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Lee HN, Park HS, Hyun D, Cho SK, Park KB, Shin SW, Soo Do Y. Combined therapy with bronchial artery embolization and tranexamic acid for hemoptysis. Acta Radiol 2021; 62:610-618. [PMID: 32551802 DOI: 10.1177/0284185120933984] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND While most previous studies have viewed tranexamic acid as a bridging or temporary therapy, our preliminary study offers insights into the combined therapy of antifibrinolytic agent with endovascular treatment for hemoptysis. PURPOSE To investigate the feasibility and safety of combined therapy, to analyze factors affecting the outcomes of combined therapy, and to compare the effectiveness of combined therapy between groups with different etiologies. MATERIAL AND METHODS Between January 2011 and December 2014, 64 patients (33 men, mean age 64.6 years) underwent combined therapy for hemoptysis. The median follow-up time was 14.7 months (range 174-2435 days). Patients were divided into a tuberculosis group (GroupTB, n=37) and a non-tuberculosis group (Groupnon-TB, n=27). RESULTS Embolotherapy was technically successful in 62/64 (96.9%) cases. The immediate clinical success rate was 96.8% (60/62). The short-term and long-term recurrence rates were 12.9% (n=8) and 19.4% (n=12), respectively. The one-, two-, and four-year recurrence-free survival rates were 61%, 49%, and 32%, respectively. There was no significant survival difference between the two groups. Suboptimal embolization was a significant risk factor for immediate clinical failure (odds ratio 29.624, P = 0.023). Optimal embolization (hazard ratio [HR] 0.199, P = 0.023) and older age (HR 0.956, P = 0.013) were significantly associated with lower recurrence risk. CONCLUSION Combined therapy is an effective and safe treatment modality for hemoptysis of various etiologies, with potential benefits for short-term recurrence vis-a-vis current literature evidence. Suboptimal embolization was the most important modifiable risk factor for treatment failure and recurrence after combined therapy.
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Affiliation(s)
- Hyoung Nam Lee
- Department of Radiology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan-si, Republic of Korea
| | - Hong Suk Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dongho Hyun
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Ki Cho
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kwang Bo Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Wook Shin
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Soo Do
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Nakamura M, Kanno K, Nishioka M. Coil embolization and a left ventricular assistive device after arterial switch operation. Ann Thorac Surg 2021; 113:e57-e58. [PMID: 33753058 DOI: 10.1016/j.athoracsur.2021.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/11/2021] [Accepted: 03/15/2021] [Indexed: 11/01/2022]
Abstract
Aortopulmonary collateral arteries are frequently found in patients with transposition of great arteries after catheterization. Although most of them are asymptomatic, it may cause heart failure or pulmonary hemorrhage after an arterial switch operation. Here, we report a case of symptomatic aortopulmonary collateral arteries following arterial switch, which necessitated support with a centrifugal pump and left ventricular assistive device owing to severe mitral regurgitation and left atrial hypertension and emergent coil embolization. Hemodynamics dramatically improved following embolization. Postoperative period was uneventful and the infant was released from the hospital on the 14th day.
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Affiliation(s)
- Makoto Nakamura
- Department of Pediatric Cardiovascular Surgery, Okinawa Prefectural Nanbu Medical Center & Children's Medical Center, 118-1, Arakawa, Haebaru-cho, Okinawa 901-1193, Japan.
| | - Kazuyoshi Kanno
- Department of Pediatric Cardiovascular Surgery, Okinawa Prefectural Nanbu Medical Center & Children's Medical Center, 118-1, Arakawa, Haebaru-cho, Okinawa 901-1193, Japan
| | - Masahiko Nishioka
- Department of Pediatric Cardiovascular Surgery, Okinawa Prefectural Nanbu Medical Center & Children's Medical Center, 118-1, Arakawa, Haebaru-cho, Okinawa 901-1193, Japan
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3
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Critical Neonatal Congenital Heart Disease – a Rare Complication after Successful Surgical Correction. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2020. [DOI: 10.2478/jce-2020-0019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Pulmonary arterial hypertension (PAH) is a rare but severe complication that should be investigated in patients diagnosed with transposition of the great arteries who have undergone neonatal arterial switch operation. Early diagnosis and aggressive combination therapy for PAH could help to improve survival in these patients. We report a favorable clinical response 6 months after the initiation of vasodilator therapy in a pediatric case with transposition of the great arteries, successfully repaired in the neonatal period, who developed pulmonary arterial hypertension at the age of 5 years.
