Improvement in long-term survival after hospital discharge but not in freedom from reoperation after the change from atrial to arterial switch for transposition of the great arteries

Transcatheter pulmonary valve replacement after arterial switch operation

BACKGROUND

Patients with d-transposition of the great arteries (d-TGA) who have undergone an arterial switch operation (ASO) can develop right ventricular outflow tract (RVOT) dysfunction with pulmonary regurgitation (PR) or stenosis. In these patients, treatment may include transcatheter pulmonary valve replacement (TPVR). Coronary compression is a contraindication occurring in 5% of typical TPVR cases. After ASO, there are various anatomical considerations that can confound TPVR, including potential coronary artery compression. Our goal is to understand feasibility of TPVR in patients following ASO.

METHODS

This was a retrospective multicenter cohort study of patients with RVOT dysfunction after ASO who underwent cardiac catheterization with intention to perform TPVR from 2008 to 2020.

RESULTS

Across nine centers, 33 patients met inclusion criteria. TPVR was successful in 22 patients (66%), 19 receiving a Melody valve and 3 a SAPIEN valve. RVOT stenosis in isolation or with PR dictated need for TPVR in nearly all patients. One serious adverse event occurred with valve embolization. After TPVR, the RVOT peak gradient decreased from 43 to 9 mm Hg (p < 0.001); PR was trivial/none in all but one patient, in whom it was mild. Coronary compression prohibiting TPVR occurred in eight patients (24%) and two patients (6%) had severe aortic regurgitation from aortic root deformation precluding TPVR. Seven patients underwent RVOT reintervention with a median of 5.3 years post-TPVR.

CONCLUSIONS

TPVR in patients with d-TGA after ASO is feasible, but in this cohort, coronary compression or aortic root distortion precluded TPVR in one-third of patients. The rate of RVOT reintervention after TPVR was higher in this cohort of ASO patients that in prior studies.

Predictors of mortality after atrial correction of transposition of the great arteries

Objectives

To determine the long-term and transplantation-free survival of all patients after atrial correction of transposition of the great arteries (TGA) in the Czech and Slovak republics, including its preoperative and perioperative determinants.

Methods

Retrospective analysis of all 454 consecutive patients after atrial correction of TGA was performed. Of these, 126 (27.8%) were female, median age at operation was 7.4 months (Q1 5.3; Q3 13.3) and 164 (36.1%) underwent the Mustard procedure. The relationships between age, weight, the complexity of TGA, operative technique, additional surgical procedures, immediate postoperative presence of tricuspid regurgitation and revision procedures during follow-up to major composite outcome, as such defined as long-term and transplantation-free survival, were tested.

Results

Early 30-day mortality did not differ between the Mustard (9.76%) and Senning (8.97%) cohorts (p=0.866). The long-term and transplantation-free survival, which differed between the Mustard and Senning cohorts in favour of the Senning procedure (HR 0.43; 95% CI 0.21 to 0.87), was shorter in complex TGA (HR 2.4; 95% CI 1.59 to 3.78) and in complex surgical interventions (HR 3.51; 95% CI 2.31 to 5.56). The immediate presence of at least moderate tricuspid regurgitation after correction was associated with a shorter long-term and transplantation-free survival in the univariate but not in the multivariable model.

Conclusions

The lower long-term survival of patients after an atrial switch operation of TGA in the Czech and Slovak republics is associated with greater complexity of TGA, complex surgical interventions and application of the the Mustard operative procedure.

Impact of Coronary Artery Anatomy in Arterial Switch Operation: In-hospital and Post-discharge Outcomes

OBJECTIVE

The influence of the coronary artery anatomy on the prognosis of patients receiving an arterial switch operation (ASO) is currently controversial, and the risk factors for this operation may change in more complicated patients. This study aimed to investigate the influence of coronary artery anomalies on the in-hospital and post-discharge outcomes of ASO in patients with transposition of the great arteries (TGA) and Taussig-Bing anomaly (TBA).

