Intervention for Supravalvar Pulmonary Stenosis After the Arterial Switch Operation

doi:10.1016/j.athoracsur.2016.01.068

The Annals of Thoracic Surgery

Volume 102, Issue 1, July 2016, Pages 154-162

Presented at the Sixty-second Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 4–7, 2015.

https://doi.org/10.1016/j.athoracsur.2016.01.068 Get rights and content

Background

The arterial switch operation is standard of care for infants born with dextrotransposition of the great arteries. Supravalvar pulmonary stenosis is a common complication that may require reintervention—balloon angioplasty, stenting, or surgical augmentation. A subset of patients requires more than one reintervention.

Methods

We performed a retrospective review of patients who underwent the arterial switch operation for dextrotransposition of the great arteries at a single institution between August 1990 and January 2014. Anatomic, perioperative and follow-up data were collected. Reinterventions were stratified in a site-specific manner. Statistical analysis was performed using IBM SPSS version 21 (IBM Corp, Armonk, NY).

Results

Of the 103 patients who met inclusion criteria, 28% (29) required reintervention for supravalvar pulmonary stenosis; 41% of those receiving primary reintervention required an additional 21 reinterventions. Balloon angioplasty of the main pulmonary artery and left pulmonary artery was associated with the need for multiple reinterventions (odds ratio 4.9, p = 0.051, and odds ratio 5.1, p = 0.029, respectively). Freedom from future reintervention at the main pulmonary artery and left pulmonary artery was significantly shorter after balloon angioplasty relative to alternative reintervention options (hazard ratio 10, p = 0.005, and hazard ratio 3.2, p = 0.02, respectively). Balloon angioplasty of the right pulmonary artery was not associated with an increased risk of reintervention (p = 0.42).

Conclusions

Supravalvar pulmonary stenosis after the arterial switch operation for dextrotransposition of the great arteries is common and more than one reintervention are required in a subset of patients. The benefit of balloon angioplasty of the main pulmonary artery and left pulmonary artery was shown to be temporary. Attempting balloon angioplasties at these locations remain reasonable, although families should be counseled about the increased incidence of, and decreased time to, subsequent reintervention that is associated with this treatment option.

Section snippets

Patients and Methods

All patients undergoing ASO at the University of Iowa Hospitals and Clinics between August 1, 1990, and January 1, 2014, were identified. Medical records for these patients were accessed. Exclusion criteria included only patients who underwent a double switch for levotransposition of the great arteries or a late ASO after an original Mustard operation.

Perioperative, postoperative, and reintervention data were collected. Perioperative data included sex, age at operation, anatomic data, bypass

Demographic Data

One hundred five patients underwent ASO at the University of Iowa Hospitals and Clinics between August 1, 1990, and January 1, 2014. One hundred three patients met inclusion criteria and were included in the study. Sixty-one percent of these patients presented with only d-TGA, whereas 35% presented with a ventricular septal defect with or without additional cardiac malformations. Sixty-eight percent of the study population was male, and the median age at operation was 8 days (IQR: 6 to 13).

Comment

We report a longitudinal review of patients who have undergone an ASO at a single institution with a focus on those patients requiring multiple reinterventions. Supravalvar pulmonary stenosis is the most common complication after ASO. Previous studies have cited incidence rates ranging from 7% to 42% 5, 6, 7, 8, 9, 10, 11, 12, 15. Over the 24-year interval of our study, 103 patients underwent ASO. Twelve percent of these patients died because of perioperative complications, and 28% required at

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Cited by (20)