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Wipf A, Christmann M, Navarini-Meury S, Dave H, Quandt D, Knirsch W, Kretschmar O. Aortopulmonary collaterals in neonates with d-transposition of the great arteries - Clinical significance early after arterial switch operation. Int J Cardiol 2018; 258:237-242. [PMID: 29444748 DOI: 10.1016/j.ijcard.2018.01.132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 12/14/2017] [Accepted: 01/30/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Purpose of this study is to evaluate the clinical significance of major aortopulmonary collateral arteries (MAPCAs) during the early postoperative course after arterial switch operation (ASO) in d-transposition of the great arteries (dTGA). METHODS Clinical data of 98 patients with simple dTGA between January 2007 and December 2016 at the University Children's Hospital Zurich, Switzerland were analyzed retrospectively. RESULTS 37 from 98 patients (38%) required cardiac catheterization (CC) due to an early complicated postoperative course or difficult coronary transfer due to special coronary anatomy. In 15 (15%) patients, hemodynamically relevant MAPCAs were found during CC and coil embolization was performed. Patients with relevant MAPCAs had a significantly longer PICU stay (7 versus 6 days, p = 0.021), longer hospital stay (41 versus 27 days, p = 0.005), longer mechanical ventilation time (5 versus 3 days, p = 0.005), longer need for inotropic support (5 versus 4 days, p = 0.001) and delayed chest closure time (3 versus 2 days, p = 0.030) in those in whom it was left open in comparison to all other patients. In patients having CC, pre-surgery oxygen saturation was significantly lower in patients with relevant MAPCAs (58% vs 70%, p 0.019). Echocardiography had a sensitivity of 53% and a specificity of 100% in detecting relevant MAPCAs, accurately. CONCLUSIONS MAPCAs are frequently found in dTGA patients and can be associated with lower baseline oxygen saturation and a prolonged postoperative course after ASO. Transthoracic echocardiography cannot replace CC as diagnostic tool. If significant MAPCAs are suspected, early CC should be performed for diagnostic and therapeutic reasons.
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Affiliation(s)
- Alexandra Wipf
- Paediatric Cardiology, University Children's Hospital, Zurich, Switzerland; Children's Research Center, University of Zurich, Switzerland
| | - Martin Christmann
- Paediatric Cardiology, University Children's Hospital, Zurich, Switzerland; Children's Research Center, University of Zurich, Switzerland.
| | - Susanne Navarini-Meury
- Paediatric Cardiology, University Children's Hospital, Zurich, Switzerland; Children's Research Center, University of Zurich, Switzerland
| | - Hitendu Dave
- Children's Research Center, University of Zurich, Switzerland; Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
| | - Daniel Quandt
- Paediatric Cardiology, University Children's Hospital, Zurich, Switzerland; Children's Research Center, University of Zurich, Switzerland
| | - Walter Knirsch
- Paediatric Cardiology, University Children's Hospital, Zurich, Switzerland; Children's Research Center, University of Zurich, Switzerland
| | - Oliver Kretschmar
- Paediatric Cardiology, University Children's Hospital, Zurich, Switzerland; Children's Research Center, University of Zurich, Switzerland
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5
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Maddali MM, Al-Maskari SN, Kandachar PS, Lacour-Gayet F. Pulmonary Hemorrhage After Arterial Switch Operation. Ann Thorac Surg 2018; 105:e113-e115. [PMID: 29455821 DOI: 10.1016/j.athoracsur.2017.07.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 07/15/2017] [Indexed: 11/17/2022]
Abstract
Major aortopulmonary collateral arteries can influence the postoperative course of arterial switch operation, with heart failure being the common clinical presentation. A relatively rare presentation of an aortopulmonary collateral artery in the form of persistent postoperative pulmonary hemorrhage was encountered after an uneventful arterial switch operation in a neonate with transposition of the great arteries, intact interventricular septum, and situs inversus totalis. The aortopulmonary collateral artery was coil embolized with a successful outcome.
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Affiliation(s)
- Madan M Maddali
- Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, Muscat, Oman.
| | - Salim N Al-Maskari
- Department of Pediatric Cardiology, National Heart Center, Royal Hospital, Muscat, Oman
| | - Pranav S Kandachar
- Department of Cardiothoracic Surgery, National Heart Center, Royal Hospital, Muscat, Oman
| | - Francois Lacour-Gayet
- Department of Cardiothoracic Surgery, National Heart Center, Royal Hospital, Muscat, Oman
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Clinical guidelines for the management of patients with transposition of the great arteries with intact ventricular septum. Cardiol Young 2017; 27:530-569. [PMID: 28249633 DOI: 10.1017/s1047951117000014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Zijlstra WMH, Elmasry O, Pepplinkhuizen S, Ivy DD, Bonnet D, Luijendijk P, Lévy M, Gavilan JL, Torrent-Vernetta A, Mendoza A, del Cerro MJ, Moledina S, Berger RMF. Pulmonary arterial hypertension in children after neonatal arterial switch operation. Heart 2017; 103:1244-1249. [DOI: 10.1136/heartjnl-2016-310624] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 12/11/2016] [Accepted: 12/19/2016] [Indexed: 12/27/2022] Open
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Sarris GE, Balmer C, Bonou P, Comas JV, da Cruz E, Chiara LD, Di Donato RM, Fragata J, Jokinen TE, Kirvassilis G, Lytrivi I, Milojevic M, Sharland G, Siepe M, Stein J, Büchel EV, Vouhé PR. Clinical guidelines for the management of patients with transposition of the great arteries with intact ventricular septum. Eur J Cardiothorac Surg 2017; 51:e1-e32. [DOI: 10.1093/ejcts/ezw360] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Cohen MS, Eidem BW, Cetta F, Fogel MA, Frommelt PC, Ganame J, Han BK, Kimball TR, Johnson RK, Mertens L, Paridon SM, Powell AJ, Lopez L. Multimodality Imaging Guidelines of Patients with Transposition of the Great Arteries: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr 2016; 29:571-621. [DOI: 10.1016/j.echo.2016.04.002] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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10
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Raja SG, Shauq A, Kaarne M. Outcomes after Arterial Switch Operation for Simple Transposition. Asian Cardiovasc Thorac Ann 2016; 13:190-8. [PMID: 15905355 DOI: 10.1177/021849230501300222] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Without intervention, babies born with transposed great arteries (TGA) are doomed to a rapid death. Jatene and coworkers deserve the credit for performing the first successful arterial switch operation (ASO) in a patient with TGA and ventricular septal defect (VSD) in 1975. Since then ASO has become the procedure of choice in most medical centers. This review article summarizes the historical aspects of arterial switch operation and assesses this procedure's outcomes.