METHODS

We retrospectively reviewed 206 patients who underwent ASO from January 2007 to December 2019. The median age at operation was 33 [interquartile range (IQR): 20-71] days. Median follow-up time was 7.2 years (IQR: 4.0-10.3 years).

RESULTS

Coronary anomalies were present in 86 patients (41.7%), with 9 (4.4%) of them having a single coronary artery. Additional coronary features included intramural courses in 5 (2.4%) patients, ostial stenosis in 1 (0.5%) patient, and accessory coronary artery orifices in 5 (2.4%) patients. There were 32 (15.5%) in-hospital deaths and 8 (4.6%) post-discharge deaths, yielding an overall survival of 81.3%, 80.7% and 79.9% at 1, 5 and 10 years, respectively. Mortality due to ASO has been drastically decreased since 2013. Patients with a single coronary artery had higher rate of in-hospital mortality, but this finding was not statistically significant. The earlier surgical era (OR: 2.756) and a longer cardiopulmonary bypass time (OR: 2.336) were significantly associated with in-hospital mortality, while coronary patterns were not. An intramural coronary artery (HR: 10.034) and a patient age of older than 1 year at the time of ASO (HR: 9.706) were independent predictors of post-discharge mortality.

CONCLUSION

ASO remains the procedure of choice for TGA with coronary anomalies with acceptable in-hospital and post-discharge outcomes in terms of overall survival and freedom of reoperation. However, intramural coronary artery is an independent risk factor for post-discharge mortality. Timely surgery within the 1st year of life helps improve overall midterm survival of ASO.

Deep Phenotypic Analysis for Transposition of the Great Arteries and Prognosis Implication

Background

Transposition of the great arteries (TGA) consists of about 3% of all congenital heart diseases and 20% of cyanotic congenital heart diseases. It is always accompanied by a series of other cardiac malformations that affect the surgical intervention strategy as well as prognosis. In this study, we comprehensively analyzed the phenotypes of the patients who had TGA with concordant atrioventricular and discordant ventriculoarterial connections and explored their association with prognosis.

Methods and Results

We retrospectively reviewed 666 patients with a diagnosis of TGA with concordant atrioventricular and discordant ventriculoarterial connections in Fuwai Hospital from 1997 to 2019. Under the guidance of the Human Phenotype Ontology database, patients were classified into 3 clusters. The Kaplan‐Meier method was used to analyze the prognosis, and the Cox proportional regression model was used to investigate the risk factors. In this 666‐patient TGA cohort, the overall 5‐year survival rate was 94.70% (92.95%–96.49%). Three clusters with distinct phenotypes were obtained by the Human Phenotype Ontology database. Kaplan‐Meier analysis revealed a significant difference in freedom from reintervention among 3 clusters (P<0.001). To eliminate the effect of surgeries, we analyzed patients who only received an arterial switch operation and still found a significant difference in reintervention (P=0.019).

Conclusions

We delineated a big cardiovascular phenotypic profile of an unprecedentedly large TGA cohort and successfully risk stratified them to reveal prognostic significance. Also, we reported the outcomes of a large TGA population in China.

Right ventricular afterload in repaired D-TGA is associated with inefficient flow patterns, rather than stenosis alone

Treatment of D- transposition of great arteries (DTGA) involves the Arterial Switch Operation (ASO), which can create PA branch stenosis (PABS) and alter PA blood flow energetics. This altered PA flow may contribute to elevated right ventricular (RV) afterload more significantly than stenosis alone. Our aim was to correlate RV afterload and PA flow characteristics using 4D flow cardiac magnetic resonance (CMR) imaging of a mock circulatory system (MCS) incorporating 3D printed replicas. CMR imaging and clinical characteristics were analyzed from 22 ASO patients (age 11.9 ± 8.7 years, 68% male). Segmentation was performed to create 3D printed PA replicas that were mounted in an MRI-compatible MCS. Pressure drop across the PA replica was recorded and 4D flow CMR acquisitions were analyzed for blood flow inefficiency (energy loss, vorticity). In post-ASO patients, there is no difference in RV mass (p = 0.07), nor RV systolic pressure (p = 0.26) in the presence or absence of PABS. 4D flow analysis of MCS shows energy loss is correlated to RV mass (p = 0.01, r = 0.67) and MCS pressure differential (p = 0.02, r = 0.57). Receiver operating characteristic curve shows energy loss detects elevated RV mass above 30 g/m² (p = 0.02, AUC 0.88) while index of PA dimensions (Nakata) does not (p = 0.09, AUC 0.79). PABS alone does not account for differences in RV mass or afterload in post-ASO patients. In MCS simulations, energy loss is correlated with both RV mass and PA pressure, and can moderately detect elevated RV mass. Inefficient PA flow may be an important predictor of RV afterload in this population.

