D-transposition of the great arteries: the current era of the arterial switch operation

Surgical procedures for coronary arteries in pediatric cardiac surgery: Risk factors and outcomes

BACKGROUND

Limited data exist regarding the coronary revascularization procedures needed during the repair of several congenital and pediatric cardiac malformations. We aimed to determine risk factors for in-hospital mortality and long-term outcomes of various pediatric coronary revascularization procedures.

METHODS

We retrospectively reviewed the records of 32 consecutive pediatric patients who underwent coronary revascularization procedures at our institution between May 1995 and June 2020. In-hospital mortality, risk factors, surgical indications, revascularization patency, and mid- and long-term follow-up data were investigated. Patients were categorized into the coronary artery bypass grafting (n = 11) and other coronary artery procedure (n = 21) groups.

RESULTS

The median age and weight of patients at the time of surgery were 9 months and 4.8 kg, respectively. There were five in-hospital deaths (5/32, 15.6%). The mortality rates were 27.2% (3/11) in the coronary artery bypass grafting group and 9.5% (2/21) in the other coronary artery procedure group (p = .206; 95% confidence interval: 0.496-25.563). The mortality rates for planned and rescue procedures were 8.3% (2/24) and 37.5% (3/8) (p = .06), respectively. The median follow-up time was 12.5 years. Control imaging studies for coronary patency were performed in 70.3% (19/27) of surviving patients. The overall coronary patency rate was 94.7% (18/19).

CONCLUSIONS

Pediatric coronary revascularization procedures with elective-planned indications can be performed with good outcomes. Young age and rescue and emergency procedures may carry an increased risk of in-hospital mortality, although not found to be statistically significant. Surviving patients require lifelong follow-up regarding the patency of reperfused coronary arteries.

Assessment of ventricular flow dynamics by 4D-flow MRI in patients following surgical repair of d-transposition of the great arteries

Objectives

To use 4D-flow MRI to describe systemic and non-systemic ventricular flow organisation and energy loss in patients with repaired d-transposition of the great arteries (d-TGA) and normal subjects.

Methods

Pathline tracking of ventricular volumes was performed using 4D-flow MRI data from a 1.5-T GE Discovery MR450 scanner. D-TGA patients following arterial switch (n = 17, mean age 14 ± 5 years) and atrial switch (n = 15, 35 ± 6 years) procedures were examined and compared with subjects with normal cardiac anatomy and ventricular function (n = 12, 12 ± 3 years). Pathlines were classified by their passage through the ventricles as direct flow, retained inflow, delayed ejection flow, and residual volume and visually and quantitatively assessed. Additionally, viscous energy losses (EL_v) were calculated.

Results

In normal subjects, the ventricular flow paths were well ordered following similar trajectories through the ventricles with very little mixing of flow components. The flow paths in all atrial and some arterial switch patients were more irregular with high mixing. Direct flow and delayed ejection flow were decreased in atrial switch patients’ systemic ventricles with a corresponding increase in residual volume compared with normal subjects (p = 0.003 and p < 0.001 respectively) and arterial switch patients (p < 0.0001 and p < 0.001 respectively). In non-systemic ventricles, arterial switch patients had increased direct flow and decreased delayed ejection fractions compared to normal (p = 0.007 and p < 0.001 respectively) and atrial switch patients (p = 0.01 and p < 0.001 respectively). Regions of high levels of mixing of ventricular flow components showed elevated EL_v.

Conclusions

4D-flow MRI pathline tracking reveals disordered ventricular flow patterns and associated EL_v in d-TGA patients.

Key Points

• 4D-flow MRI can be used to assess intraventricular flow dynamics in d-TGA patients.

• d-TGA arterial switch patients mostly show intraventricular flow dynamics representative of normal subjects, while atrial switch patients show increased flow disorder and different proportions of intraventricular flow volumes.

• Flow disruption and disorder increase viscous energy losses.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-07813-0.

Elective Non-Urgent Balloon-Atrial Septostomy in Infants with d-Transposition of the Great Arteries Does Not Eliminate the Need for PGE1 Therapy at the Time of Arterial Switch Operation

Once a mainstay in the treatment of neonates with d-transposition of the great arteries (d-TGA), the application of balloon atrial septostomy (BAS) in the d-TGA population has become more selective. Currently, there is no clear evidence for or against a selective BAS strategy. The aims of this single-center retrospective study were to determine the incidence of BAS in the neonatal d-TGA population in the current era, to measure the rate of procedural success, and to compare the outcomes and complication rates of patients who underwent BAS to those who underwent neonatal ASO alone. Between 2012 and 2018, 147 patients with d-TGA underwent initial medical management and ASO, 73 of which underwent BAS. The percentage of patients that underwent BAS decreased from 73 to 33% over the study time period. In patients with d-TGA with intact ventricular septum, 33% of patients remained off of PGE₁ at the time of surgery regardless of BAS. In d-TGA with ventricular septal defect, 85.7% of those that underwent BAS and 54.1% of those who did not remained off of PGE₁ at the time of surgery, however, this difference did not reach statistical significance. In this single institution retrospective cohort of patients with d-TGA, the performance of a technically successful balloon atrial septostomy did not eliminate the need for PGE₁ therapy at the time of definitive ASO. This was true regardless of the presence or absence of a ventricular septal defect.

Preoperative Anemia and Outcomes After Corrective Surgery in Neonates With Dextro-Transposition of the Great Arteries

OBJECTIVES

The authors aimed to assess whether untreated preoperative anemia was associated with increased risk for adverse outcomes after the arterial switch operation in neonates with dextro-transposition of the great arteries (d-TGA).

DESIGN

Retrospective cohort study.

SETTING

Single cardiac surgery center.

PARTICIPANTS

Eighty-two newborns with d-TGA.

INTERVENTIONS

The authors categorized the cohort into the following two groups: the infants with preoperative anemia group (defined as a hematocrit <0.40 L/L) and the control group.

MEASUREMENTS AND MAIN RESULTS

Preoperative anemia was diagnosed in 21 (25.6%) infants. Anemic infants received intraoperative red blood cell transfusions significantly more often than controls (81.0% v 34.4%, p < 0.001). No differences were observed in the incidence of adverse events, duration of hospitalization (median 27 days v 26 days, p = 0.881), and mortality (0% v 4.9%, p = 0.566). Postnatal hematocrit was the only variable independently associated with preoperative anemia in multivariate logistic regression analysis (unit odds ratio, 0.832; 95% confidence interval, 0.743-0.931; p = 0.001).

CONCLUSIONS

Untreated preoperative anemia was not associated with adverse outcomes in neonates undergoing reparative surgery for d-TGA.

