artery diameter discrepancy were identified as risk factors for significant NAR in patients with d-TGA. However, no specific risk factors were identified in patients with cc-TGA. With the application of neoaortic sinotubular junction reconstruction, no significant NAR was recorded in patients with aortic and pulmonary artery discrepancy. After an arterial switch operation, we report a favorable incidence of NAR and rare neoaortic valve replacement. Significant NAR was associated with aorta-pulmonary discrepancy and previous pulmonary artery banding. Patients with cc-TGA may require close monitoring. Patients with aortic and pulmonary artery diameter discrepancy may benefit from sinotubular junction reconstruction.

Long-term outcomes of the arterial switch operation for transposition of the great arteries and ventricular septal defect and/or aortic arch obstruction.

Long-term outcomes after the arterial switch operation (ASO) for complex transposition of the great arteries (TGA) should be clarified. A retrospective study was conducted in patients operated on between 1982 and 1998. Overall 220 postoperative survivors, 79.1% with a ventricular septal defect, 13.2% with multiple ventricular septal defects, and 29.1% with aortic arch obstruction, were followed for 17 years (0-28 years). The conditional survival rate was 96.7% [95% confidence interval (CI): 94.4-99.1] at 25 years. Late sudden death occurred in 2 asymptomatic patients. The cumulative incidence rate of death or reinterventions was 3.8% (95% CI: 2.9-4.8) at 25 years, with age at ASO <10 days and aortic regurgitation at discharge identified as independent risk factors. The cumulative incidence rate of neoaortic regurgitation was 41.6% (95% CI: 20.5-62.8) at 25 years with an aorto-pulmonary diameter mismatch at the time of the ASO, age at ASO <10 days and aortic regurgitation at discharge identified as independent risk factors. At the last follow-up, 53 patients (24.1%) had neoaortic root dilatation with an aortic sinus z-score ≥3 and 6 of them had a Bentall operation at a median delay of 14.1 years since the ASO. The only independent factors for neoaortic root dilatation were male sex and an aorto-pulmonary diameter mismatch at the time of the ASO. Despite a continual rate of reinterventions, long-term survival and cardiovascular outcome are excellent after ASO for complex TGA. Dilatation of the neoaortic root and neoaortic regurgitation may be observed with time and 2 late sudden deaths occurred, justifying a close follow-up in all patients.

The functional status of neoaortic valve and left ventricular outlet tract after arterial switch operation for transposition of great arteries with left ventricular outlet tract obstruction.

To assess the function of the left ventricular outlet tract and neoaortic valve after arterial switch operation for patients with transposition of the great arteries and left ventricular outlet tract obstruction. The data of 40 patients, who underwent arterial switch surgery with transposition of the great arteries with left ventricular outlet tract obstruction and a concomitant left ventricular outlet tract obstruction relieving procedure, were retrospectively analysed. Ultrasonic cardiogram and intraoperative findings, surgical methods and early and follow-up results were also summarized. Early death occurred in one case. One patient died in follow-up stage and 3 patients were lost during follow-up. In all the 35 patients accepting follow-up, 1 patient had a reoccurring left ventricular outlet tract obstruction, 1 patient had mild neoaortic stenosis, whereas mild and moderate neoaortic regurgitation occurred in 11 and 2 patients, respectively. The median pressure gradient across the left ventricular outlet tract was 6.8 mmHg (range: 2-49 mmHg) during follow-up which was statistically significant compared with that before surgery. We defined death, reintervention and rehospitalization for cardiac reasons as a cardiac event; the survival rate of being free from cardiac event for 1 year and 5 years was 92.8 ± 0.04%, respectively. Anatomical features and pressure gradient should be used together to evaluate the severity of obstruction, whereas the mid-term outcomes can be satisfied after arterial switch operation for the appropriate candidates.

Current expectations of the arterial switch operation in a small volume center: a 20-year, single-center experience.