Early and Late Outcomes after Arterial Switch Operation: A 40-Year Journey in a Single Low Case Volume Center

Background and Objectives: The results of the arterial switch operation in large congenital heart centers are excellent, and the results in small and medium centers are improving. The objective of this article is to share our experience utilizing the international knowledge transfer program to improve early and late arterial switch operation outcomes in our center. Materials and Methods: A retrospective analysis of patients who underwent the arterial switch operation in Vilnius University Santaros Clinics Cardiothoracic Surgery Center between 1977–2020 was performed. Results: A total of 127 consecutive arterial switch operations were performed in our center. Surgical mortality during the entire study period was 24.6%. Surgical mortality prior to the program, during the program, and after the program was 88.24%, 41.7%, and 5.81%, respectively (p < 0.0001). The surgical mortality of patients operated on during the last 10 years was 4%. The overall survival estimate for the 97 surviving patients was 96.9%, 94.9%, 93.8%, 93.8%, 93.8%, 93.8% at 1, 3, 5, 10, 15, and 20 years, respectively. Risk factors for early mortality included longer aortic cross-clamp time and operation prior to the knowledge transfer program. The only significant risk factor for late reintervention was concomitant aortic arch obstruction treated at the time of the arterial switch. Conclusions: The surgical treatment of transposition of the great arteries by means of an arterial switch with good results can be possible in low-to-medium volume congenital heart surgery centers. International knowledge transfer programs between high-expertise high-volume congenital heart centers and low-to-medium volume congenital heart centers may help to shorten the learning curve and improve early and late outcomes after an arterial switch. The risk factors for surgical mortality and intervention-free survival in low-volume surgical centers are similar to those in high-volume centers. Late arterial switch-related complications are similar to those among different-sized congenital heart centers.

The Coronary Arteries in Adults after the Arterial Switch Operation: A Systematic Review

Coronary artery status in adults long after the arterial switch operation (ASO) is unclear. We conducted a systematic review to provide an overview of coronary complications during adulthood and to evaluate the value of routine coronary imaging in adults after ASO, in light of current guidelines. Articles were screened for the inclusion of adult ASO patients and data on coronary complications and findings of coronary imaging were collected. A total of 993 adults were followed with a median available follow-up of only 2.0 years after reaching adulthood. Myocardial ischemia was suspected in 17/192 patients (8.9%). The number of coronary interventions was four (0.4%), and coronary death was reported in four (0.4%) patients. A lack of ischemia-related symptoms cannot be excluded because innervation studies indicated deficient cardiac innervation after ASO, although data is limited. Anatomical high-risk features found by routine coronary computed tomography (cCT) included stenosis (4%), acute angle (40%), kinking (24%) and inter-arterial course (11%). No coronary complications were reported during pregnancy (n = 45), although, remarkably, four (9%) patients developed heart failure. The 2020 European Society of Cardiology (ESC) guidelines state that routine screening for coronary pathologies is questionable. Based on current findings and in line with the 2018 American ACC/AHA guidelines a baseline assessment of the coronary arteries in all ASO adults seems justifiable. Thereafter, an individualized coronary follow-up strategy is advisable at least until significant duration of follow-up is available.

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.