Clinical Outcome of Patients with Transposition of the Great Arteries and Intramural Coronary Artery

To review the early and intermediate outcomes of patients with transposition of the great arteries (TGA) and intramural coronary artery (IMCA) who underwent arterial switch operation (ASO) at our center. Among 450 patients with TGA who underwent an ASO between 2010 and 2018, 26 (5.8%) patients were identified with IMCA. The left coronary artery was intramural in 21 of 26 patients. We adopted coronary transfer using double coronary buttons with unroofed intramural course for all 26 patients. Early mortality for patients with IMCA was 3 of 26 (11.5%) compared with 10 of 424 (2.4%) for those without IMCA (p = 0.007). Six patients suffered major adverse events, including extracorporeal membrane oxygenation support in 3 patients, delayed sternal closure in 6 patients. The follow-up was available for all 23 survivors, with the mean follow-up period of 73.5 ± 28.7 months. There was no late death and reinterventions, and all patients were asymptomatic at last follow-up. One patient exhibited moderate neopulmonary regurgitation, and 1 patient presented with distal stenosis of the right pulmonary artery. Coronary transfer using double coronary buttons with unroofed intramural course was a good option for patients with TGA and IMCA. With this technique, ASO could be performed with optimal early and intermediate outcomes.

Impact of aortic arch curvature in flow haemodynamics in patients with transposition of the great arteries after arterial switch operation

AIMS 

In this study, we will describe a comprehensive haemodynamic analysis and its relationship to the dilation of the aorta in transposition of the great artery (TGA) patients post-arterial switch operation (ASO) and controls using 4D-flow magnetic resonance imaging (MRI) data.

METHODS AND RESULTS 

Using 4D-flow MRI data of 14 TGA young patients and 8 age-matched normal controls obtained with 1.5 T GE-MR scanner, we evaluate 3D maps of 15 different haemodynamics parameters in six regions; three of them in the aortic root and three of them in the ascending aorta (anterior-left, -right, and posterior for both cases) to find its relationship with the aortic arch curvature and root dilation. Differences between controls and patients were evaluated using Mann-Whitney U test, and the relationship with the curvature was accessed by unpaired t-test. For statistical significance, we consider a P-value of 0.05. The aortic arch curvature was significantly different between patients 46.238 ± 5.581 m-1 and controls 41.066 ± 5.323 m-1. Haemodynamic parameters as wall shear stress circumferential (WSS-C), and eccentricity (ECC), were significantly different between TGA patients and controls in both the root and ascending aorta regions. The distribution of forces along the ascending aorta is highly inhomogeneous in TGA patients. We found that the backward velocity (B-VEL), WSS-C, velocity angle (VEL-A), regurgitation fraction (RF), and ECC are highly correlated with the aortic arch curvature and root dilatation.

CONCLUSION 

We have identified six potential biomarkers (B-VEL, WSS-C, VEL-A, RF, and ECC), which may be helpful for follow-up evaluation and early prediction of aortic root dilatation in this patient population.

Growth Pattern of the Neo-Aorta after Arterial Switch Operation during Childhood

Background and Objectives

Neo-aortic root dilatation (ARD) and annular dilatation (AAD) tend to develop after arterial switch operation (ASO). However, the trend of neo-aortic growth has not been well established. This paper aims to identify this trend, its associated factors, and predictors of neo-aortic dilatation after ASO.

Methods

We analyzed the growth trend of the neo-aortic root, annulus, and sinotubular junction (STJ) z-scores using random coefficients model and the risk factors affecting neo-aortic dilatation in 163 patients who underwent ASO from 2006 to 2015.

Results

Among 163 patients, 41 had a ventricular septal defect, and 11 had Taussig-Bing (TB) anomaly. The median follow-up duration was 6.61 years. The increased in the neo-aortic root z-score was different between the trapdoor and non-trapdoor coronary artery transfer techniques (0.149/year, p<0.001 vs. 0.311/year, p<0.001). Moreover, the neo-aortic annulus and STJ z-score significantly increased over time after ASO (0.067/year, p<0.001; 0.309/year, p<0.001). Pulmonary artery banding (PAB) was rather a negative affecting factor. The probabilities of freedom from ARD, AAD, and neo-aortic STJ dilatation at 10 years after ASO were 33.4%, 53.9%, and 65.4%. Neo- aortic regurgitation within 1 year was the predictor of ARD, AAD, and neo-aortic STJ dilatation. TB anomaly, PAB, and native pulmonary sinus z-score were other predictors for ARD.

Conclusion

The growth of neo-aortic root, annulus, and STJ after ASO was greater than somatic growth during childhood. The coronary artery transfer technique affected the growth pattern of the neo-aortic root.

Outcomes after corrective surgery for congenital dextro-transposition of the arteries using the arterial switch technique: a scoping systematic review

BACKGROUND

Dextro-transposition of the great arteries (D-TGA) is the most frequent cyanotic congenital heart pathology in neonates. Surgical correction of this condition is possible using the arterial switch operation (ASO) which was first performed by Jatene in 1975.

OBJECTIVES

The aim of this study was to summarise the evidence on short- (less than 1 year), medium- (1-20 years), and long-term (more than 20 years) outcomes of children with D-TGA treated with the ASO. The primary outcome was survival. Secondary outcomes were freedom from cardiac reoperations, occurrence of aortic insufficiency, pulmonary stenosis, coronary artery anomalies, neuropsychological development problems and quality of life.

METHODS

We searched MEDLINE, EMBASE, CINAHL, LILACS, and reference lists of included articles for studies reporting outcomes after ASO for D-TGA. Screening, data extraction and risk of bias assessment were done independently by two reviewers. We pooled data using a random-effects meta-analysis of proportions and, where not possible, outcomes were synthesized narratively. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to assess the certainty of the evidence for each outcome.

MAIN RESULTS

Following ASO for TGA, short-term survival was 92.0% (95% CI 91.0-93.0%; I² = 85.8%, 151 studies, 30,186 participants; moderate certainty evidence). Medium-term survival was 90.0% (95% CI 89.0-91.0%; I² = 84.3%, 133 studies; 23,686 participants, moderate certainty evidence), while long-term survival was 87.0% (95% CI 80.0-92.0 %; I² = 84.5%, 4 studies, 933 participants, very low certainty evidence). Evaluation of the different secondary outcomes also showed satisfactory results in the short, medium and long term. Subgroup analysis suggests slightly higher survival following ASO for TGA in the second surgical era (1998 to 2018) than in the first surgical era (1975 to 1997) in the short and medium term [93.0% (95% CI 92.0-94.0) vs 90.0% (95% CI 89.0-92.0) and 93.0% (95% CI 91.0-94.0) vs 88.0% (87.0-90.0%) respectively] but not in the long term [81.0% (95% CI 76.0-86.0%) vs 89.0% (80.0-95.0%)].