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Affiliation(s)
- Shahzad G Raja
- Department of Pediatric Cardiac Surgery, Alder Hey Hospital, Liverpool, United Kingdom.
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Shikata F, Okamura T, Higaki T, Okura M, Yajima C, Kojima A, Uchita S, Sakashita Y, Namiguchi K, Yasugi T, Izutani H. Aortopulmonary collateral arteries: a rare complication after arterial switch operation for transposition of the great arteries. Surg Case Rep 2016; 1:97. [PMID: 26943421 PMCID: PMC4595413 DOI: 10.1186/s40792-015-0098-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 10/01/2015] [Indexed: 11/10/2022] Open
Abstract
Collateral vascular arteries from the descending aorta to the pulmonary arteries are uncommon after arterial switch operation. Here, we report the case of a baby girl treated with coil embolization for abnormal blood flow from the descending aorta to the pulmonary arteries after arterial switch operation. A baby girl weighing 1324 g was delivered at 32 weeks 4 days of gestation, and she had D-transposition of the great arteries and a ventricular septal defect. She underwent nitrogen inhalation to reduce pulmonary blood flow before arterial switch operation. After the operation, she presented with left heart failure due to the presence of abnormal blood flow from the descending aorta to the pulmonary arteries, and she was successfully treated with coil embolization. After the treatment, her condition improved dramatically, and she was discharged without any complications.
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Affiliation(s)
- Fumiaki Shikata
- Department of Cardiovascular Surgery, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan.
| | - Toru Okamura
- Department of Cardiovascular Surgery, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Takashi Higaki
- Department of Pediatric Cardiology, Ehime University, Toon, Ehime, Japan
| | - Masahiro Okura
- Department of Cardiovascular Surgery, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Chisato Yajima
- Department of Pediatric Cardiology, Ehime University, Toon, Ehime, Japan
| | - Ai Kojima
- Department of Cardiovascular Surgery, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Shunji Uchita
- Department of Cardiovascular Surgery, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Yuji Sakashita
- Department of Cardiovascular Surgery, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Kenji Namiguchi
- Department of Cardiovascular Surgery, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Takumi Yasugi
- Department of Cardiovascular Surgery, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Hironori Izutani
- Department of Cardiovascular Surgery, Ehime University, Shitsukawa, Toon, Ehime, 791-0295, Japan
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Abstract
A neonate with transposition of the great arteries and intact ventricular septum presented without pulmonary over-circulation, and subsequently developed pulmonary haemorrhage after corrective surgery. Postoperative CT revealed an aortopulmonary collateral artery arising from the descending aorta, and we performed successful embolisation on postoperative day 9. Aggressive imaging modalities such as angiography and/or CT imaging with contrast can detect unexpected extra-pulmonary blood supply and guide further management.