Twenty-Three-Year Experience With the Arterial Switch Operation: Expectations and Long-Term Outcomes

We aimed to describe the short- and long-term outcomes of patients after an arterial switch operation (ASO) at a single institution during a 23-year period. A retrospective chart review of all patients <18 months of age who underwent an ASO between January 1995 and March 2018 at Texas Children's Hospital, Houston, TX was performed. Primary endpoints include mortality and reintervention. Perioperative mortality was defined as mortality occurring in-hospital and/or <30 days after surgery. Survival and freedom-from-reintervention were analyzed using Kaplan-Meier method, log-rank tests, and Cox regression models. The cohort included 394 patients. Diagnoses included 204 patients (52%) with intact ventricular septum, 137 (35%) with a ventricular septal defect, 17 (4%) with a ventricular septal defect and left ventricular outflow tract obstruction (LVOTO), and 36 (9%) with Taussig-Bing anomaly. Median age at surgery was 8 days (range: 1 day to 17 months) and median weight was 3.4 (range: 0.8-12.0) kg. Overall perioperative mortality was 1.3% (n = 5), 0.3% (n = 1) since 1999. Overall survival at 5, 10, and 15 years was 98.2%, 97.8%, and 97.8%, respectively. Perioperative morality was associated with prematurity (P = 0.012), <2.5 kg (P< 0.001), and longer circulatory arrest (P = 0.024) after univariate analysis. Reintervention was associated with a longer cross-clamp time (P < 0.001), <2.5 kg (P = 0.009), LVOTO resection (P = 0.047), and genetic syndrome (P= 0.011) after multivariable analysis. Current ASO expectations should include a perioperative mortality risk of <1% and good long-term survival. Reinterventions are more frequent in patients <2.5 kg, concomitant LVOTO resection, a genetic syndrome, and longer cross-clamp time.

Late Survival and Patient-Perceived Health Status of the Congenital Heart Surgeons' Society dextro-Transposition of the Great Arteries Cohort

BACKGROUND

Improved survival for patients with dextro-transposition of the great arteries (d-TGA) has led to an increased focus on functional health status (FHS). We assessed late survival and patient-perceived FHS for repaired TGA patients.

METHODS

From 1985-1990, 830 neonates admitted to 24 Congenital Heart Surgeons' Society (CHSS) institutions with d-TGA underwent repair, including 516 arterial switch, 110 Mustard, 175 Senning, and 29 Rastelli operations. Median follow-up was 24.0 years (range, 0-32.7 years). We performed multiphase parametric hazard analysis for death after repair. Patients completed Pediatric Quality of Life Inventory (PedsQL) Core Scales and Cardiac Module Adult Forms. Patient and operative factors and CHSS General Questionnaire responses were analyzed for association with FHS using multiple linear regression.

RESULTS

Survival at 30 years after repair was arterial switch, 80% ± 2%; Mustard, 81% ± 5%; Senning, 70% ± 4%; and Rastelli, 86% ± 8%. The arterial switch had the lowest hazard for late death. TGA patients reported FHS similar to a healthy population in all domains except physical health (lower scores). Symptoms, including chest pain and fainting, and having a pacemaker were associated with lower, and being employed with higher, self-reported physical health. Arterial switch patients reported higher FHS than the atrial switch patients in all domains.

CONCLUSIONS

Arterial switch patients have a lower risk of premature death and better FHS than those with an atrial switch. Increased surveillance in atrial switch patients is warranted because of their increased risk of late death. Presence of symptoms, pacemaker, and lack of employment are associated with reduced FHS.

Pregnancy outcomes and mid-term prognosis in women after arterial switch operation for dextro-transposition of the great arteries - Tertiary hospital experiences and review of literature

OBJECTIVE

Arterial switch operation (ASO) for dextro-transposition of the great arteries (d-TGA) has gradually replaced the atrial switch operation and has become the standard operation. To date, the outcomes of pregnant women with d-TGA after this new operation have not been investigated. In this study, we investigated the impact of ASO on pregnant outcomes and mid-term prognosis in women with d-TGA and compared with the atrial switch operation through the literature review.