CONCLUSIONS

Pooled data from many sources suggests that the ASO for D-TGA leads to high rates of survival in the short, medium, and long term.

Perinatal and perioperative factors associated with mortality and an increased need for hospital care in infants with transposition of the great arteries: A nationwide 11-year population-based cohort

INTRODUCTION

Newborn infants with transposition of the great arteries (d-TGA) need immediate care for an optimal outcome. This study comprised a nationwide 11-year population-based cohort of d-TGA infants, and assessed whether the implementation of a nationwide systematic fetal screening program, or other perinatal, or perioperative factors, are associated with mortality or an increased need for hospital care.

MATERIAL AND METHODS

The national cohort consisted of all live-born infants with simple d-TGA (TGA ± small ventricular septal defect, n = 127) born in Finland during 2004-2014. Data were collected from six national registries. Prenatal diagnosis and perinatal and perioperative factors associated with mortality and length of hospitalization were evaluated.

RESULTS

Preoperative mortality was 7.9%, and the total mortality was 8.7%. The prenatal detection rate increased after introducing systematic fetal anomaly screening from 5.0% to 37.7% during the study period (P < .0001), but the total mortality rate remained unchanged. All prenatally diagnosed infants (n = 27) survived. Lower gestational age (odds ratio 0.68, P = .012) and higher maternal age at birth (odds ratio 1.16, P = .036) were associated with increased mortality in multivariable analysis. Older infant age at time of operation (P = .002), longer aortic clamp time (P < .001), and higher maternal body mass index (P = .027) were associated with longer initial hospital stay. An extended need for hospital care during the first year of life was multi-factorial.

CONCLUSIONS

In our cohort, none of the prenatally diagnosed d-TGA infants died. As a result of the limited prenatal detection rates, however, the sample size was insufficient to reach statistical significance. The d-TGA infants born with lower gestational age and to older mothers had increased mortality.

Intraoperative Extubation Post Arterial Switch Operation for Transposition of the Great Arteries With Intact Ventricular Septum: A One-Year, Single Center Experience

We sought to examine the clinical impact of intraoperative extubation (IE) in neonates undergoing the arterial switch operation (ASO) for D-transposition of the great arteries with intact ventricular septum (dTGA/IVS). This was a single center retrospective study of patients who underwent ASO for dTGA/IVS in the 12 months after an institutional change in practice favoring IE when clinically feasible. A control group was obtained by identifying the same number of consecutive patients with dTGA/IVS who underwent ASO immediately prior to this institutional change in practice, none of whom were extubated intraoperatively. Primary outcome measures included morbidity, mortality, length of hospital and intensive care unit stay and reintubation rates. There were no significant differences in the preoperative and operative characteristics between the 2 groups. Of the 10 patients who underwent ASO for dTGA/IVS in the 12 months post institutional change in practice, all (100%) were extubated intraoperatively and none (0%) required reintubation. The median length of intensive care unit stay was 2 days for both the intraoperative and non-IE groups (mean 2.2 and 3 days respectively). The median length of stay in hospital was 4 days in the IE group and 5.5 days in the non-IE group (mean 4.5 and 6 days respectively). No patients died and there was no significant difference in morbidity between the 2 groups. Our data suggests IE post ASO for dTGA/IVS is safe and displays a statistically insignificant trend toward earlier discharge from hospital.

Technical Performance Score's Association With Arterial Switch Operation Outcomes

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Modified Closed Coronary Transfer is a Good Alternative to the Trap-Door Method During Arterial Switch Operation: a Retrospective Propensity-Matched Comparison

Objective

To compare the early and long-term results of patients in whom was performed modified closed coronary transfer with the results of patients in whom was performed trap-door transfer techniques by utilizing propensity-matching analysis to provide optimal identical patient matching for the groups.

Methods

From August 2015 to December 2017, 127 consecutive patients underwent arterial switch operation due to simple and complex transposition of the great arteries, with or without additional arch and complex coronary pattern, by a single surgical team included into the study. Of these, in 70 patients it was performed modified closed coronary transfer technique and in 57 patients it was performed trap-door style coronary transfer technique. The patients were divided into two groups in terms of coronary transfer method. In the final model, after propensity matching, 47 patients from each group having similar propensity score were included into the study.

Results

There was no significant difference between the groups regarding patient characteristics. Cross-clamp time and operation time were significantly lower in the modified technique group compared with the other group (P=0.03 and P=0.05, respectively). When compared the early and late postoperative outcomes, there was no significant difference between the groups. Postoperative echocardiographic findings were mostly similar between the groups.

Conclusion

The patients in whom was performed our modified technique demonstrate overall good outcomes and the current technique ensures shorter arterial cross-clamp and operation times. It may be an alternative method to the trap-door technique for the coronary transfer during the arterial switch operation.

Time course and predictors for neoaortic root dilatation and neoaortic valve regurgitation during adult life after arterial switch operation

INTRODUCTION AND OBJECTIVES

There are limited data on the long-term development of neoaortic root dilatation (NRD) and neoaortic valve regurgitation (AR) after arterial switch operation (ASO) for transposition of the great arteries during adult life.

METHODS

We performed a retrospective longitudinal analysis of 152 patients older than 15 years who underwent ASO for transposition of the great arteries and who were followed-up for 4.9±3.3 years in 2 referral centers. Sequential changes in body surface-adjusted aortic root dimensions and progression to moderate/severe AR were determined in patients with 2 or more echocardiographic examinations. Risk factors for dilatation were tested by Cox regression to identify predictors of AR progression.

RESULTS

At baseline, moderate AR was present in 9 patients (5.9%) and severe AR in 4 (2.6%), of whom 3 had required aortic valve surgery. Initially, the median neoaortic root dimension was 20.05±2.4mm/m², which increased significantly to 20.73±2.8mm/m² (P <.001) at the end of follow-up. The mean change over time was 0.14mm/m²/y (95%CI, 0.07-0.2). Progressive AR was observed in 20 patients (13.5%) and 6 patients (4%) required aortic valve surgery. Progressive AR was associated with bicuspid valve, AR at baseline, NRD at baseline, and neoaortic root enlargement. Independent predictors were bicuspid valve (HR, 3.3; 95%CI, 1.1-15.2; P=.037), AR at baseline (HR, 5.9; 95%CI, 1.6-59.2; P=.006) and increase in NRD (HR, 4.1 95%CI, 2-13.5; P=.023).

