Long-Term Results After Primary One-Stage Repair of Transposition of the Great Arteries and Aortic Arch Obstruction

A new predictor of the optimal pulmonary artery reconstruction method during the arterial switch operation

OBJECTIVES

The aim of this study was to more accurately predict the optimal pulmonary artery (PA) reconstruction procedure (Lecompte manoeuvre or original Jatene procedure) during the arterial switch operation, we focused on the horizontal sectioning (HS) angle between the left hilum PA and the great arteries using preoperative computed tomography imaging.

METHODS

We defined the HS angle α (β) as the angle between the tangential line from the posterior (anterior) wall of the left PA at the hilum to the left anterior (right posterior) surface of the main PA and the tangential line from the left surface of the ascending aorta to the left anterior (right posterior) surface of the main PA. We identified 14 consecutive patients diagnosed with transposition of the great arteries or transposition of the great artery-type double-outlet right ventricle who underwent preoperative computed tomography imaging. The original Jatene or Lecompte procedure was used for 9 (OJ group) and 5 (L group) patients. Relationships of the great arteries of the OJ and L groups were side by side in 8 and 2 patients, oblique in 1 and 1 patient and anteroposterior in 0 and 2 patients, respectively.

RESULTS

In the OJ group, β was greater than α in all patients. The median α/β value was 0.618. In group L, α was greater than β in all patients. The median α/β was 1.307. Left PA stenosis caused by stretching was not observed in the L group. Coronary obstruction was not identified in the OJ group. Left PA stenosis behind the neo-ascending aorta was observed in 1 patient in the OJ group and required reoperation.

CONCLUSIONS

The HS angle may be a useful predictor of optimal intraoperative PA reconstruction during arterial switch operation, especially for side-by-side or oblique relationships.

Outcomes of Arterial Switch Operation With Aortic Arch Reconstruction

BACKGROUND

This study investigated the outcomes and factors associated with reintervention or development of significant pulmonary stenosis (PS) after repair of transposition of the great arteries (TGA) or Taussig-Bing anomaly (TBA) with aortic arch obstruction.

METHODS

A total of 51 patients with TGA or TBA who underwent an arterial switch operation and aortic arch reconstruction between 2004 and 2020 were included. The outcomes of interest were all-cause death, including heart transplantation, all-cause reintervention, right-sided reintervention, and development of significant PS.

RESULTS

The median age and body weight at repair were 9 days and 3.2 kg, respectively. Forty-nine patients (96.1%) underwent 1-stage repair. A total of 28 patients (54.9%) had TBA, and 8 patients (15.7%) had interrupted aortic arch. There were 5 early deaths (9.8%) and 2 late deaths during a median follow-up duration of 59 months. The transplant-free survival rate 10 years after repair was 82.6%. A total of 21 reinterventions were required in 10 patients. The significant PS-free survival rate 10 years after repair was 68.8%. In univariable analysis, a higher ratio of the diameter of the main pulmonary artery to the ascending aorta was associated with all-cause reintervention (P = .007) and right-sided reintervention (P = .002). A smaller aortic annulus z-score at the pulmonary position was associated with the development of significant PS (P = .049).

CONCLUSIONS

The rates of overall mortality and reintervention after repair were not negligible. A higher degree of size discrepancy between the 2 great arteries was associated with all-cause or right-sided reintervention. A smaller aortic annulus z-score at the pulmonary position was associated with the development of significant PS.

One-stage repair of transposition complex and interrupted aortic arch in children

BACKGROUND/AIM

A transposition complex with an interrupted aortic arch (IAA) is rare and surgically challenging because of its anatomical diversity and complexity. Herein, we aimed to present our 20-year experience with one-stage arterial switch surgery associated with IAA repair.

METHODS

From January 2000 to April 2017, 11 patients were diagnosed with transposition complex and IAA and underwent one-stage repair at our center. These patients were retrospectively reviewed. Two patients had transposition of the great arteries, while the others had double outlet right ventricles, of whom eight had subpulmonary ventricular septal defects (VSDs; Taussig-Bing anomalies), and one had a noncommitted VSD. In terms of the IAA, three patients underwent repair by extended end-to-end anastomosis, and one 16-mm prosthetic vascular graft was replaced in an elder patient. The remaining patients underwent autologous pericardial patch enlargement. All the variables were summarized and reported with descriptive statistics.

RESULTS

Three early deaths occurred in this study. The median follow-up time was approximately 5 years (range: 3-14 years). No late deaths were reported. Only one patient required percutaneous re-intervention for recurrent coarctation. Moderate aortic regurgitation was observed in three patients. However, there was no requirement for aortic valvuloplasty or valve replacement. One patient had more than moderate tricuspid regurgitation. The other survivors are presently healthy.