Right Ventricular Systolic Dysfunction in Adults With Anatomic Repair of d-Transposition of Great Arteries
2023, American Journal of Cardiology
The purpose of this study was to assess the prevalence of right ventricular (RV) systolic dysfunction in adults with anatomic repair of dextro-transposition of great arteries (d-TGAs), and to determine its relation to clinical outcomes across multiple domains (functional status, peak oxygen consumption, N-terminal pro-brain natriuretic peptide, and heart failure hospitalization). Adults with anatomic repair for d-TGA and with echocardiographic images for strain analysis were divided into 2 groups: (1) d-TGA status after an arterial switch operation (d-TGA–ASO group) and (2) d-TGA status after a Rastelli operation (d-TGA–Rastelli group). RV systolic function was assessed using RV global longitudinal strain (RVGLS), and RV systolic dysfunction was defined as RVGLS >-18%. We identified 151 patients (median age 21 years [19 to 28]; d-TGA–ASO group 89 [59%], and d-TGA–Rastelli group 62 [41%]). The mean RVGLS was −22 ± 4%, and 47 patients (31%) had RV systolic dysfunction. The d-TGA–Rastelli group had lower (less negative) RVGLS than that of the d-TGA–ASO group (−19 ± 3% vs −25 ± 3%, p <0.001) and higher prevalence of RV systolic dysfunction (48% vs 19%, p <0.001). RVGLS (absolute value) was associated with peak oxygen consumption (r = 0.58, p <0.001; adjusted R² = 0.28), log–N-terminal pro-brain natriuretic peptide (r = −0.41, p = 0.004; adjusted R² = 0.21), New York Heart Association class III/IV (odds ratio 2.29, 1.56 to 3.19, p = 0.01), and heart failure hospitalization (hazard ratio 0.93, 0.88 to 0.98, p = 0.009). RV systolic dysfunction was common in adults with d-TGA and anatomic repair and was associated with clinical outcomes. Longitudinal studies are required to determine the risk factors for progressive RV systolic dysfunction and to identify strategies for preventing RV systolic dysfunction in this population.
Commentary: Branch pulmonary artery stenosis after the arterial switch operation: Is prevention better than cure?
2022, Journal of Thoracic and Cardiovascular Surgery
Branch pulmonary artery stenosis after arterial switch operation: The effect of preoperative anatomic factors on reintervention
2022, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
More than one-third of patients required subsequent reintervention for branch PA stenosis in the current study. Previous long-term follow-up studies also observed a similar requirement for multiple reinterventions to manage MPA stenosis.12,21 Previous studies reported the risk of MPA stenosis is greatest in the first postoperative year and then decreases thereafter, whereas the cumulative branch PA reintervention incidence rate steadily increased until 4 to 5 postoperative years in the current cohort (Figure 2, A).
We hypothesized that preoperative patient characteristics and branch pulmonary artery (PA) size might influence the rate of postoperative branch PA reintervention in patients with transposition of the great arteries who undergo the arterial switch operation (ASO).
The retrospective single-center study included 262 consecutive (2008-2017) newborns who underwent the ASO. Demographic characteristics, echocardiography, and clinical outcomes were reviewed. Competing risk analysis modeled incidence of branch PA reintervention and cause-specific hazard regression for predictors analyses.
Median age and weight were 7 (range, 5-11) days and 3.4 (range, 3.1-3.8) kg, respectively. Various types of early branch PA reinterventions (concomitant revision or reintervention during the intensive care unit stay) were required in 28 (10.7%) patients. These patients had prolonged ventilation (P < .001), intensive care unit duration (P < .001), worse right ventricular function (P = .043), and high in-hospital mortality (P = .010). Branch PA dimensions significantly decreased immediately after ASO compared with baseline measurements. The median follow-up duration was 20.8 (range, 0.9-44.7) months. Branch PA reintervention was common among survivors without early reinterventions (9.4%), and even more frequent among those with early reinterventions (25%). Subsequent reintervention (all catheter-based) was necessary for more than one-third of patients after initial branch PA reintervention. The multivariable analysis showed preoperative dimension of the left PA (hazard ratio, 0.527 [95% CI, 0.337-0.823]; P = .005), and right PA (hazard ratio, 0.503 [95% CI, 0.318-0.796]; P = .003) were independently associated with late branch PA reinterventions.
Branch PA reintervention was common and often required surgical or catheter-based reinterventions after ASO. PA branch diameters became significantly smaller after ASO. Smaller preoperative branch PA predicted late branch PA reintervention, indicating a smaller margin of geometrical tolerance to this effect.
Technical Performance Score's Association With Arterial Switch Operation Outcomes
2021, Annals of Thoracic Surgery
Outcomes after the arterial switch operation (ASO) for dextro-transposition of the great arteries have improved significantly since its inception in the 1980s. This study reviews contemporaneous outcomes and predictors for late reinterventions after ASO.
We retrospectively reviewed patients who underwent ASO for dextro-transposition of the great arteries from 1997 to 2017. Technical performance score (TPS) class (class 1, trivial or no residua; class 2, minor residua; class 3, major residua or reintervention) was assigned at discharge based on echocardiographic evaluation of components of the ASO. Multivariable Cox regression identified patient- and procedure-specific factors associated with postdischarge reinterventions.
Among 598 patients, 410 (69%) underwent ASO and 188 (31%) underwent ASO with ventricular septal defect repair. Median age at surgery was 5 days (interquartile range, 3 to 7); median follow-up time was 8.2 years; 408 (68%) were male; 50 (8.3%) were premature; and 10 (1.7%) had noncardiac anomalies or syndromes. Survival to hospital discharge was 98% (n = 591). Among 349 patients with follow-up, freedom from unplanned reintervent2ion at 5 years was 99% for TPS class 1, compared with 84% for class 2 and 30% for class 3. On multivariable Cox regression, classes 2 and 3 had significantly higher hazard for reintervention (class 2 hazard ratio 10.6; 95% confidence interval, 2.5 to 44.2; P = .001; class 3 hazard ratio 58.2, 95% confidence interval, 13.1 to 259; P < .001).
At our center, ASO was associated with relatively low mortality. Class 2 and class 3 TPS were the most important independent predictors of reinterventions after discharge. Therefore, TPS can serve as a tool for identifying high-risk patients who warrant closer follow-up.
Commentary: Get in the Groove When Stuck Doing the Switch
2021, Operative Techniques in Thoracic and Cardiovascular Surgery
Long-term Outcomes of the Arterial Switch Operation for D-Transposition of the Great Arteries
2018, Progress in Cardiovascular Diseases
Citation Excerpt :
The appearance of the PAs draped over the ascending aorta are represented in Figs 4 and 5. The frequency of PA intervention (stenting and angioplasty) required after ASO with LeCompte maneuver reported in the literature varies from 3 to 28% and is center specific.5,34,37 Multidisciplinary review at an ACHD center with ACHD cardiologists, interventionalists, surgeons and imagers is extraordinarily useful in determining indications, timing, and methods of repair, as the guidelines for this continue to evolve.
Dextrotransposition of the great arteries (d-TGA) is a relatively rare form of complex childhood congenital heart disease, which occurs in approximately 0.2 in 1000 live births (Long et al, 2010). The most common palliative procedure for this anatomy has become the arterial switch operation (ASO). We will review in this paper the evidence that is currently available regarding the clinical management following the ASO. Individuals with d-TGA who undergo ASO at a young age thus far have excellent long-term outcomes. Long-term complications for the ASO should be monitored for and patients should have routine follow-up with specialists in adult congenital heart disease.

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Original articleCongenital heart surgeryIntervention for Supravalvar Pulmonary Stenosis After the Arterial Switch Operation

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Demographic Data

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

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Clinical outcomes after the arterial switch operation for transposition: patient support, procedural and institutional risk factors

Circulation

Original article
Congenital heart surgery
Intervention for Supravalvar Pulmonary Stenosis After the Arterial Switch Operation