CONCLUSIONS

In adult life, NRD and AR progress over time after ASO. Predictors of progressive AR are bicuspid valve, AR at baseline, and increase in NRD.

Outcome of arterial switch operation for transposition of the great arteries. A 35-year follow-up study

BACKGROUND

Arterial switch operation (ASO) is today the first-choice surgical treatment for patients with transposition of the great arteries. Long-term outcome data still remain scarce. Moreover, the course of these patients is not uneventful. Therefore, we wanted to evaluate long-term outcome and determine on which variables to focus during follow-up.

METHODS

Clinical records of 318 patients who underwent ASO between October 1981 and July 2018 were reviewed. Perioperative, post-operative, and interventional data were collected to determine mortality and the need for re-intervention. Descriptive statistics and Kaplan-Meier survival analysis were performed.

RESULTS

Mean follow-up time was 11.1 SD 8.5 years (range 0-35) with a mean age of 12.5 SD 9.0 years (range 0-37) at latest follow-up. In-hospital mortality was 7.5% and overall survival 90.9% for a maximum follow-up time of 35 years. Causes of early mortality were cardiogenic shock, severe pulmonary hypertension, septic shock and multiple organ failure. Causes of late mortality were cardiogenic shock, severe pulmonary hypertension, pacemaker lead fracture and fire death. Re-intervention free survival at 5-year was 91.6%, at 10-year 90.7%, at 20-year 79.2%. For all survivors, the most frequent sequelae after ASO were pulmonary artery stenosis (80.9%), of which 13.5% needed an intervention. The threshold for intervening on lesions at the level of the pulmonary artery bifurcation was higher and the percutaneous re-intervention rate was higher for non-bifurcation lesions.

CONCLUSIONS

Despite a relatively high peri-operative mortality, TGA patients have an excellent overall long-term survival. However, a large proportion of patients requires re-interventions, mainly for pulmonary artery stenosis.

Left Ventricular Stiffness in Adolescents and Young Adults After Arterial Switch Operation for Complete Transposition of the Great Arteries

We tested the hypothesis that left ventricular (LV) myocardial stiffness is altered in patients with transposition of great arteries (TGA) after arterial switch operation (ASO) and explored its associations with myocardial calibrated integrated backscatter (cIB) and LV myocardial deformation. Thirty-one patients and twenty-two age-matched controls were studied. LV myocardial stiffness was assessed by diastolic wall strain (DWS) and stiffness indices including (E/e)/LV end-diastolic dimension, (E/LV global longitudinal early diastolic strain rate)/LV end-diastolic volume, and (E/LV global circumferential early diastolic strain rate)/LV end-diastolic volume, where E and e are early diastolic transmitral and mitral annular velocities, respectively. LV myocardial cIB and longitudinal and circumferential myocardial deformation were determined by conventional and speckle tracking echocardiography. Patients had significantly lower DWS, higher stiffness indices, and greater myocardial cIB than controls (all p < 0.05). The LV longitudinal and circumferential systolic strain and systolic and diastolic strain rates were significantly lower in patients than controls (all p < 0.05). Greater average myocardial cIB was associated with lower DWS (r = - 0.44, p = 0.002). Worse DWS and LV stiffness indices were found to correlate with lower mitral annular systolic velocity, mitral annular late diastolic velocity, and LV longitudinal late diastolic strain rate (all p < 0.05). LV longitudinal and circumferential systolic strain and strain rate were also found to correlate with DWS (all p < 0.05). In conclusion, LV myocardial stiffening occurs in adolescents and young adults with TGA after ASO and is associated with impairment of ventricular systolic and diastolic myocardial deformation and myocardial fibrosis.

Is Fetal Intelligent Navigation Echocardiography Helpful in Screening for d-Transposition of the Great Arteries?

OBJECTIVES

To evaluate the performance of fetal intelligent navigation echocardiography (FINE) applied to spatiotemporal image correlation (STIC) volumes in generating 3 specific abnormal cardiac views (left ventricular outflow tract, right ventricular outflow tract, and 3-vessel and trachea) used to screen for d-transposition of the great arteries (d-TGA).

METHODS

In this prospective study, 1 or more STIC volumes were obtained from the 4-chamber view in 34 second- and third-trimester fetuses with d-TGA. Each appropriate STIC volume was evaluated by STICLoop (Samsung Medison, Seoul, Korea) before applying the FINE method. One optimal volume per fetus was selected by observers. The visualization rates of the 3 specific abnormal cardiac views of d-TGA and their diagnostic elements were calculated, and the reliability between 2 observers was verified by the intraclass correlation coefficient.

RESULTS

Fetal intelligent navigation echocardiography applied to STIC volume data sets of fetuses with d-TGA successfully generated the 3 specific abnormal cardiac views in the following manner for 2 observers: 75.0% (n = 21) for the left ventricular outflow tract, 89.2% (n = 25) for the right ventricular outflow tract, and 85.7% (n = 24) for the 3-vessel and trachea view. Twenty-four (85.7%) of the STIC volume data sets showed 2 or 3 of the abnormal cardiac views. The interobserver intraclass correlation coefficients between the 2 observers ranged from 0.842 to 1.000 (95% confidence interval), indicating almost perfect reliability for the 2 observers.

CONCLUSIONS

In cases of d-TGA, the FINE method has a high success rate in generating 3 specific abnormal cardiac views and therefore can be performed to screen for this congenital defect.

Neoaortic Regurgitation in Patients with Transposition Long Term After an Arterial Switch Operation and Its Relation to the Root Diameters and Surgical Technique Used

Neoaortic regurgitation and root dilatation are common findings in patients with transposition after an arterial switch operation. The aim of this study was to describe the relation between neoaortic regurgitation long term after an arterial switch procedure, aortic root diameters, and surgical technique used. We also assessed the agreement of the neoaortic regurgitation grade and root diameters in different imaging modalities. For this retrospective study, we qualified 56 consecutive patients who, according to our institutional protocol, had a routine postoperative evaluation of more than 16 years with multimodality imaging studies. Neoaortic regurgitation was assessed by both transthoracic echocardiography and magnetic resonance imaging, and the root diameters obtained by echocardiography and tomography were compared to the reference values and associated with the presence of neoaortic insufficiency. Neoaortic insufficiency was present in 75% of examined patients; the vast majority of them had trace or mild regurgitation, and its qualitative evaluation was significantly different between echocardiography and magnetic resonance imaging. In our study group, the neoaortic valve and aortic sinus were larger in relation to the normal values, and they were significantly correlated with the presence of neoaortic insufficiency, but not with the surgical technique used. Values obtained by echocardiography and tomography correlated well but were significantly different. Transthoracic echocardiography has a tendency to overestimate the severity of regurgitation compared to magnetic resonance imaging. Neoaortic valve and sinus dilatation are significantly correlated with valve insufficiency, but in most cases of root dilatation, the valve remains competent.

