Long-term survival and functional follow-up in patients after the arterial switch operation

doi:10.1016/S0003-4975(99)01039-5

The Annals of Thoracic Surgery

Volume 68, Issue 5, November 1999, Pages 1692-1697

Presented at the Thirty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 25–27, 1999.

https://doi.org/10.1016/S0003-4975(99)01039-5 Get rights and content

Abstract

Background. For many years, the arterial switch operation (ASO) has been the therapy of choice for patients with transposition of the great arteries (TGA). Although excellent short- and mid-term results were reported, long-term results are rare.

Methods. Between May 1983 and September 1997, ASO was performed on 285 patients with simple TGA (n = 171), TGA with ventricular septal defect (VSD) (n = 85), and Taussig-Bing (TB) anomaly (n = 29). This retrospective study describes long-term morbidity and mortality over a 15-year period.

Results. Hospital mortality was 3.5% for simple TGA, 9.4% for TGA with VSD, and 13.8% for TB anomaly. Late death occured in 2 patients, 1 with simple TGA and 1 with TGA and VSD. The cumulative survival for all patients at 5 and 10 years is 93%, and at 15 years is 86%. Reoperations were required in 31 patients and were most common for stenosis of the right ventricular outflow tract (RVOT). However, no correlation was found between technical variations on pulmonary artery reconstruction and this type of complication. Forty-six patients underwent follow-up angiography, which revealed five cases with coronary occlusion or stenosis. Follow-up is complete in 96% of the patients from 1 to 15.2 years. Sinus rhythm is present in 97%; 88% of the patients show no limitations on exertion.

Conclusions. The ASO can be performed with low early mortality, almost absent late mortality, and infrequent need for reoperation. The favorable long-term results demonstrate that the ASO can be considered as the optimal approach for patients with TGA and special forms of double-outlet right ventricle.

Section snippets

Material and methods

Between May 1983 and September 1997, 285 ASOs were performed by three surgeons at the German Heart Center of Munich. Of these 285 patients, 171 had simple TGA, 85 had TGA with VSD, and 29 patients had transposition-like forms of DORV with subpulmonary (25), noncommitted (2), perimembranous (1), and inlet VSD (1). Patients with Taussig-Bing (TB) anomaly and DORV represent one group in this study. Age at operation for ASO, associated cardiac anomalies, and coronary anatomy are shown in Table 1for

Mortality

Early mortality occurred in 6 patients (3.5%) with simple TGA. Acute myocardial failure within 12 hours perioperatively, was the primary cause. One patient developed fatal myocardial infarction 10 days after switch operation. In one case, intraoperative death was associated with an intramural course of the coronary artery. Eight patients (9.4%) with TGA and VSD died early postoperatively. Six died due to acute myocardial failure within 24 hours, 1 patient due to renal failure in the presence of

Comment

This retrospective analysis of our experience with the ASO confirms that the ASO can be accomplished with low early and late mortality in patients with TGA. The reported early mortality of 3.4% and the negligible late mortality for simple TGA agrees well with previous reports 3, 10. However, it should be emphasized that these results were not influenced by a “learning curve,” because in the first 2 years of this series, only patients with TGA and VSD or TB anomaly/DORV were chosen for anatomic

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Cited by (161)