METHODS AND RESULTS

There were 20 pregnancies in 10 women with d-TGA after ASO and 6 resulted in abortion. Among 14 successful pregnancies in 10 women, 11 pregnancies achieved the term delivery and 3 pregnancies, including 1 twin pregnancy, resulted in preterm labor. Maternal cardiovascular events occurred in 4 (heart failure and arrhythmias in 3 and arrhythmia in 1), and all were controllable with medications. Risk factors for the peripartum cardiac events were older age at ASO and delivery, and higher concentration of brain natriuretic peptide (BNP) at first trimester (p<0.05). In 7-60 month-follow-up after delivery, no case showed deterioration of functional class and systemic ventricular function. According to the literature review, women after ASO demonstrated a better prognosis than those after the atrial switch operation.

CONCLUSIONS

The majority of women with d-TGA after ASO tolerated pregnancy and delivery well. The older age at ASO, an elderly pregnancy, and higher BNP levels at the first trimester were possibly risk factors of peripartum cardiovascular events among the group. The literature reviews and this study may indicate the advantage of systemic left ventricle compared with systemic right ventricle in long-term outcomes after delivery.

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.

Implantation of ventricular assist device for systemic right ventricular failure in a patient with transposition of the great arteries and post-Mustard procedure: a case report

Background

Ventricular assist device (VAD) is usually attached by an inflow cannula to the apex of the systemic left ventricle (LV), but very few cases with implantation of the VAD in the morphologic right ventricle (RV) have been described.

Case presentation

We describe the case of a 41-year-old male who developed severe systemic RV failure related to a Mustard procedure he had as an infant for treatment of TGA. His heart failure was refractory and irreversible, and therefore, he underwent VAD implantation for systemic RV support. Although the patient developed pulmonary congestion on postoperative day (POD) 5, he was discharged on POD 60. He is now looking forward to receiving heart transplantation.

Conclusions

Placement of a VAD for systemic RV failure could be a life-saving treatment in adult patients with heart failure due to congenital heart disease.

Long-term Management of the Arterial Switch Patient

PURPOSE OF REVIEW

This review paper describes the management of patients with dextro-transposition of the great arteries (D-TGA) with a focus on the complications seen and the appropriate care required to identify and prevent adverse events.

RECENT FINDINGS

D-TGA is a form of cyanotic congenital heart disease (CHD) representing ~ 3% of all CHD and almost 20% of all cyanotic CHD. Since the late 1980s, standard of care is to repair these patients with an arterial switch operation (ASO) as opposed to a Mustard/Senning operation. The long-term survival and complication rates are superior in the ASO. Long-term follow-up is recommended for all D-TGA patients and includes management with adult congenital heart disease specialists and the use of echocardiography and advanced imaging with CT or MRI. The most common complications seen are pulmonary stenosis, coronary artery stenosis, and neo-aortic regurgitation. Careful evaluation of new symptoms or declining function is essential in preventing and treating these long-term sequelae.

Long-Term Survival of Individuals Born With Congenital Heart Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Estimates of long-term survival are required to adequately assess the variety of health and social services required by those with congenital heart disease (CHD) throughout their lives.

METHODS AND RESULTS

Medline, Embase, and Scopus were searched from inception to June 2015 using MeSH headings and keywords. Population-based studies that ascertained all persons born with CHD within a predefined area and reported survival estimates at ≥5 years were included. Unadjusted survival estimates for each CHD subtype at ages 1 year, 5 years, 10 years, and so forth were extracted. Pooled survival estimates for each age were calculated using meta-analyses. Metaregression was performed to examine the impact of study period on survival. Of 7840 identified articles, 16 met the inclusion criteria. Among those with CHD, pooled 1-year survival was 87.0% (95% CI 82.1-91.2), pooled 5-year survival was 85.4% (95% CI 79.4-90.5), and pooled 10-year survival was 81.4% (95% CI 73.8-87.9). There was significant heterogeneity of survival estimates among articles (P<0.001 for 1-, 5-, and 10-year survival). A more recent study period was significantly associated with greater survival at ages 1 year (P=0.047), 5 years (P=0.013), and 10 years (P=0.046). Survival varied by CHD subtype, with 5-year survival being greatest for those with ventricular septal defect (96.3%, 95% CI 93.7-98.2) and lowest for those with hypoplastic left heart (12.5%, 95% CI 0.0-41.4).