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Sandeep N, Uchida Y, Ratnayaka K, McCarter R, Hanumanthaiah S, Bangoura A, Zhao Z, Oliver-Danna J, Leatherbury L, Kanter J, Mukouyama YS. Characterizing the angiogenic activity of patients with single ventricle physiology and aortopulmonary collateral vessels. J Thorac Cardiovasc Surg 2015; 151:1126-35.e2. [PMID: 26611747 DOI: 10.1016/j.jtcvs.2015.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/11/2015] [Accepted: 10/01/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Patients with single ventricle congenital heart disease often form aortopulmonary collateral vessels via an unclear mechanism. To gain insights into the pathogenesis of aortopulmonary collateral vessels, we correlated angiogenic factor levels with in vitro activity and angiographic aortopulmonary collateral assessment and examined whether patients with single ventricle physiology have increased angiogenic factors that can stimulate endothelial cell sprouting in vitro. METHODS In patients with single ventricle physiology (n = 27) and biventricular acyanotic control patients (n = 21), hypoxia-inducible angiogenic factor levels were measured in femoral venous and arterial plasma at cardiac catheterization. To assess plasma angiogenic activity, we used a 3-dimensional in vitro cell sprouting assay that recapitulates angiogenic sprouting. Aortopulmonary collateral angiograms were graded using a 4-point scale. RESULTS Compared with controls, patients with single ventricle physiology had increased vascular endothelial growth factor (artery: 58.7 ± 1.2 pg/mL vs 35.3 ± 1.1 pg/mL, P < .01; vein: 34.8 ± 1.1 pg/mL vs 21 ± 1.2 pg/mL, P < .03), stromal-derived factor 1-alpha (artery: 1901.6 ± 1.1 pg/mL vs 1542.6 ± 1.1 pg/mL, P < .03; vein: 2092.8 pg/mL ± 1.1 vs 1752.9 ± 1.1 pg/mL, P < .02), and increased arterial soluble fms-like tyrosine kinase-1, a regulatory vascular endothelial growth factor receptor (612.3 ± 1.2 pg/mL vs 243.1 ± 1.2 pg/mL, P < .003). Plasma factors and sprout formation correlated poorly with aortopulmonary collateral severity. CONCLUSIONS We are the first to correlate plasma angiogenic factor levels with angiography and in vitro angiogenic activity in patients with single ventricle disease with aortopulmonary collaterals. Patients with single ventricle disease have increased stromal-derived factor 1-alpha and soluble fms-like tyrosine kinase-1, and their roles in aortopulmonary collateral formation require further investigation. Plasma factors and angiogenic activity correlate poorly with aortopulmonary collateral severity in patients with single ventricles, suggesting complex mechanisms of angiogenesis.
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Affiliation(s)
- Nefthi Sandeep
- Laboratory of Stem Cell and Neurovascular Biology, Genetics and Developmental Biology Center, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md; Division of Pediatric Cardiology, Children's National Health System, Washington, DC
| | - Yutaka Uchida
- Laboratory of Stem Cell and Neurovascular Biology, Genetics and Developmental Biology Center, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Kanishka Ratnayaka
- Division of Pediatric Cardiology, Children's National Health System, Washington, DC
| | - Robert McCarter
- Department of Biostatistics & Informatics, Children's National Health System, Washington, DC
| | | | - Aminata Bangoura
- Division of Pediatric Cardiology, Children's National Health System, Washington, DC
| | - Zhen Zhao
- Department of Laboratory Medicine, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Jacqueline Oliver-Danna
- Department of Laboratory Medicine, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Linda Leatherbury
- Division of Pediatric Cardiology, Children's National Health System, Washington, DC
| | - Joshua Kanter
- Division of Pediatric Cardiology, Children's National Health System, Washington, DC
| | - Yoh-Suke Mukouyama
- Laboratory of Stem Cell and Neurovascular Biology, Genetics and Developmental Biology Center, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md.
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MRI shows limited mixing between systemic and pulmonary circulations in foetal transposition of the great arteries: a potential cause of in utero pulmonary vascular disease. Cardiol Young 2015; 25:737-44. [PMID: 24932863 PMCID: PMC4411741 DOI: 10.1017/s1047951114000870] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To investigate the relationship between foetal haemodynamics and postnatal clinical presentation in patients with transposition of the great arteries using phase-contrast cardiovascular magnetic resonance. BACKGROUND A severe and irreversible form of persistent pulmonary hypertension of the newborn occurs in up to 5% of patients with transposition and remains an important cause of morbidity and mortality in these infants. Restriction at the foramen ovale and ductus arteriosus has been identified as a risk factor for the development of pulmonary hypertension, and this can now be studied with magnetic resonance imaging using a new technique called metric optimised gating. METHODS Blood flow was measured in the major vessels of four foetuses with transposition with intact ventricular septum (gestational age range: 35-38 weeks) and compared with values from 12 normal foetuses (median gestational age: 37 weeks; range: 34-40 weeks). RESULTS We found significantly reduced flows in the ductus arteriosus (p<0.01) and foramen ovale (p=0.03) and increased combined ventricular output (p=0.01), ascending aortic (p=0.001), descending aortic (p=0.03), umbilical vein (p=0.03), and aorto-pulmonary collateral (p<0.001) flows in foetuses with transposition compared with normals. The foetus with the lowest foramen ovale shunt and highest aorto-pulmonary collateral flow developed fatal pulmonary vascular disease. CONCLUSIONS We found limited mixing between the systemic and pulmonary circulations in a small group of late-gestation foetuses with transposition. We propose that the resulting hypoxia of the pulmonary circulation could be the driver behind increased aorto-pulmonary collateral flow and contribute to the development of pulmonary vascular disease in some foetuses with transposition.