Impact of different neo-pulmonary artery surgical reconstruction techniques during the arterial switch operation on right ventricular outflow tract obstruction. A multicenter study up to 34-years' follow-up
2023, Progress in Pediatric Cardiology
RVOTO remains the most common complication after ASO in simple TGA.
To clarify which neo-pulmonary artery reconstruction surgical technique helps to minimize postoperative right ventricular outflow tract obstruction (RVOTO) after the arterial switch operation (ASO) for transposition of the great arteries (TGA).
Patients with isolated d-TGA were identified in the German Registry for Congenital Heart Defects. ASO for isolated d-TGA at an age younger than 10 days between 1986 and 2015 at 16 centers was performed in 106 registered patients. They were divided into two groups (Group 1 - Pantaloon n = 36, Group 2-non Pantaloon n = 70) depending on the neo-pulmonary surgical reconstruction technique used during ASO. Endpoints were RVOTO development, need for reoperation or reintervention for RVOTO, and death. RVOTO was diagnosed echocardiographically.
Median follow-up was 9 (4–29) years: the pantaloon group's (group 1) cumulative follow-up was 389 patient-years and 15 (5–34) years, and the non-pantaloon group's (group 2) 1119 patient-years, p = 0.0001. We observed mild RVOTO in 56 % in group 1 and 60 % in group 2 (p-value = 0.53). Group one's moderate RVOTO (3 %) versus 9 % in group 2 (9 %) (p = 0.42). Severe RVOTO was 5 % in group one and 7 % in group two (p = 0.99). There was no difference in freedom from re-operation and survival in both groups. (log-rank p = 0,63, log-rank p = 0,25, respectively).
Development of mild RVOTO is a common complication in the long-term follow-up after ASO after applying both surgical techniques. We found that both types of neo-pulmonary artery reconstruction techniques were safe in terms of developing severe RVOTO.
Left bronchial compression after an arterial switch operation with the LeCompte maneuver for transposition of the great arteries: A case report and literature review
2023, Journal of Cardiology Cases
Left bronchial compression is a rarely reported, postoperative complication of the arterial switch operation with the LeCompte maneuver for transposition of the great arteries. Postoperative neopulmonary root dilatation and the anterior-posterior, anatomical relationship of the great vessels may cause this condition. Hypoxic pulmonary vasoconstriction may mask the condition even if the left bronchus has been severely obstructed. The apparent inconsistency between the abnormally decreased pulmonary blood flow and the absence of any irregularities in the vascular structure that might account for it suggested hypoxic pulmonary vasoconstriction to be the cause. We present herein a case of left bronchial compression presenting malacia after an arterial switch operation with the LeCompte maneuver and also present a review of seven, other, reported cases.
Left bronchial compression is a rare complication of the arterial switch operation with the LeCompte maneuver for transposition of the great arteries and is possibly caused by root dilatation and the anatomical relationship of the great vessels. Hypoxic pulmonary vasoconstriction may mask the condition.
Surgery ot the transposition of great arteries in the neonatal period
2021, Cirugia Cardiovascular
La transposición de grandes arterias (D-TGA) es una de las cardiopatías congénitas más frecuentes. La aparición del switch arterial supuso un antes y un después en el manejo de esta patología. Hoy en día es una técnica estandarizada y con excelentes resultados. En este estudio buscamos analizar el estado actual de la cirugía de D-TGA en periodo neonatal mediante revisión de nuestra experiencia.
Estudio observacional retrospectivo. Se incluyó a los pacientes intervenidos mediante switch arterial en nuestro centro entre enero de 2007 y septiembre de 2020.
Setenta y cuatro pacientes intervenidos. La mortalidad global fue del 10,8% (15,6% en 2007-2012 y 7,1% en 2013-2020). El 44,6% de los pacientes presentaban D-TGA compleja. La presencia de patrones coronarios anómalos, lesiones asociadas o cirugía tardía no elevó significativamente la mortalidad. El tiempo de estancia en cuidados intensivos y hospitalario (mediana + rango intercuartílico) fue de 10 (7-17) y 20 (14-30) días, respectivamente.
Con un seguimiento medio de 5,3 ± 3,75 años, la supervivencia fue del 100%. La supervivencia libre de reintervención fue de 87,6% a 10 años. La tasa de reintervención fue mayor (p < 0,01) en los pacientes con anomalía de Taussig-Bing o coartación de aorta.
El switch arterial se considera de elección para el tratamiento de la D-TGA en periodo neonatal, por sus buenos resultados perioperatorios y a largo plazo. Los pacientes sometidos a esta técnica pueden requerir reintervenciones, fundamentalmente por obstrucción del tracto de salida de ventrículo derecho o patología de la válvula y la raíz neoaórtica.
Transposition of the great arteries (D-TGA) is one of the most common congenital heart diseases. The development of the arterial switch operation supposed a great achivement in the management of this pathology. Today it is a standardized technique with excellent results. In this study we seek to analyze the current status of the surgery for D-TGA in the neonatal period by reviewing our experience.
Retrospective observational study. We included all patients who underwent arterial switch operation in our center between January 2007 and September 2020.
74 patients underwent arterial switch operation. Overall mortality was 10.8% (15.6% in 2007-2012 and 7.1% in 2013-2020). 44.6% of the patients presented complex D-TGA. The presence of abnormal coronary patterns, associated malformations, or late surgery did not significantly increase mortality. The length of stay in ICU and hospital (median + interquartile range) was 10 (7-17) and 20 (14-30) days respectively.