CONCLUSIONS

Among persons with CHD, the mortality rate is greatest during the first year of life; however, this systematic review and meta-analysis showed that survival decreases gradually after infancy and into adulthood.

Intervention for Supravalvar Pulmonary Stenosis After the Arterial Switch Operation

BACKGROUND

The arterial switch operation is standard of care for infants born with dextrotransposition of the great arteries. Supravalvar pulmonary stenosis is a common complication that may require reintervention-balloon angioplasty, stenting, or surgical augmentation. A subset of patients requires more than one reintervention.

METHODS

We performed a retrospective review of patients who underwent the arterial switch operation for dextrotransposition of the great arteries at a single institution between August 1990 and January 2014. Anatomic, perioperative and follow-up data were collected. Reinterventions were stratified in a site-specific manner. Statistical analysis was performed using IBM SPSS version 21 (IBM Corp, Armonk, NY).

RESULTS

Of the 103 patients who met inclusion criteria, 28% (29) required reintervention for supravalvar pulmonary stenosis; 41% of those receiving primary reintervention required an additional 21 reinterventions. Balloon angioplasty of the main pulmonary artery and left pulmonary artery was associated with the need for multiple reinterventions (odds ratio 4.9, p = 0.051, and odds ratio 5.1, p = 0.029, respectively). Freedom from future reintervention at the main pulmonary artery and left pulmonary artery was significantly shorter after balloon angioplasty relative to alternative reintervention options (hazard ratio 10, p = 0.005, and hazard ratio 3.2, p = 0.02, respectively). Balloon angioplasty of the right pulmonary artery was not associated with an increased risk of reintervention (p = 0.42).

CONCLUSIONS

Supravalvar pulmonary stenosis after the arterial switch operation for dextrotransposition of the great arteries is common and more than one reintervention are required in a subset of patients. The benefit of balloon angioplasty of the main pulmonary artery and left pulmonary artery was shown to be temporary. Attempting balloon angioplasties at these locations remain reasonable, although families should be counseled about the increased incidence of, and decreased time to, subsequent reintervention that is associated with this treatment option.

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

This paper aims to update clinicians on "hot topics" in the management of patients with D-loop transposition of the great arteries (D-TGA) in the current surgical era. The arterial switch operation (ASO) has replaced atrial switch procedures for D-TGA, and 90% of patients now reach adulthood. The Adult Congenital and Pediatric Cardiology Council of the American College of Cardiology assembled a team of experts to summarize current knowledge on genetics, pre-natal diagnosis, surgical timing, balloon atrial septostomy, prostaglandin E1 therapy, intraoperative techniques, imaging, coronary obstruction, arrhythmias, sudden death, neoaortic regurgitation and dilation, neurodevelopmental (ND) issues, and lifelong care of D-TGA patients. In simple D-TGA: 1) familial recurrence risk is low; 2) children diagnosed pre-natally have improved cognitive skills compared with those diagnosed post-natally; 3) echocardiography helps to identify risk factors; 4) routine use of BAS and prostaglandin E1 may not be indicated in all cases; 5) early ASO improves outcomes and reduces costs with a low mortality; 6) single or intramural coronary arteries remain risk factors; 7) post-ASO arrhythmias and cardiac dysfunction should raise suspicion of coronary insufficiency; 8) coronary insufficiency and arrhythmias are rare but are associated with sudden death; 9) early- and late-onset ND abnormalities are common; 10) aortic regurgitation and aortic root dilation are well tolerated; and 11) the aging ASO patient may benefit from "exercise-prescription" rather than restriction. Significant strides have been made in understanding risk factors for cardiac, ND, and other important clinical outcomes after ASO.