Superior vena caval thrombosis after a neonatal arterial switch procedure

Superior vena cava (SVC) and inferior vena cava obstructions were once well-documented complications from the Mustard repair for D-transposition of the great arteries (TGA), occurring in 10%–40% patients; however, they are rarely documented with the current, more common arterial switch operation (ASO). Similarly, SVC thrombosis is an uncommon, severe complication following neonatal cardiac surgery. We report a case of persistent SVC thrombosis, SVC syndrome, and chylothorax arising after ASO, refractory to thrombolysis and stent placement. A 6-day-old neonate with prenatally known TGA underwent an arterial switch procedure. Despite an initially unremarkable postoperative course, he developed respiratory difficulty after starting enteral feeding. Soft-tissue swelling was noted in the neck, chest, and upper face. An SVC thrombus was identified with cardiac catheterization. Multiple thrombolytic modalities were attempted. His postoperative course was further complicated by recurrent chylothoraces, respiratory failure, sepsis, anasarca, and renal failure. He was eventually transferred to a larger center for a special lymphatics evaluation, where two lymphovenous anastomoses were unsuccessful. He was sent to his home hospital, where he died from extended-spectrum beta-lactamase Klebsiella sepsis. Early diagnosis of SVC syndrome and prompt thrombolysis may prevent the complications encountered in this patient. More research is needed in neonatal thrombolysis and anticoagulation.

Prognostic power of anaerobic threshold parameters in patients with transposition of the great arteries and systemic right ventricle

INTRODUCTION

Both transposition of the great arteries (TGA) previously submitted to a Senning/Mustard procedure and congenitally corrected TGA (cc-TGA) have the systemic circulation supported by the morphological right ventricle, thereby rendering these patients to heart failure events risk. The aim of this study was to evaluate cardiopulmonary exercise test parameters for stratifying the risk of heart failure events in TGA patients.

METHODS

Retrospective evaluation of adult TGA patients with systemic circulation supported by the morphological right ventricle submitted to cardiopulmonary exercise test in a tertiary centre. Patients were followed up for at least 1 year for the primary endpoint of cardiac death or heart failure hospitalisation. Several cardiopulmonary exercise test parameters were analysed as potential predictors of the combined endpoint and their predictive power were compared (area under the curve).

RESULTS

Cardiopulmonary exercise test was performed in 44 TGA patients (8 cc-TGA), with a mean age of 35.1 ± 8.4 years. The primary endpoint was reached by 10 (22.7%) patients, with a mean follow-up of 36.7 ± 26.8 months. Heart rate at anaerobic threshold had the highest area under the curve value (0.864), followed by peak oxygen consumption (pVO2) (0.838). Heart rate at anaerobic threshold ≤95 bpm and pVO2 ≤20 ml/kg/min had a sensitivity of 87.5 and 80.0% and a specificity of 82.4 and 76.5%, respectively, for the primary outcome.

CONCLUSION

Heart rate at anaerobic threshold ≤95 bpm had the highest predictive power of all cardiopulmonary exercise test parameters analysed for heart failure events in TGA patients with systemic circulation supported by the morphological right ventricle.

Can we predict potentially dangerous coronary patterns in patients with transposition of the great arteries after an arterial switch operation?

INTRODUCTION

Coronary artery complications are the main reason for early mortality after an arterial switch operation. Late complications are relatively rare, and there is no consensus regarding the need or indications for routine follow-up coronary artery evaluations or the best first-line assessment modality. The aim of this study was to present the long-term post-operative frequency of coronary abnormalities in asymptomatic patients with transposition of the great arteries discovered by coronary CT angiography and potential "red flags" revealed by other examinations.

PATIENTS AND METHODS

A group of 50 consecutive asymptomatic patients who underwent routine long-term coronary artery evaluation after an arterial switch operation according to our institutional protocol were qualified for this study. This routine in-hospital visit included a detailed medical interview, electrocardiography, echocardiography, Holter electrocardiography examinations, and laboratory and cardiopulmonary exercise tests. Patients who showed significant abnormalities were qualified for perfusion scintigraphy.

RESULTS

Unfavourable coronary abnormalities were detected in 30 patients (60%) and included ostial stenosis, muscular bridge, coronary fistula, interarterial course, proximal kinking, high ellipticity index, proximal acute angulation (<30 degree) of the left coronary artery, and proximal acute angulation of the right coronary artery. These features could not be predicted based on the medical interviews, surgical reports, or non-invasive screening test results.

CONCLUSION

Complex coronary configurations with potentially dangerous coronary features are common in patients with transposition after an arterial switch operation. Such high-risk patients cannot be identified indirectly, and coronary CT angiography provides accurate information that is useful for post-operative management.

Urinary metabolomics reveals kynurenine pathway perturbation in newborns with transposition of great arteries after surgical repair

INTRODUCTION

Transposition of the great arteries (TGA) is a cyanotic congenital heart defect that requires surgical correction, with the use of cardiopulmonary-bypass (CPB), usually within 3 weeks of life. The use of CPB in open heart surgery results in brain hypoperfusion and in a powerful systemic inflammatory response and oxidative stress.

OBJECTIVE

We aimed to develop a novel untargeted metabolomics approach to detect early postoperative changes in metabolic profile following neonatal cardiac surgery.

METHODS

We studied 14 TGA newborns with intact ventricular septum undergoing arterial switch operation with the use of CPB. Urine samples were collected preoperatively and at the end of the surgery and were analyzed using an untargeted metabolomics approach based on UHPLC-high resolution mass spectrometry.

RESULTS

Since post surgery metabolic spectra were heavily contaminated by metabolites derived from administered drugs, we constructed a list of drugs used during surgery and their related metabolites retrieved from urine samples. This library was applied to our samples and 1255 drugs and drug metabolites were excluded from the analysis. Afterward, we detected over 39,000 unique compounds and 371 putatively annotated metabolites were different between pre and post-surgery samples. Among these metabolites, 13 were correctly annotated or identified. Metabolites linked to kynurenine pathway of tryptophan degradation displayed the highest fold change.

CONCLUSIONS

This is the first report on metabolic response to cardiac surgery in TGA newborns. We developed an experimental design that allowed the identification of perturbed metabolic pathways and potential biomarkers of brain damage, limiting drugs interference in the analysis.