During the follow up period (mean follow-up of 5.3 ± 3.75 years) survival rate was 100%. Reoperation-free survival was 87.6% at 10 years. Reoperation rate was higher (p < 0.01) in patients with Taussig-Bing anomaly or coarctation of the aorta.
The arterial switch operation is considered of choice for the treatment of D-TGA in the neonatal period, due to its good perioperative and long-term results. These patients may require reinterventions, mainly due to right ventricular outflow tract obstruction and pathology of the neo-aortic valve and root.
Echocardiography and MRI parameters associated with exercise capacity in patients after the arterial switch operation
2020, Journal of Cardiology
Citation Excerpt :
We observed an overall good RV function in our cohort, although limited studies have focused on RV performance after ASO. Taylor et al. demonstrated preserved global RV function at 10 years after ASO [26], similar to Haas et al. [27] and Grotenhuis et al. [21]. Given the impact of increased RV afterload related to PS, monitoring of RV function during follow-up appears to be important after ASO.
The arterial switch operation (ASO) for transposition of the great arteries has excellent survival, but a substantial number of patients suffer from a reduced exercise capacity. The goal of this study was to identify imaging parameters associated with a reduced exercise capacity in patients after ASO.
A retrospective analysis was performed of ASO patients who underwent cardiopulmonary exercise testing (CPET) between 2007 and 2017. Reduced exercise performance was defined as a reduced workload peak (W_peak) with Z-score <−2 or a peak oxygen uptake indexed for weight (VO_2peak/kg) with Z-score <−2. Data on echocardiography and cardiac magnetic resonance performed within 1 year of the CPET were collected for comparison.
A total of 81 ASO patients (age 17 ± 7 years) were included. Reduced exercise performance was found in 22 patients (27%) as expressed by either a reduced W_peak and/or a reduced VO_2peak/kg. Main pulmonary artery gradient and tricuspid regurgitation gradient by echocardiography were found to be associated with reduced W_peak (p = 0.031; p = 0.020, respectively). The main pulmonary artery gradient and tricuspid regurgitation gradient by echocardiography were found to be associated with reduced VO_2peak/kg (p = 0.009; p = 0.019, respectively). No left ventricular parameters were found to be associated with abnormal exercise performance.
This study demonstrates that ASO patients frequently experience reduced exercise capacity. Echocardiographic evidence of main pulmonary artery stenosis and increased right ventricular pressure were associated with reduced exercise capacity, and are therefore key to monitor during serial follow-up of ASO patients.
Arterial Switch Operation: Operative Approach and Outcomes
2019, Annals of Thoracic Surgery
The arterial switch operation has excellent early outcomes. Although the majority of patients are growing into healthy adults, a small subset require reoperation for pulmonary stenosis as well as neoaortic root dilatation and neoaortic valve regurgitation, especially as follow-up increases. Challenging subgroups include patients with anomalous coronary anatomy, concomitant aortic arch obstruction, Taussig-Bing anomaly, ventricular septal defect, and low operative weight, and patients with an intact interventricular septum who present late.
Longitudinal Associations between Neurodevelopment and Psychosocial Health Status in Patients with Repaired D-Transposition of the Great Arteries
2019, Journal of Pediatrics
To examine associations between measurements of neurodevelopment and psychosocial health status at age 8 and 16 years in patients with repaired dextro-transposition of the great arteries.
In the 16-year follow-up of the Boston Circulatory Arrest Study, 137 parents completed the Child Health Questionnaire—Parent Form-50, of whom 135 had completed the Child Health Questionnaire—Parent Form-50 when their child was age 8 years. Psychosocial and physical summary scores were used to assess change in health status from age 8 to 16 years. A comprehensive battery of neurodevelopmental testing was performed at ages 8 and 16 years to examine associations with adolescent health status.
Lower psychosocial summary scores of 16 year old subjects with dextro-transposition of the great arteries were highly associated with numerous concurrent domains of neurodevelopmental function, most notably with higher (worse) scores on the Conners' Attention Deficit Hyperactivity Disorder/Diagnostic and Statistical Manual-4th Edition Scales (parent: r = −0.62, P < .001; adolescent: r = −0.43, P < .001) and the Behavior Rating Inventory of Executive Function Global Executive Composite (parent: r = −0.66, P < .001; adolescent: r = −0.39, P < .001). Psychosocial and physical summary scores tracked from ages 8 to 16 years (r = 0.44 and 0.47, respectively, P < .001 for each). Higher (worse) scores of multiple attention measures at age 8 years predicted worse psychosocial summary scores at age 16 years.
Attention deficits at age 8 years were highly predictive of worse psychosocial health status in adolescence. Further studies are needed to assess whether treatment of childhood attention deficit hyperactivity disorder could improve adolescent well-being.

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Original ArticlesLong-term survival and functional follow-up in patients after the arterial switch operation

Abstract

Section snippets

Material and methods

Mortality

Comment

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Am Coll Cardiol

Successful anatomic correction of transposition of the great vessels. A preliminary report

Arq Bras Cardiol

Original Articles
Long-term survival and functional follow-up in patients after the arterial switch operation