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Prifti E, Ademaj F, Baboci A, Kajo E, Vanini V. Coil embolization of an anomalous bronchial artery originating from the left subclavian artery following arterial switch operation: a case report. J Med Case Rep 2015; 9:55. [PMID: 25889771 PMCID: PMC4375850 DOI: 10.1186/s13256-015-0540-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 01/30/2015] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Bronchial arteries originate from the descending aorta at the level of the T5-T6 vertebrae following an intrapulmonary course along the major bronchi. When bronchial arteries take off from a vessel other than the descending aorta, the anatomy is defined as an anomalous origin of the bronchial artery. CASE PRESENTATION A 3-day-old boy from Kosovo with dextro-transposition of the great arteries who developed progressive heart failure required an emergency arterial switch operation. Because of persistent pulmonary edema after completion of the arterial switch operation at our institution, the patient could not be weaned off mechanical ventilation. Transthoracic echocardiography revealed an anomalous accelerated flow, indicating an anomalous systemic pulmonary shunt. Arterial catheterization revealed an abnormal bronchial artery originating from the left subclavian artery and bifurcating to both lungs. The anomalous ectatic bronchial artery was successfully occluded by coil embolization. The improvement of the patient's hemodynamic status resulted in an uneventful post-operative course. CONCLUSION A coil embolization procedure was successfully performed to treat an anomalous bronchial artery originating from the left subclavian artery after a switch operation in a patient with transposition of the great arteries. When clinically indicated, catheter-based therapy with coil embolization can be performed to successfully treat anomalous bronchial arteries by reducing as such the pulmonary overflow.
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Affiliation(s)
- Edvin Prifti
- Cardiac Surgery Department, Tirana University Medical Center, Tirana, Albania.
| | - Fadil Ademaj
- Heart Disease Department, Gjakova Hospital, Rr Prizren, Gjakove, Kosovo.
| | - Arben Baboci
- Cardiac Surgery Department, Tirana University Medical Center, Tirana, Albania.
| | - Efrosina Kajo
- Cardiac Surgery Department, Tirana University Medical Center, Tirana, Albania.
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Li S, Zhang Y, Li S, Wang X, Zhang R, Lu Z, Yan J. Risk Factors Associated with Prolonged Mechanical Ventilation after Corrective Surgery for Tetralogy of Fallot. CONGENIT HEART DIS 2014; 10:254-62. [PMID: 25059746 DOI: 10.1111/chd.12205] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION This study examined early postoperative results to identify perioperative factors that are associated with prolonged mechanical ventilation (PMV) in tetralogy of Fallot (TOF) patients undergoing corrective surgery. METHODS We retrospectively examined the role of perioperative variables in determining the period of mechanical ventilatory support in TOF patients undergoing corrective surgery. A total of 821 patients were included in the study. The cohort was divided into a PMV group that included patients with >90th percentile for duration of mechanical ventilation and a non-PMV group which included all other patients. RESULTS Non-PMV group consisted of 751 patients (454 males, 297 females; median age 12 months, interquartile range 8-19 months; mean weight 9.60 ± 2.98 kg). PMV group consisted of 70 patients (51 males, 19 females; median age 8 months, interquartile range 6.75-13 months; mean weight 8.64 ± 1.95 kg). No patients died in the non-PMV group compared with two deaths due to acute respiratory distress syndrome in the PMV group. Univariate risk factors for PMV included age, weight, left ventricular end-diastolic volume index (LVEDVI), McGoon ratio, Nakata index, previous palliative operations, cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, preoperative major aortopulmonary collateral arteries (MAPCAs) occlusion by coils in hybrid procedure, postoperative right ventricular/left ventricular systolic pressure ratio, central venous pressure (CVP), left atrial pressure (LAP), endotracheal reintubation, vasoactive-inotropic score (VIS), renal replacement therapy, and early-onset ventilator-associated pneumonia (VAP). In a multivariable model, age, LVEDVI, McGoon ratio, Nakata index, previous palliative operations, CPB time, blood returning to left atrium during surgery as a surrogate marker for significant aortopulmonary collateral presence, and early-onset VAP were the independent risk factors for PMV. CONCLUSIONS The risk factors for PMV were age, LVEDVI, McGoon ratio, Nakata index, previous palliative operations, CPB time, VIS, LAP, blood returning to left atrium during surgery, and early-onset VAP.
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Affiliation(s)
- Shengli Li
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Yajuan Zhang
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Shoujun Li
- Department of Cardiovascular Surgery, Pediatric Cardiac Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Xu Wang
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Rongyuan Zhang
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Zhongyuan Lu
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Jun Yan
- Department of Cardiovascular Surgery, Pediatric Cardiac Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
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17
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Saileela R, Shanthi C, Manohar K, Subramanyan R, Cherian K. Myocardial ischemia following arterial switch operation: An uncommon etiology. Ann Pediatr Cardiol 2012; 5:194-6. [PMID: 23129913 PMCID: PMC3487212 DOI: 10.4103/0974-2069.99626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Myocardial ischemia following arterial switch operation (ASO) usually occurs due to coronary ostial narrowing that might result from technical failure in translocation of the coronary arteries to the neoaorta. We present an unusual case report of neonatal myocardial ischemia caused by coronary steal secondary to aortopulmonary collaterals, following ASO in transposition of great arteries.