Acute coronary artery obstruction following surgical repair of congenital heart disease

OBJECTIVES

Acute coronary artery obstruction is a rare complication of congenital heart disease surgery but imposes a high burden of morbidity and mortality. Previous case series have described episodes in specific congenital heart lesions or surgical repairs but have not examined the complication in all-comers to congenital heart surgery. We hypothesize that shorter time from a clinically recognized postoperative sentinel event suggestive of coronary ischemia to diagnosis of coronary obstruction is associated with improved clinical outcomes.

METHODS

This was a single-center, retrospective review of patients diagnosed with acute coronary artery obstruction by angiography following surgical repair of congenital heart disease between January 2000 and June 2016.

RESULTS

In total, 34 patients were identified. The most common procedures associated with coronary artery obstruction were the Norwood procedure, arterial switch operation, and aortic valve repair/replacement. In total, 79% required mechanical circulatory support, 41% died, and 27% were listed for heart transplant. Patients who died or were listed for heart transplant had longer median sentinel-event-to-cardiac-catheterization time (28 [6-168] hours vs 10 [3-56] hours, P = .001), and longer median sentinel-event-to-intervention time (32 [11-350] hours vs 13 [5-59] hours, P = .003). Patients with hypoplastic left heart syndrome were at greater risk of death or transplant listing (odds ratio, 9.23, P = .03).

CONCLUSIONS

Time from clinically relevant postoperative sentinel event to diagnosis of coronary artery obstruction by angiography was associated with transplant-listing-free survival. Clinicians should maintain a high index of suspicion for coronary obstruction and consider early catheterization and coronary angiography for patients in whom post-operative coronary compromise is suspected.

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

BACKGROUND

The 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).

METHODS

A 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.

RESULTS

Overall 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.

CONCLUSIONS

CA reimplantation after neoaortic reconstruction yields better results in mortality and intraoperative or postoperative CA-related problems in ASO without increasing postoperative neoaortic valve regurgitation.

Arterial switch operation for transposition of the great arteries: A single-centre 32-year experience

OBJECTIVE

Arterial switch operation (ASO) is nowadays the standard of care for neonates with D-transposition of the great arteries (D-TGA). We evaluated our early and late results with ASO for D-TGA.

MATERIALS AND METHODS

We collected data on 267 patients with D-TGA, either with intact ventricular septum (D-TGA/IVS; n = 182, 68%) and with other associated congenital heart malformations (complex D-TGA; n = 85, 32%) that underwent ASO between January 1987 and July 2018.

RESULTS

Median age at ASO was 8 days (interquartile range [IQR], 6-12 days). Fifteen patients (5.6%) died in hospital (6/182 with D-TGA/IVS, 3.3% and 9/85 with complex D-TGA, 11%; P = 0.02). Median follow-up time was 10.2 years (IQR, 3.7-18 years). There were 2 (0.8%) late sudden deaths. Overall survival at 10 and 20 years was 94% and 93%, respectively. Thirty-five patients (14%) required either reoperations or reinterventions, mainly for right ventricular outflow tract obstruction (n = 28, 11%). Freedom from reoperation/reintervention at 10 and 20 years was 87% and 78%, respectively. All patients were in NYHA I at latest clinical examination. Six over 173 patients (3.4%) who underwent a postoperative evaluation of their coronaries presented acquired anomalies. Forty-four patients (17%) who performed a cardiopulmonary exercise testing (CPET) have a predicted VO ₂ comparable to normal peers.

CONCLUSIONS

The results of ASO for D-TGA are excellent, with a fairly low mortality and reoperation/reintervention rate. Functional capacity evaluated with CPET is comparable to normal peers. Continuous follow-up for detecting asymptomatic acquired coronary artery disease is mandatory. A reassessment of competitive sport eligibility criteria for specific D-TGA patients should be considered.

Functional outcomes in children with anatomically repaired transposition of the great arteries with regard to congenital ventricular septal defect and coronary pattern

OBJECTIVE

Despite decreasing mortality, functional impairments in children with transposition of the great arteries (TGA) are still a concern. This study analyses health-related physical fitness (HRPF), arterial stiffness and health-related quality of life (HRQoL) in children with anatomically repaired TGA regarding congenital ventricular septal defect (VSD) and coronary patterns.

PATIENTS AND METHODS

68 children with anatomically repaired TGA with or without VSD (12.9±3.7 years, 19.1% female) were investigated between August 2014 and October 2017. HRPF was assessed by five tests of the FITNESSGRAM, arterial stiffness was measured by oscillometric measurement using Mobil-O-Graph and HRQoL was analysed with a self-report questionnaire (KINDL-R). All test results were compared with a healthy reference cohort (n=2116, 49.1% female) adjusted for sex and age.

RESULTS

Children with anatomically repaired TGA had significantly worse HRPF (z-score: -0.58±0.81, p<0.001), increased pulse wave velocity (TGA: 4.9±0.3 m/s vs healthy: 4.8±0.3 m/s, p=0.028) and central systolic blood pressure (TGA: 105.9±5.8 mm Hg vs healthy: 103.3±5.7 mm Hg, p=0.001). No difference was found for HRQoL between the two groups (total HRQoL score: TGA: 76.5±10.2 vs healthy: 75.2±10.1, p=0.315). Neither the coronary pattern nor a congenital VSD resulted in significant differences in all functional outcomes.

CONCLUSION

Children with anatomically repaired TGA exhibit impaired HRPF and increased arterial stiffness whereas their HRQoL is normal. The underlying coronary pattern seems to have no influence on the functional outcome, nor does an accompanied congenital VSD.

Management of the Adult with Arterial Switch

Dextro-transposition of the great arteries (d-TGA) is a lethal congenital heart defect in which the great arteries-the pulmonary artery and aorta-are transposed to create ventriculoarterial discordance. Corrective surgical interventions have resulted in significant improvements in morbidity and mortality for this once-fatal congenital heart defect. The initial palliative surgery for d-TGA was the atrial switch operation, which provided physiological correction. The Mustard and Senning "atrial switch" procedures, in which an atrial baffle is created to produce a discordant atrioventricular connection on the existing discordant ventriculoarterial connection, showed preliminary success for the correction of d-TGA. However, follow-up evaluations demonstrated increasing complications from the right ventricle utilized as a systemic ventricle, resulting in progressive right ventricular dysfunction. Thus, the search continued for an anatomical correction of d-TGA to return the great arteries to their normal ventricular connections. The arterial switch operation (ASO), though attempted and theorized by many, was first successfully performed by Dr. Jatene and colleagues in 1975. For ASO, the distal main pulmonary artery and the distal ascending aorta are transected and then anastomosed to their respective ventricles with relocation of the coronary arteries to the neoaorta. The ASO has replaced the atrial switch operation since the 1980s and is now the standard surgical correction for d-TGA. As more patients who have undergone ASO are living into adulthood, late complications of this procedure have become more evident. The most common late postoperative complications include coronary artery stenosis, neoaortic root dilation, neoaortic insufficiency, and neopulmonic stenosis. Adults who have undergone ASO in childhood will need follow-up with surveillance imaging and evaluation of new symptoms or declining function to prevent and manage late postoperative complications. This review describes the management strategies for common late complications in patients who have undergone ASO.

