Original Article
Cardiac Outcome up to 15 Years After the Arterial Switch Operation

https://doi.org/10.1016/j.hlc.2007.06.523Get rights and content

Aims

To assess the cardiac outcome and risk factors for mortality of infants following the arterial switch operation (ASO).

Methods

A single-centre retrospective review was conducted. Preoperative assessment, operative management and outcome was detailed for 244 patients undergoing the ASO at Green Lane Hospital for transposition of the great arteries (TGA) or double outlet right ventricle.

Results

The postoperative survival at 1, 5 and 15 years was 85%, 84% and 83%, respectively. The calendar year of ASO and the presence of a ventricular septal defect (VSD) were the primary predictors of early mortality. Late mortality was associated with a side-by-side configuration of the great arteries. Re-intervention following ASO was more common in patients with prolonged cardiopulmonary bypass time.

Conclusions

Low early and late morbidity and mortality can be obtained in infants with TGA or double outlet right ventricle by definitive repair utilising the ASO.

Introduction

Transposition of the great arteries (TGA) is the most common congenital cyanotic heart defect and accounts for approximately 8% of cardiac malformations. Initial attempts at anatomical repair were associated with poor outcome, leading to the development of physiological repair by Mustard1 and Senning.2 The atrial baffle procedures (Mustard and Senning operations) have significant late sequelae including arrhythmia, right ventricular dysfunction, stenosis of the interatrial baffles and tricuspid regurgitation, resulting in continuing late mortality risk.3, 4

The first successful arterial switch operation (ASO) was reported by Jatene et al. in 1975.5 This procedure results in anatomic correction. It involves connection of each proximal great artery to the distal end of the other great artery along with the translocation of the coronary arteries to the pulmonary artery. The ASO has many advantages over the Mustard and Senning operations, including the maintenance of sinus rhythm, utilisation of the left ventricle as the systemic ventricle and the mitral valve as the systemic atrioventricular valve. Initially, the operation was associated with high early morbidity, but both mortality and morbidity have been reduced by improved preoperative and postoperative care and variations in surgical technique, such as that described by Lecompte et al.,6 reducing the likelihood of pulmonary outflow obstruction. The ASO is now considered the operation of choice for the treatment of all types of TGA.7

The ASO was first undertaken at our institution in the late 1970s in infants with TGA and ventricular septal defect (VSD), and was more commonly used from 1984. The Senning operation continued to be used for infants with TGA and an intact ventricular septum until 1988. Early and mid-term results in children undergoing the ASO for TGA are promising.8, 9, 10, 11, 12, 13, 14 Long-term follow-up is limited. In this study, we review the cardiac outcome of children who had the ASO performed at our institution between 1984 and 1999.

Section snippets

Methods

Patients with TGA or double outlet right ventricle, who were treated with the ASO at Green Lane Hospital from September 1984 to January 1999, were included in this study. A retrospective chart review of all patients was undertaken to obtain details of preoperative assessment and operative management. Follow-up data were acquired from review of charts held at Green Lane Hospital or by correspondence with the patient's cardiologist or paediatrician. Survival was recorded to the last documented

Patient Population

This study included 244 patients. Follow-up was established in 212 of 213 patients (99.5%) surviving to hospital discharge and 94.4% and 61.5% of patients to one and five years, respectively. Median length of follow-up was five years (IQR 3, 9). Simple TGA with an intact ventricular septum was present in 136 (56%) patients, 98 (40%) patients had complex TGA with VSD and three had multiple VSDs. Other patient characteristics, including the position of the great arteries and coronary artery

Discussion

Medium-term survival after ASO performed at our institution in 1995 and 1996 was shown to be excellent by Armishaw et al. in 2000.15 A 96% survival at a mean follow-up interval of 16 months was reported which is similar to survival described by other centres. The cohort of patients undergoing the ASO reported by Armishaw et al. is included in a larger group of patients for this review.

The outcome of this population who underwent surgery in a single centre demonstrates an overall survival rate

Conclusion

Early mortality has been well documented for our institution's early experience of performing the ASO. Several reports, together with the analysis of our experience, confirm that the ASO can be accomplished with low early and late mortality in patients with TGA. The ASO has therefore now been established as the procedure of choice for definitive repair of TGA and has been performed routinely at Green Lane Hospital for almost two decades.

Complex cardiac anatomy has been shown to influence both

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