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Affiliation(s)
- R Saileela
- Department of Pediatric Cardiology and Cardiothoracic Surgery, Frontier Lifeline and Dr. K. M. Cherian Heart Foundation, Chennai, India
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18
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Angle JF, Siddiqi NH, Wallace MJ, Kundu S, Stokes L, Wojak JC, Cardella JF. Quality Improvement Guidelines for Percutaneous Transcatheter Embolization. J Vasc Interv Radiol 2010; 21:1479-86. [DOI: 10.1016/j.jvir.2010.06.014] [Citation(s) in RCA: 178] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Revised: 06/08/2010] [Accepted: 06/26/2010] [Indexed: 10/19/2022] Open
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19
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Golzarian J, Sapoval MR, Kundu S, Hunter DW, Brountzos EN, Geschwind JFH, Murphy TP, Spies JB, Wallace MJ, de Baere T, Cardella JF. Guidelines for Peripheral and Visceral Vascular Embolization Training. J Vasc Interv Radiol 2010; 21:436-41. [DOI: 10.1016/j.jvir.2010.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2009] [Revised: 01/18/2010] [Accepted: 01/19/2010] [Indexed: 11/25/2022] Open
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20
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Veshti A, Vida VL, Padalino MA, Stellin G. The role of aortopulmonary collaterals after an arterial switch operation: a word of caution. Pediatr Cardiol 2009; 30:347-8. [PMID: 18836756 DOI: 10.1007/s00246-008-9310-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2008] [Accepted: 09/13/2008] [Indexed: 11/28/2022]
Abstract
This report describes the case of a neonate with dextro-transposition of the great arteries and an intact ventricular septum who required postoperative extracorporeal membrane oxygenation support for an unexplained postoperative left ventricular dysfunction after an arterial switch operation. After surgery, a large aortopulmonary collateral suspected of causing overload to the left ventricle was diagnosed. Percutaneous embolization of the aortopulmonary collateral caused prompt improvement in patient's conditions and rapid weaning from mechanical ventilation support.
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Affiliation(s)
- Altin Veshti
- Pediatric and Congenital Cardiac Surgery Unit, University of Padua, Padua, Italy
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21
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Cho MJ, Park JA, Lee HD, Sung SC, Choo KS. Outcomes of the arterial switch operation in complete transposition of the great arteries. KOREAN JOURNAL OF PEDIATRICS 2009. [DOI: 10.3345/kjp.2009.52.8.910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Min Jung Cho
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan, Korea
| | - Ji Ae Park
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan, Korea
| | - Hyoung Doo Lee
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan, Korea
| | - Si Chan Sung
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Children's Hospital, Pusan, Korea
| | - Ki Seok Choo
- Department of Radiology, Pusan National University Children's Hospital, Pusan, Korea
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22
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Irving C, Chaudhari M. Enlarged bronchial collateral artery complicating recovery after arterial switch for simple transposition of the great arteries. Interact Cardiovasc Thorac Surg 2008; 7:1176-7. [DOI: 10.1510/icvts.2008.188003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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23
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Jowett V, Derrick G, Tsang V, Marek J. Coil Occlusion of Aortopulmonary Collateral Arteries Before Arterial Switch Procedure in an Infant With Transposition of the Great Arteries. Circ Cardiovasc Imaging 2008; 1:e17-8. [DOI: 10.1161/circimaging.108.792143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Victoria Jowett
- From the Great Ormond Street Hospital for Children, London, United Kingdom
| | - Graham Derrick
- From the Great Ormond Street Hospital for Children, London, United Kingdom
| | - Victor Tsang
- From the Great Ormond Street Hospital for Children, London, United Kingdom
| | - Jan Marek
- From the Great Ormond Street Hospital for Children, London, United Kingdom
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24
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Santoro G, Carrozza M, Russo MG, Calabrò R. Symptomatic aorto-pulmonary collaterals early after arterial switch operation. Pediatr Cardiol 2008; 29:838-41. [PMID: 18185950 DOI: 10.1007/s00246-007-9183-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2007] [Revised: 11/22/2007] [Accepted: 11/23/2007] [Indexed: 11/28/2022]
Abstract
Enlarged bronchial arteries and/or systemic-to-pulmonary collaterals have been frequently demonstrated in association with transposition of the great arteries. They are usually clinically silent, although they might be large enough to cause accelerated pulmonary vascular obstructive disease or symptomatic cardiac volume overload after surgical repair. We report on a low-weight neonate with transposition of the great arteries and intact ventricular septum who showed a stormy postoperative course because of multiple aorto-pulmonary collaterals early after a successful arterial switch operation. Percutaneous coil embolization of these anomalous vessels resulted in sudden weaning from mechanical ventilation and hospital discharge in a few weeks.
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Affiliation(s)
- Giuseppe Santoro
- Cardiology and Pediatric Cardiac Surgery, A.O. "Monaldi", 2nd University of Naples, Naples, Italy.
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25
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Wernovsky G, Rome JJ, Tabbutt S, Rychik J, Cohen MS, Paridon SM, Webb G, Dodds KM, Gallagher MA, Fleck DA, Spray TL, Vetter VL, Gleason MM. Guidelines for the outpatient management of complex congenital heart disease. CONGENIT HEART DIS 2008; 1:10-26. [PMID: 18373786 DOI: 10.1111/j.1747-0803.2006.00002.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
An increasingly complex group of children is now being followed as outpatients after surgery for congenital heart disease. A variety of complications and physiologic perturbations, both expected and unexpected, may present during follow-up, and should be anticipated by the practitioner and discussed with the patient and family. The purpose of this position article is to provide a framework for outpatient follow-up of complex congenital heart disease, based on a review of current literature and the experience of the authors.