CONCLUSIONS

Although one-stage repair for transposition complex and IAA still has non-negligible mortality even in older children, the late outcomes of survivors are acceptable. Owing to the high rate of valve regurgitation, closer follow-up is necessary for these patients.

A Simplified Approach to Predicting Reintervention in the Arterial Switch Operation

We investigated patients with transposition anatomy suitable for the arterial switch operation (ASO) to evaluate a simplified approach to prediction of reintervention. A retrospective review was performed of 180 consecutive patients who underwent ASO from 2009 to 2018. Patients were classified as Category I (n = 122) d-transposition of great arteries (dTGA) + intact ventricular septum, Category II (n = 28) dTGA + ventricular septal defect (VSD) and Category III (n = 30) dTGA + Aortic arch obstruction (AAO) +/- VSD or Taussig-Bing Anomaly (TBA) +/- AAO. Outcomes included reintervention-free survival (using Kaplan-Meier estimates) and predictors of reintervention. Median follow up was 3.3 (interquartile range 1.7-5.8) years with no difference between categories(P = 0.082). There were 3 mortalities- 2 early (one each in Category I and II) and one late (in Category I). Reintervention-free survival for the whole group at 1, 3, 5 and 8 years was 94%, 91%, 90% and 86% respectively. Conventional criteria predicting reintervention included the presence of TBA(P = 0.0054) and AAO(P = 0.027). Low birth weight did not predict reintervention(P = 0.2). When analyzed by category, multivariable analysis showed that patients in Category III carried a high risk of reintervention [Hazard risk (HR) = 7.43, 95% confidence interval (CI)=(2.39, 23.11), P < 0.001], but so did those in Category II [HR=6.90, 95% CI = (2.19, 21.75, P < 0.001] when compared to Category I. Conventional risk factors for technical difficulty may not be the best predictors of reintervention. A simplified approach highlights Category II patients (dTGA + VSD) as being at substantial risk of re-intervention, and not part of a low risk cohort.

Alternative pulmonary artery reconstruction technique in the arterial switch operation

OBJECTIVES

Late complications of arterial switch operations (ASO) for transposition of the great arteries, such as neo-pulmonary artery (PA) stenosis and/or neoaortic regurgitation, have been reported. We developed an alternative reconstruction method called the longitudinal extension (LE) method to prevent PA bifurcation stenosis (PABS).

METHODS

We identified 48 patients diagnosed with transposition of the great arteries and performed ASO using the Lecompte manoeuvre for neo-PA reconstruction. In 9 consecutive patients (from 2014), the LE method was performed (LE). Before 2014, conventional techniques were performed in 39 patients (C). The median body weight and age in the LE and C groups were 3.0 and 3.1 kg and 12 and 26 days, respectively. In the LE group, 1 patient underwent bilateral PA banding before ASO. In C, PA banding and arch repair were performed in 1 patient each. Patients who received concomitant procedures were included.

RESULTS

The median follow-up in LE and C groups was 1.9 and 10.1 years, respectively. Early mortality/late death was not found in group LE and in 1 patient in group C. Only 1 case required ascending aorta sliding plasty in LE, and 8 patients needed PA augmentation for PABS in C. The median velocity of right/left PA was measured as 1.6/1.9 m/s in LE and 2.1/2.3 m/s in C, so it showed a lower value in LE.

CONCLUSIONS

Excellent mid-term results were obtained with the LE method. It was considered a useful procedure in preventing PABS, which is a primary late complication of ASO. Further follow-up and investigations are needed.

Arterial switch operation in patients with Taussig-Bing anomaly and aortic arch obstruction

BACKGROUND

Arterial switch operation (ASO) in children with Taussig-Bing anomaly and associated aortic arch obstruction (AAO) is technically demanding. This study sought to determine outcomes of patients with Taussig-Bing anomaly and AAO who underwent ASO at a single institution.

METHODS

From 1983 to 2015, 844 patients underwent an ASO for biventricular repair at The Royal Children's Hospital. Twenty-eight (3.3%, 28/844) patients had Taussig-Bing anomaly and AAO.

RESULTS

Twenty-one (75%, 21/28) patients underwent ASO and AAO repair as a single stage procedure and 7 (25%, 7/28) patients had arch repair prior to ASO. There were no early or late deaths. Follow-up after hospital discharge was available for all patients. Median follow-up was 17.5 years (interquartile range 9.2 to 22.3 years, range 4.0 to 31.5 years). All patients were in NYHA Class I at last follow-up. Freedom from reintervention was 61% (95%CI 40-76%) and 56% (95%CI 36-73%) at 5 and 15 years after ASO. The most common reinterventions were repair of recurrent AAO, branch pulmonary artery stenosis and neo-aortic valve repair. Four (14%, 4/28) patients required 5 reinterventions (3 reoperations and 2 catheter reintervention) for recurrent AAO at a median 2.2 years after ASO (interquartile range 2.1-2.3 years).

