Original ArticleCardiac Outcome up to 15 Years After the Arterial Switch Operation
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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2016, Journal of the American Society of EchocardiographyCitation Excerpt :Mortality risk for the ASO has decreased significantly since the procedure was initially described in 1975.18 Current reviews suggest that the surgical mortality is now <5%,37,41-46 but there are anatomic subtypes that have higher perioperative mortality. These include certain CA patterns, multiple VSDs, aortic arch anomalies, and inlet (AV canal) type VSD and straddling AV valve.
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2014, Journal of the American College of CardiologyCitation Excerpt :In most infants with early post-operative ischemia, global and/or regional ventricular dysfunction is seen by echocardiography (49,67). Unexplained profound ventricular dysfunction, low cardiac output syndrome, or hemodynamically significant arrhythmias, including supraventricular tachycardia, junctional ectopic tachycardia, or ventricular tachycardia, should raise suspicion of early coronary insufficiency (41,46,51,68,69). Cardiac catheterization and angiography is the preferred method to evaluate coronary obstruction in the unstable neonate.