Great vessel root and artery dimensions in transposition of the great arteries repaired with atrial switch operation

To describe great-vessel dimensions in patients with D-loop transposition of the great arteries (TGA) who have undergone atrial switch operation (ATSO). Patients who have undergone arterial switch operation for TGA have a high incidence of dilation of the neoaortic root. The incidence and degree of great artery dilation in patients who have undergone ATSO for TGA has not previously been described. A retrospective database review identified patients with TGA and intact ventricular septum who underwent ATSO at <1 year of age with cardiac magnetic resonance (CMR) within the previous 5 years (n = 39). A control group of patients referred for CMR with normal findings was identified for comparison (n = 40). Measurements of the annulus, root, sinotubular junction, and great vessels were performed, and interobserver/intraobserver variability was assessed. Median age of subjects at ATSO was 3 months (range 1-12) with median age at CMR of 29 years (range 18-40). For aortic measurements, mean z scores (± SDs) for patients relative to body surface area (BSA)-adjusted normal controls were as follows: annulus 1.41 (0.80), root 2.04 (1.48), sinotubular junction 2.16 (1.26), and great vessel 1.86 (1.53). For pulmonary measurements, similar values were as follows: annulus 1.82 (1.42), root 3.25 (2.01), sinotubular junction 2.47 (1.79), and great vessel 3.96 (3.08). In all cases, the p value was <0.001, and no confidence interval included the value 0. Adult patients with TGA repaired with ATSO in infancy have a greater incidence of dilation of both great vessels, particularly the pulmonary artery. These results may indicate abnormalities in the vascular structure of both great arteries in TGA that may predispose to progressive arterial dilation.

Cardiovascular outcomes after the arterial switch operation for D-transposition of the great arteries

BACKGROUND

Data regarding long-term outcomes after the arterial switch operation for D-transposition of the great arteries are scarce.

METHODS AND RESULTS

A single-institution retrospective cohort study was conducted to assess cardiovascular outcomes after an arterial switch operation between 1983 and 1999. Patients without follow-up visits within 3 years were contacted and secondary sources of information obtained. Overall, 400 patients, 154 (38.3%) with a ventricular septal defect, 238 (59.5%) with an intact septum, and 9 (2.3%) with a Taussig-Bing anomaly, were followed for a median of 18.7 years. In perioperative survivors, overall and arrhythmia-free survival rates at 25 years were 96.7±1.8% and 96.6±0.1%, respectively. Late mortality was predominantly a result of sudden deaths and myocardial infarction. At 25 years, 75.5±2.5% remained free from surgical or catheter-based reintervention. Freedom from an adverse cardiovascular event was 92.9±1.9% at 25 years. Independent predictors were a single right coronary artery (hazard ratio, 4.58; 95% confidence interval, 1.32-15.90), P=0.0166) and postoperative heart failure (hazard ratio, 6.93; 95% confidence interval, 1.57-30.62; P=0.0107). At last follow-up, the left ventricular ejection fraction was 60.3±8.9%, 97.3% had class I symptoms, and 5.2% obstructive coronary artery disease. Peak oxygen uptake was 35.1±7.6 mL/kg/min (86.1±15.1% predicted), with a chronotropic index <80% in 34.2%. At least moderate neoaortic and pulmonary regurgitation were present in 3.4% and 6.6%, respectively, and more than mild neoaortic and pulmonary stenosis in 3.2% and 10.3%.

CONCLUSIONS

Long-term and arrhythmia-free survival is excellent after arterial switch operation. Although sequelae include chronotropic incompetence and neoaortic, pulmonary, and coronary artery complications, most patients maintain normal systolic function and exercise capacity.

Twenty-eight years' experience of arterial switch operation for transposition of the great arteries in a single institution

OBJECTIVES

We reviewed our 28 years of experience of arterial switch operation (ASO) for transposition of the great arteries to investigate late sequelae of this procedure.

METHODS

387 patients who underwent ASO from 1984 to 2010 were included in this retrospective study. The longitudinal data were estimated by the Kaplan-Meier method and compared using a log-rank test. Risk factors for late sequelae were analysed by the multivariable Cox proportional hazards model.