Surgical Age and Morbidity After Arterial Switch for Transposition of the Great Arteries

BACKGROUND

Transposition of the great arteries (TGA) is a complex congenital heart disease that requires early diagnosis as well as advanced surgical repair and postoperative support. This study sought to investigate the impact of surgical timing on early postoperative morbidity.

METHODS

This study reviewed all patients with TGA repaired at a single institution (Skåne University Hospital, Lund, Sweden) by arterial switch operation (ASO) between June 2001 and June 2017. Major postoperative morbidity (MPM) and death within 30 days after ASOs were documented. Patients with double-outlet right ventricle, chromosomal abnormalities, and noncardiac diseases were excluded. MPM was defined as the presence of at least 1 of the following: delayed sternum closure, reoperation, prolonged mechanical ventilation, noninvasive ventilation after extubation, peritoneal dialysis, extracorporeal membrane oxygenation, and readmission.

RESULTS

A total of 241 patients were included, with medians for birth weight, gestational week, and age at surgery of 3.5 kg, 39 weeks, and 5 days, respectively. MPM was encountered in 32.3% of patients. Prematurity (P = .001) and need for aortic arch repair at the time of ASO (P = .04) were associated with a significant increase in MPM. Non-A coronary anatomy, associated ventricular septal defect requiring surgical closure, and fetal diagnosis of TGA had no significant impact on MPM (P = .35, .08, and .21, respectively). There was no significant difference in MPM among the surgical groups (P = .49).

CONCLUSIONS

Early complications after ASO do occur and are mostly associated with prematurity and the need for aortic arch repair. Timing of surgical repair does not seem to influence the rate of these complications.

Associations Between Age at Arterial Switch Operation, Brain Growth, and Development in Infants With Transposition of the Great Arteries

BACKGROUND

Brain injury, impaired brain growth, and long-term neurodevelopmental problems are common in children with transposition of the great arteries. We sought to identify clinical risk factors for brain injury and poor brain growth in infants with transposition of the great arteries undergoing the arterial switch operation, and to examine their relationship with neurodevelopmental outcome.

METHODS

The brains of 45 infants with transposition of the great arteries undergoing surgical repair were imaged pre- and postoperatively using magnetic resonance imaging. Brain weight z scores were calculated based on brain volume and autopsy reference data. Brain injury scores were determined as previously described. Neurodevelopment was assessed at 18 months using the Bayley-III scores of infant development. The relationships between clinical variables, brain injury, perioperative brain growth, and 18-month Bayley-III scores were analyzed.

RESULTS

On preoperative imaging, moderate or severe white matter injury was present in 10 of 45 patients, whereas stroke was seen in 4 of 45. A similar prevalence of injury was seen on postoperative imaging, and we were unable to identify any clinical risk factors for brain injury. Brain weight z scores decreased perioperatively in 35 of 45 patients. The presence of a ventricular septal defect ( P=0.009) and older age at surgery ( P=0.007) were associated with impaired perioperative brain growth. When patients were divided into those undergoing surgery during the first 2 weeks of life (32/45) versus those being repaired later (13/45), infants repaired later had significantly worse perioperative brain growth (late repair postoperative brain weight z = -1.0±0.90 versus early repair z = -0.33±0.64; P=0.008). Bayley-III testing scores fell within the normal range for all patients, although age at repair ( P=0.03) and days of open chest ( P=0.03) were associated with a lower composite language score, and length of stay was associated with a lower composite cognitive score ( P=0.02).

CONCLUSIONS

Surgery beyond 2 weeks of age is associated with impaired brain growth and slower language development in infants with transposition of the great arteries cared for at our center. Although the mechanisms underlying this association are still unclear, extended periods of cyanosis and pulmonary overcirculation may adversely impact brain growth and subsequent neurodevelopment.

Natural history of complex transposition of great arteries in an adult: a case report

BACKGROUND

Transposition of the great arteries is the most common cyanotic cardiac lesion in newborns. Transposition of the great arteries without surgical correction is fatal during the first year of life. Contemporary outcome studies have shown that survival rates after surgery are excellent and most patients live to adulthood.

CASE SUMMARY

Woman with complex transposition of the great arteries with atrial and ventricular septal defects and subvalvular and valvular pulmonary stenosis, who has survived until the age of 31 years without surgery. The diagnosis was made by echocardiography and cardiac magnetic resonance. She underwent successful corrective surgical treatment after this age, by means of a Jatene operation.

CONCLUSION

In transposition of the great arteries patients, a high index of cases dies in the first month of life. Our case represents a natural history of the complex transposition of the great arteries. Non-invasive imaging studies are very useful for the diagnosis and follow-up of patients with transposition of the great arteries, especially echocardiography and cardiac magnetic resonance. In our case, the multimodality approach and the corrective surgery allowed her to survive.

Obstetric outcomes following atrial and arterial switch procedures for transposition of the great arteries (TGA) - A single, tertiary referral centre experience over 20 years

Repair of transposition of the great arteries usually involves an atrial switch or arterial switch operation, which can complicate physiological adaptation to the demands of pregnancy and adversely affect the fetus. We retrospectively compared outcomes of 48 completed pregnancies in 23 women with surgically corrected transposition of the great arteries (38 atrial switch/10 arterial switch operation) under joint cardiac-obstetric care in our tertiary referral clinic between 1997 and 2017. Most women delivered vaginally (85%). The pre-term delivery rate was high (atrial switch 39%; arterial switch operation 40%). Small for gestational age occurred in 56% of babies, significantly more in the atrial switch group (66%) than arterial switch operation (20%), p = 0.013. Women with surgically corrected transposition of the great arteries wishing to become pregnant are at high risk of obstetric complications, primarily pre-term delivery and small for gestational age baby. They require more careful ultrasound surveillance beyond 36 weeks' gestation and/or may benefit from early induction of labour. Trial registration: Text/Not applicable.