CONCLUSIONS

Patients with Taussig-Bing anomaly and AAO can undergo the ASO with excellent survival. Reintervention is equally common for both left and right sided obstruction.

Management of aortic arch hypoplasia in neonates and infants

OBJECTIVES

Surgical management of aortic arch hypoplasia (AAH) with associated intracardiac anomalies is a challenge in newborns. We reviewed the characteristics and outcomes of neonates and infants who underwent pulmonary artery banding concomitant to arch repair and single-stage total repair at our institution.

METHODS

Medical records of 60 patients undergoing aortic arch reconstruction for AAH from 2014 to 2019 were retrospectively reviewed. Twenty-five patients were female (41.6%), and the age of the patients ranged from 4 to 120 days (median, 19.5 days). The patients were divided into two groups: Group 1 (23 patients) underwent pulmonary artery banding concomitant to arch repair, and Group 2 (37 patients) underwent single-stage total repair in addition to arch repair. All arch repair procedures consisted of an extended (to the midportion of the ascending aorta) patch aortoplasty.

RESULTS

Postoperative early mortality occurred in 12 patients, eight in Group 1 (34.8%) and four in Group 2 (10.8%). There was an early survival advantage in Group 2 (p = .019). Recoarctation occurred in 13 cases (21.6%), and 11 (18.3%) of them required reintervention (balloon angioplasty: 7, reoperation: 4). On univariate analysis, risk factors associated with death were pulmonary artery banding (hazard ratio [HR], 0.44; confidence interval [CI], 0.09-2; p = .019), prematurity (HR, 4.67; CI, 1.34-16.18; p = <.001), preoperative mechanical ventilation support requirement (HR, 0.048; CI, 0.52-6.39; p = .048), and functional single ventricle (HR, 0.43; CI, 0.1-1.86; p = .006). The mean duration of follow-up was 21.9 ± 15.1 months, and there was no late death in either group.

CONCLUSION

Single-stage repair of AAH with intracardiac pathologies has better results than palliation, according to survival rates and postoperative results. The use of the patch augmentation technique in AAH is valid and associated with an acceptable incidence of recurrent arch obstruction.

Primary repair of transposition of the great arteries with an interrupted aortic arch: a case report and literature review

Transposition of the great arteries (TGA) and interruption of the aortic arch (IAA) are uncommon congenital heart diseases. The association between TGA and IAA is rare. The aim of this study is to present a case with combined TGA and IAA, who underwent the primary repair and review the literature with similar cases. The one-month-old patient was admitted with tachypnea and cyanosis. Delayed diagnosis was caused due to the absence of prenatal examination. Echocardiography and computed tomography angiography confirmed TGA with anterior-posterior-oriented great arteries, wide patent ductus arteriosus, type B IAA, ventricular septal defect (VSD) and pulmonary arterial hypertension. The patient underwent a single-stage primary surgical repair process leading to VSD closure, reconstruction of the aortic arch and arterial switch operation in October 2019. The patient is doing well at a 3-month follow-up post-surgery. The echocardiogram suggests a normal systolic function of the ventricles and trivial regurgitation for both aortic and pulmonary valves. CONCLUSIONS: The single-stage repair with VSD closure, reconstruction of aortic arch and arterial switch operation might be an applicable approach for most of the patients with combined TGA and IAA. Long term follow-up is required as a high re-intervention rate for recurrent coarctation, supravalvular aortic stenosis, neoaortic valve regurgitation, obstruction of the right heart system and coronary stenosis has been reported.

Transposition Complex with Aortic Arch Obstruction: Outcomes of One-Stage Repair Over 10 Years