BackgroundWe reviewed our 20-year experience with arterial switch operation (ASO) for transposition of the great arteries (TGA) or double outlet right ventricle with subpulmonary ventricular septal defect (Taussig-Bing anomaly) to assess the early and long-term outcomes.MethodsBetween January 1995 and December 2014, 139 consecutive patients who underwent ASO for TGA or Taussig-Bing anomaly were included in this retrospective study. The median age at the operation was 9 (0–485) days, and 97 patients (70 %) underwent ASO less than 2 weeks. The median weight was 3.3 (2.1-10.3) kg. The patients were divided into three groups; simple TGA (n = 78) included patients with TGA with intact ventricular septum, complex TGA (n = 46) included those who had TGA with ventricular septal defect or other anomalies, and Taussig-Bing anomaly (n = 15). Median follow-up duration was 72.5 (0.4-230) months.ResultsThere were 3(2.2 %) in-hospital deaths. One patient (0.7 %) underwent early reoperation due to coronary insufficiency. Late deaths occurred in 3 (2.2 %) of 136 survivors. The Kaplan-Meier’s survival rate was 97.6 ± 1.4 % at 15 years. Twenty-three patients (16.9 %) required 26 reintervention. The freedom from reintervention rates were 82.5 ± 3.7 % at 5 years and 75.8 ± 4.7 % at 10 years, respectively. Median interval between ASO and first reintervention was 22.8 (6.4-89.2) months. The multivariate analysis showed that diagnosis of Taussig-Bing anomaly (hazard ratio, 7.09; P < 0.001) and side by side great artery relationship (hazard ratio, 7.98; P = 0.001) were independent risk factors for reoperation. Five patients (3.9 %) had developed at least moderate neo-aortic regurgitation during the follow-up and one patient underwent reoperation mainly for neo-aortic regurgitation. By multivariate analysis, Taussig-Bing anomaly was the risk factor for at least moderate neo-aortic regurgitation (P = 0.035).ConclusionsASO can be performed with a low risk of early mortality and satisfactory long-term outcomes even in a small volume center. Close long-term surveillance is mandatory to detect structural or hemodynamic changes.

The Externally Supported Ross Operation: Early Outcomes and Intermediate Follow-Up

The externally supported Ross (supported Ross), consisting of a Dacron (DuPont, Wilmington, DE) graft to support the neoaortic root, has been used in adolescent and adult patients to prevent neoaortic dilatation. Outcomes after the supported Ross technique were compared with the Ross procedure using the standard aortic root replacement technique (standard Ross). This was a retrospective analysis of 36 adolescent and young adult patients who underwent the Ross procedure between 1992 and 2013. The outcomes of supported Ross procedures in 26 patients were compared with the Ross procedure in 10 patients. End points included survival, neoaortic root dilatation, development of neoaortic regurgitation, and the need for reintervention. The median age at operation was 14 years (range, 11 to 31 years), and indications for the operation were mixed lesions (47%), followed by aortic regurgitation (42%) and stenosis (11%). There were no early deaths. The mean follow-up was 2.2 years (range, 1 to 11 years). At the 1-year (p= 0.01) and 3-year (p < 0.05) follow-up, patients in the supported Ross cohort had a smaller neoaortic root z-score. Neither cohort had a large number of patients with significant neoaortic regurgitation, with 1 patient in the supported cohort compared with 3 patients in the standard cohort. Overall, 4 patients (40%) in the standard Ross cohort had required reintervention, including 3 directed at the neoaortic root. One patient in the supported Ross cohort required early reintervention for revision of the right coronary artery. At intermediate follow-up, patients who underwent the supported Ross technique were less likely to have neoaortic root dilatation compared with patients who underwent a standard Ross procedure. Further studies are needed to evaluate the long-term durability of this technique, particularly in regards to the development of significant aortic regurgitation, the rate of reintervention, and application to younger and smaller patients.

G161 Transposition of great arteries, a 15 year experience of 74 patients in wales: incorporation of outflow tract view in the antenatal scans leading to better antenatal detection and clinical outcomes

Background Antenatal detection rate of transposition of the great arteries (TGA) has remained very low around 25% in the UK. This may have improved with the addition of outflow tract view to the routine 20 week foetal anomaly screening protocols with better overall outcomes. Patients and methods All children who were diagnosed with simple TGA at our centre for Paediatric Cardiology over a 15 year period were included in this study. Clinical case notes were retrospectively reviewed and outcome data was evaluated. Results There were 74 patients; 54 diagnosed postnatally, 20 antenatally. All 8 preterm deliveries were in postnatally diagnosed group. 32 had simple TGA and 42 had additional defects. Male: female ratio was 3.5:1. Antenatal detection rate improved from 0–20% to 75% in the recent years. 40% of cases diagnosed postnatally were unwell at presentation and most of them needed ventilatory support. Majority of the patients in our cohort needed prostin infusion following delivery and 60% of them underwent balloon septostomy before arterial switch operation was performed. Only one out of 74 patients had Mustard’s operation in our series. Postoperative complications were more common in postnatally diagnosed patients (26% vs 10%). There were no deaths in the antenatally detected group. Early mortality rate was 6.8% and operative mortality was 1.4% with no postoperative deaths being recorded after 2007. Echo abnormalities were seen in 83% at 2 years and 91% at 10 years follow up with neo aortic regurgitation being the commonest. Intervention free survival was 96%. 7% were on medications mainly due to impaired LV function. Growth and development issues, exercise intolerance and arrhythmias were uncommon in our series. Survival rate at 5 years was 88.1%. Conclusion Inclusion of outflow tract view has led to substantial improvement in antenatal detection of TGA. This, in turn, has made a major impact on the clinical outcomes owing to better cardiovascular status at presentation, lower postoperative complications and reduced mortality rates.