Computational Study of Pulmonary Flow Patterns After Repair of Transposition of Great Arteries

Patients that undergo the arterial switch operation (ASO) to repair transposition of great arteries (TGA) can develop abnormal pulmonary trunk morphology with significant long-term complications. In this study, cardiovascular magnetic resonance was combined with computational fluid dynamics to investigate the impact of the postoperative layout on the pulmonary flow patterns. Three ASO patients were analyzed and compared to a volunteer control. Results showed the presence of anomalous shear layer instabilities, vortical and helical structures, and turbulent-like states in all patients, particularly as a consequence of the unnatural curvature of the pulmonary bifurcation. Streamlined, mostly laminar flow was instead found in the healthy subject. These findings shed light on the correlation between the post-ASO anatomy and the presence of altered flow features, and may be useful to improve surgical planning as well as the long-term care of TGA patients.

The Adult with Post-operative Congenital Heart Disease: a Systematic Echocardiographic Approach

PURPOSE OF REVIEW

This article attempts to review some of the commonly seen repaired congenital heart defects in the adult population (ACHD), with a focus on important echocardiographic findings that may assist a practitioner in recognizing and managing this group of patients.

RECENT FINDINGS

The prevalence of ACHD population is increasing, and currently, there are over 1 million adults with congenital heart disease. At the current time, the total number of ACHD patients exceeds the total number of pediatric patients with CHD. The recently released 2018 American College of Cardiology/American Heart Association guidelines for the management of adults with congenital heart disease (ACHD) recommends transthoracic echocardiography for all ACHD patients for initial assessment and serial assessment as needed (class of recommendation: I) and echocardiography remains the mainstay for diagnosing and managing these patients in adjunct with other available imaging modalities. It is imperative for all cardiologists to be familiar with the echocardiographic features of the commonly seen repaired CHD in adult population.

The Relationship Between Pre-operative Left Ventricular Longitudinal Strain and Post-operative Length of Stay in Patients Undergoing Arterial Switch Operation Is Age Dependent

INTRODUCTION

Post-operative length of stay (LOS) after the arterial switch operation (ASO) is variable. The association between pre-operative non-invasive measures of ventricular function and post-operative course has not been well established. The aims of this study were to (1) evaluate the relationship between pre-operative non-invasive measures of ventricular function and post-operative LOS and (2) evaluate the change in ventricular function after ASO.

METHODS

Data were reviewed in consecutive ASO patients between 2010 and 2016. The primary outcome was post-operative LOS. Echocardiograms obtained during the pre-operative period and at the time of discharge were retrospectively analyzed using speckle-tracking echocardiography. Pearson's correlation between patient-specific, pre-operative, and echocardiographic data versus post-operative LOS was assessed.

RESULTS

Fifty-two patients were included in analyses, 39 neonates and 13 infants. Left ventricular (LV) longitudinal strain correlated with post-operative LOS for infants age > 28 days (r = 0.62, p = 0.03), but not for neonates (r = 0.14, p = 0.40). Operative age (r = - 0.42, p = 0.003), weight at surgery (r = - 0.48, p ≤ 0.001), and cardiopulmonary bypass time (r = 0.30, p = 0.045) also correlated with post-operative LOS. Standard 2D measures of ventricular function did not correlate with post-operative LOS. LV ejection fraction and longitudinal strain worsened post-operatively.

CONCLUSION

Higher pre-operative LV longitudinal strain (representing worse LV function) is associated with increased post-operative LOS after ASO in infants > 28 days, but not in neonates. LV ejection fraction and longitudinal strain worsened after ASO. Future studies should assess the utility of performing STE in risk stratifying patients prior to ASO.

Evaluation of Left Ventricular Function Long Term After Arterial Switch Operation for Transposition of the Great Arteries

Long-term after arterial switch operation for transposition of the great arteries, abnormal coronary anatomy and altered loading conditions could compromise ventricular function. The current study investigates whether left ventricular function, measured with echocardiographic bi-plane ejection fraction and deformation imaging, in patients long term after arterial switch operation for transposition of the great arteries differs from healthy peers. A cross-sectional cohort study of patients at least 12 years after arterial switch operation was analyzed with bi-plane Simpson's left ventricular ejection fraction (LVEF) and deformation (speckle tracking) echocardiography. 81 patients, median age 20.6 (interquartile range 13.5-28.4) years, were included. LVEF was normal on average at 55.5 ± 6.1%. Global longitudinal strain (GLS) was lower in patients compared to healthy peers throughout all age groups and on pooled average (- 15.4 ± 1.1% vs. - 23.2 ± 0.9%). Although LVEF is normal on average in patients after arterial switch operation for transposition of the great arteries, GLS is impaired compared to healthy peers. The reduced GLS could indicate sub-clinical myocardial dysfunction.

Longitudinal Associations between Neurodevelopment and Psychosocial Health Status in Patients with Repaired D-Transposition of the Great Arteries

OBJECTIVE

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.

STUDY DESIGN

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.

RESULTS

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.

CONCLUSIONS

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.

Utility of Follow-Up Annual Echocardiograms in Patients With Complete Transposition of the Great Arteries After Arterial Switch Operations

The arterial switch operation (ASO) in complete transposition of the great arteries (TGA) has increased long-term survival. Annual follow-up echocardiograms are recommended, but evidence-based guidelines do not exist. We sought to assess how often a patient with TGA after ASO who had no symptoms or change in physical exam underwent an intervention based solely on echocardiographic changes. We retrospectively reviewed all records from patients with TGA and a history of ASO followed at our institution between November 1983 and January 2015. Changes in echocardiograms resulting in hospital admission, significant medication change, interventional catheterization, or surgical procedure were identified through the surgical and cardiac catheterization laboratory databases and patient charts. These changes were referred to as an actionable change (AC). Interventions were defined as being driven by either clinical (change in physical exam, patient and/or parental concerns) or echocardiographic findings. A total of 1,792 echocardiograms from 149 patients were reviewed. Median number of echocardiograms per patient was 12 (1 to 34). Of the 1,792 echocardiograms, 20 (1.12%) were associated with AC. The most common intervention for an AC was cardiac catheterization (13 of 20, 65%). Most AC (15 of 20, 75%) occurred in the first decade after ASO. AC occurred in 83% (5 of 6) of those with a history of both ASO and arch repair. Annual echocardiograms in patients with TGA after ASO are rarely useful and are unnecessary. In conclusion, decreasing surveillance of asymptomatic patients to biennial follow-up echocardiograms in asymptomatic patients without physical examination changes is safe and would decrease medical expenses.