The surgical management of transposition complex with aortic arch obstruction remains technically demanding due to anatomic complexity. Even in the recent surgical era, there are centers that address this anomaly with a staged strategy. This report presents our experiences with a one-stage repair of transposition complexes with aortic arch obstructions more than the last 10 years. Since 2003, 19 patients with a transposition of the great arteries (TGA, 2 patients) or a double outlet of the right ventricle (DORV, 17 patients) and aortic arch obstruction have undergone one-stage repair of their anomalies. The mean age was 6.7 ± 2.3 days, and the mean body weight was 3.4 ± 0.3 kg. The 2 patients with TGA exhibited coarctation of the aorta. The 17 patients with DORV all exhibited the Taussig-Bing type. The great artery relationships were anteroposterior in 4 patients (21.1%). The coronary artery anatomies were usual (1LCx; 2R) in 8 patients (42.1%). There were 2 early deaths (10.5%). Seven patients (36.8%) required percutaneous interventions. One patient required re-operation for pulmonary valvar stenosis and left pulmonary artery patch angioplasty. The overall survival was 84.2%. The freedom from mortality was 83.5% at 5 years, and the freedom from intervention was 54.4% at 5 years. The one-stage repair of transposition complexes with aortic arch obstructions resulted in an acceptable survival rate and a relatively high incidence of postoperative catheter interventions. Postoperative catheter interventions are highly effective. Transposition complexes combined with aortic arch obstructions can be managed by one-stage repair with good early and midterm results.

First successful repair of an aortico-to-right ventricular tunnel (ARVT) in d-transposition of the great arteries with aortic valve atresia and ventricular septal defect

The presented case reports on the first successful complex biventricular repair in a neonate with an aortico-to-right ventricular tunnel and dextrotransposition of the great arteries complicated by aortic atresia.

Pediatric Applications of Surgical Patch Angioplasty of the Main Coronary Trunks

Objectives:

Obstruction of the main coronary trunks, although rare among the general pediatric population, remains an important complication of the arterial switch operation (ASO). Surgical patch angioplasty (SPA) is a technique whereby myocardial revascularization is achieved through direct ostial enlargement, restoring antegrade coronary flow, avoiding competitive flow, and preserving conduit material. This study investigates the indications, techniques, and outcomes of SPA in the pediatric population.

Methods:

A systematic literature review identified 15 studies incorporating 92 patients. The primary outcome of interest was 30-day mortality. Secondary outcomes included 30-day major adverse cardiac and cerebrovascular events, mortality at last follow-up, reintervention rate, symptomatic status, angiographic patency, and myocardial perfusion status at last follow-up.

Results:

The SPA was most frequently performed to treat ostial occlusion as a complication of the ASO (73.9%). Of the procedures, 77.2% involved the left main stem, 8.7% the left anterior descending artery, and 14.1% the right coronary artery. Saphenous vein was the commonest patch type (60.9%) followed by autologous pericardium (23.9%). Of the procedures, 96.7% were considered successful with an uneventful postoperative recovery. Overall hospital mortality was 2.2%. At a mean of 39 months of follow-up, 84.8% of the patients were asymptomatic, 51.1% of the repairs were angiographically patent, 9.8% had myocardial perfusion defects, and 6.5% required repeat revascularization.

Conclusion:

Current evidence suggests that SPA shows encouraging outcomes in a pediatric population and, with increasing experience, may provide a definitive solution to coronary artery occlusion.

Late Complications Following the Arterial Switch Operation

The arterial switch operation has been the principal treatment for transposition of the great arteries and its variants for the last 25 years. Early mortality has decreased significantly over time, but long-term complications include pulmonary artery stenosis, coronary artery obstruction, neoaortic valvar insufficiency, arrhythmia, and aortic arch obstruction. This article provides an overview of the history, anatomic patterns, surgical results, and possible operative solutions discussed in the literature for patients with transposition of the great arteries who undergo arterial switch operations that result in late complications. Published journal articles were identified through PubMed literature search. The authors selected 72 articles for analysis. It is concluded that modifications can be made to the arterial switch operation in an effort to meet the challenges presented by late complications.

Factors prolonging length of stay in the cardiac intensive care unit following the arterial switch operation

The arterial switch operation has become the preferred procedure for surgical management of transposition, defined on the basis of concordant atrioventricular and discordant ventriculo-arterial connections. We conducted a retrospective evaluation of our experience in 61 infants with this segmental combination, seen from January, 1997, to July, 2003, in order to determine the factors that are associated with a prolonged postoperative course. Factors independently associated with a prolonged postoperative stay in the cardiac intensive care unit included prematurity, difficulty in feeding, capillary leak, need for preoperative inotropic support, and postoperative infectious complications. Future research is warranted designed to minimize the impact of capillary leak and postoperative infectious complications. In addition, based on these results, our practice has evolved to initiate enteral feedings in the preoperative period if feasible, with such enteral feedings resumed as soon as possible following surgery.

Surgery for aortic arch disease in the neonate

Disease of the aortic arch is a common component of congenital heart disease requiring surgical treatment in the neonate. While sometimes found in isolation, aortic arch disease must be placed into the larger context of frequently associated pathology. This review describes the anatomic variations of neonatal aortic arch pathology, surgical approaches and techniques, and expected outcomes.