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Affiliation(s)
- Gil Wernovsky
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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26
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Cohen MS, Wernovsky G. Is the arterial switch operation as good over the long term as we thought it would be? Cardiol Young 2006; 16 Suppl 3:117-24. [PMID: 17378050 DOI: 10.1017/s1047951106001041] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Surgical intervention for hearts with transposition, defined as concordant atrioventricular and discordant ventriculo-arterial connections, has been one of the landmark achievements in the field of paediatric cardiac surgery. In the early 1950s, pioneer surgeons attempted to palliate patients with transposed arterial trunks with an early form of the arterial switch operation. As a result of initially dismal outcomes secondary to difficulties with coronary arterial transfer, the unprepared nature of the morphologically left ventricle, and primitive methods for cardiopulmonary bypass, the arterial switch was abandoned in favour of several procedures achieving correction at atrial and venous levels, culminating in the Mustard and Senning operations.1,2These innovative procedures produced the earliest surviving children with transposition. Although the atrial switch procedures achieved widespread acceptance and success during the mid-1960s through the mid-1980s, the search for an operation to return the great arteries to their normal anatomic positions continued. This pursuit was stimulated primarily by the accumulating observations in mid-to-late term follow up studies of: an increasing frequency of important arrhythmic complications, including sinus nodal dysfunction, atrial arrhythmias, and sudden, unexplained death, by the development of late right ventricular dysfunction and significant tricuspid regurgitation in a ventricle potentially unsuited for a lifetime of systemic function by a small but important prevalence of obstruction of the systemic and/or pulmonary venous pathways, and by dissatisfaction with the operative mortality in the subgroup of infants complicated by additional presence of a large ventricular septal defect.3–6As we have already discussed, a number of novel procedures to achieve anatomic correction had been described as early as 1954, but clinical success was not accomplished until 1975, when Jatene and co-workers7astounded the world of paediatric cardiology with their initial description.
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Affiliation(s)
- Meryl S Cohen
- Division of Cardiology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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27
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Blume ED, Wernovsky G. Long-term results of arterial switch repair of transposition of the great vessels. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 1998; 1:129-138. [PMID: 11486215 DOI: 10.1016/s1092-9126(98)70018-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
The arterial switch operation has become the preferred surgical procedure for transposition of the great arteries worldwide. The low operative mortality at "low-risk" institutions has been well documented. The advantages of the arterial switch compared with atrial-level repairs include a lower incidence of arrhythmias and the likelihood of normal systemic ventricular function over the long term. However, the long-term sequelae of this operation must be continually evaluated, including the fate of the supravalvular pulmonary and aortic anastomoses, growth of the aortic root, competency of the neoaortic valve, patency of the coronary arteries, effects on the conduction system, and adequacy of ventricular function. These anatomic results, as well as the neurodevelopmental outcomes of these patients, are summarized in this review. Copyright 1998 by W.B. Saunders Company
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28
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Drooz AT, Lewis CA, Allen TE, Citron SJ, Cole PE, Freeman NJ, Husted JW, Malloy PC, Martin LG, Van Moore A, Neithamer CD, Roberts AC, Sacks D, Sanchez O, Venbrux AC, Bakal CW. Quality improvement guidelines for percutaneous transcatheter embolization. SCVIR Standards of Practice Committee. Society of Cardiovascular & Interventional Radiology. J Vasc Interv Radiol 1997; 8:889-95. [PMID: 9314384 DOI: 10.1016/s1051-0443(97)70679-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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29
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Massin MM, Nitsch GB, Däbritz S, Messmer BJ, von Bernuth G. Angiographic study of aorta, coronary arteries, and left ventricular performance after neonatal arterial switch operation for simple transposition of the great arteries. Am Heart J 1997; 134:298-305. [PMID: 9313611 DOI: 10.1016/s0002-8703(97)70138-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This retrospective study attempts to assess the growth pattern of the aorta and the coronary arteries and the left ventricular function approximately 1 year after neonatal arterial switch operation for simple transposition of the great arteries. Seventy-one patients underwent cardiac catheterization and cineangiocardiography an average of 13.5 months after the operation. The diameters of aortic annulus, aorta at different sites, and coronary arteries were compared with normal ranges taken from the literature. Left ventricular systolic performance was also evaluated. Observations included the following: Neoaortic annulus and root were larger than normal, trivial or mild neoaortic regurgitation was frequently observed, and the development of aortic anastomosis was normal. One patient had unexpected coronary occlusion, one had a coronary artery fistula, and two had a hypoplastic left anterior descending coronary artery. Except in one child who underwent an internal mammary bypass graft immediately after anatomic correction, the global left ventricular performance was normal. Six patients had regional wall motion abnormalities. Our midterm results are encouraging, but potential late complications remain concerns that must continue to be evaluated in long-term follow-up studies.
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Affiliation(s)
- M M Massin
- Department of Pediatric Cardiology, Rheinisch-Westfälische Technische Hochschule, Aachen, Germany
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30
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Bridges ND, Lock JE, Mayer JE, Burnett J, Castaneda AR. Cardiac catheterization and test occlusion of the interatrial communication after the fenestrated Fontan operation. J Am Coll Cardiol 1995; 25:1712-7. [PMID: 7759728 DOI: 10.1016/0735-1097(95)00055-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Our objective was to determine whether catheterization data obtained after a fenestrated Fontan operation influenced patient management or predicted functional status. BACKGROUND Cardiac catheterization after a fenestrated Fontan operation is undertaken to identify residual lesions and to observe the patient's response to test occlusion of the baffle fenestration. METHODS Sixty patients undergoing both a fenestrated Fontan operation before July 1991 and a postoperative catheterization before March 1992 were included in the study. Catheterization data were collected according to a test occlusion protocol; these data were reviewed, and the patient's clinical status at follow-up was ascertained. RESULTS Test occlusion resulted in a significant increase in systemic venous pressure, arterial oxygen saturation and arteriovenous difference in oxygen content (p < 0.0001). After test occlusion, systemic venous pressure was 40% higher and systemic venous saturation 23% lower among patients with an unfavorable versus a favorable response to test occlusion, although differences between the two groups were subtle or inapparent in the baseline state. Branch pulmonary artery stenosis (identified and balloon dilated in 6 patients) and grade 2 or 3 aortopulmonary collateral vessels (identified and coil embolized in 20) were associated with elevation in systemic venous pressure (p < 0.01). After an average of 2 years of follow-up, there were no deaths, and 50 (83%) of 60 patients were in New York Heart Association functional class I. The only postoperative characteristic significantly associated with being in functional class I at follow-up was a systemic venous pressure < 17 mm Hg. CONCLUSIONS Cardiac catheterization with test occlusion of the interatrial communication provides useful information after a fenestrated Fontan operation. Conditions associated with elevated systemic venous pressure should be sought and treated, and the response of systemic venous pressure to test occlusion should be considered when deciding whether to close an interatrial communication.
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Affiliation(s)
- N D Bridges
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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31
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Colan SD, Boutin C, Castañeda AR, Wernovsky G. Status of the left ventricle after arterial switch operation for transposition of the great arteries. Hemodynamic and echocardiographic evaluation. J Thorac Cardiovasc Surg 1995; 109:311-21. [PMID: 7853884 DOI: 10.1016/s0022-5223(95)70393-4] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The potential for improved preservation of systemic ventricular function represents an important reason for the increasing popularity of the arterial switch operation. In support of this expectation, prior studies in patients early after arterial switch operation have found normal ventricular contractility and function. This study was conducted to extend those observations to up to 10 years of follow-up and to directly examine the effects of a coexisting ventricular septal defect or short-term preparatory banding of the pulmonary artery before the arterial switch operation. METHODS Patients operated on from 1983 through 1991 were included. Echocardiographic and catheterization data were collected as part of a prospective evaluation of outcome in all patients who undergo the arterial switch operation at Boston Children's Hospital, with inclusion of data from the most recent catheterization only. Echocardiograms performed at least 6 months after the operation were included, with assessment of both the most recent status as well as serial trends. Whenever possible, echocardiographic evaluation included data necessary to perform analysis of ventricular mechanics including indices of afterload, preload, and contractility. Comparison was made to normal values and between subgroups defined on the basis of an arterial switch operation with or without ventricular septal defect and those who had a rapid two-stage arterial switch operation. RESULTS Invasive measures of left and right ventricular filling pressures, cardiac index, and pulmonary vascular resistance did not differ among the three groups. Overall, echocardiographic left ventricular end-diastolic dimension, wall thickness, mass, afterload (end-systolic wall stress), function (fractional shortening and rate-corrected velocity of fiber shortening), contractility (stress-velocity and stress-shortening relations), and preload were normal, and none of these variables was different between the groups with and without a ventricular septal defect. Serial evaluation indicated a slight but significant trend toward ventricular dilatation, perhaps related to a relatively high incidence of at least mild aortic regurgitation (30%). In contrast, in the rapid two-stage group the echocardiographic indices of left ventricular function (fractional shortening and velocity of fiber shortening) and contractility (stress-velocity and stress-shortening relations) were found to be mildly but significantly reduced compared with normal subjects and with the other arterial switch operation groups. Over the duration of follow-up encompassed by this study, no tendency toward progressive depression of function was seen. CONCLUSIONS As the length of observation after the arterial switch operation continues to increase, left ventricular size, mass, functional status, and contractility continues to be normal, with no evidence of time-related deterioration of function. As previously reported, the rapid two-stage arterial switch operation does represent a higher risk for mild impairment of myocardial mechanics.
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Affiliation(s)
- S D Colan
- Department of Pediatrics, Harvard Medical School, Boston, Mass
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