RESULTS

The mean follow-up time was 10.0 years. There were 13 early deaths and 17 late deaths. All late deaths were within 1 year, except for three patients. Actuarial survival was 92.2 and 91.6% at 10 and 20 years, respectively. Sixty-six patients (17.1%) had developed pulmonary stenosis (PS) and 29 patients (7.5%) had developed moderate or more aortic insufficiency (AI) during follow-up. Selective coronary angiography was performed in 210 patients (54.3%) at 9.6 ± 5.1 years after ASO. Left main tract occlusion was found in 2 patients (2/210; 1.0%) and hypoplastic left coronary artery was found in 10 patients (10/210; 4.8%). Among these 12 patients, 8 patients were asymptomatic. Re-operation was performed in 76 patients (19.6%), pulmonary artery plasty for PS in 58 patients (15.0%), aortic valve replacement for AI including two Bentall operations in 9 patients (2.3%) and others. Freedom from re-operation was 78.2 and 62.8% at 10 and 20 years, respectively. The risk factor for PS was the use of equine pericardium for reconstruction (P < 0.0001). Factors associated with moderate or more AI was the presence of left ventricular outflow tract obstruction (P = 0.004). There were no risk factors for late coronary lesions. Three hundred and forty surviving patients (340/357; 95.2%) were in NYHA functional class I. Treadmill test, which was performed on 217 patients (56.1%) at 14.3 ± 5.4 years after ASO, revealed that the maximum heart rate was 97.5 ± 7.6% of normal and peak oxygen consumption was 105.2 ± 20.5% of normal.

CONCLUSIONS

ASO was performed with satisfactory results in the overall survival and functional status. PS was the main reason for re-operation. Coronary lesions can appear late without any symptoms. Benefits of ASO can be achieved by long-term follow-ups of PS, AI and coronary lesions.

Independent risk factors for cardiac operations in adults with congenital heart disease: a retrospective study of 543 operations for 500 patients

Adults with congenital heart disease (CHD) are an increasing population requiring cardiac operations. To date, the perioperative risk factors for this group have not been identified. This study aimed to identify clinical, morphologic, and hemodynamic risk factors for an adverse outcome. This study retrospectively analyzed a cohort of 500 patients (ages >16 years) who underwent 543 operations between January 2004 and December 2008 at a single center. The composite end point of an adverse outcome was in-hospital death, a prolonged intensive care exceeding 4 days, or both. The composite end point was reached by 253 of the patients (50.6%). Of the 500 patients, 13 (2.6%) died within 30 days after the operation. After logistic regression analysis, the following eight items remained significant: male gender (P = 0.003; odds ratio [OR] 1.8; 95% confidence interval [CI] 1.2-2.6), cyanosis (P > 0.006; OR 3.7; 95% CI 1.5-9.4), functional class exceeding 2 (P = 0.004; OR 2.2; 95% CI 1.3-3.7), chromosomal abnormalities (P = 0.004; OR 3.3; 95% CI 1.4-7.7), impaired renal function (P = 0.019; OR 3.8; 95% CI 1.2-11.5), systemic right ventricle (RV) in a biventricular circulation (P = 0.027; OR 3.3; 95% CI 1.1-9.5), enlargement of the systemic ventricle (P = 0.011; OR 1.7; 95% CI 1.1-2.6), and operation with extracorporeal circulation (P = 0.002; OR 4.3; 95% CI 1.7-11.4). Early mortality in the current adult CHD population is low. Morbidity, however, is significant and influenced by the patients' conditions (male gender, chromosomal abnormalities), history (cyanosis, New York Hospital Association [NYHA] class), and underlying morphology (systemic RV). This information for a large cohort of patients could help progress toward more adequate counseling for adults with a congenital heart defect.

Right ventricular function with standard and speckle-tracking echocardiography and clinical events in adults with D-transposition of the great arteries post atrial switch

BACKGROUND

The prognostic value of deformation parameters of the systemic right ventricle in adults with D-transposition of the great arteries and prior atrial switch has not been reported.

METHODS

Sixty-four adults with D-transposition of the great arteries and prior atrial switch (mean age, 29 ± 6 years; 22 women; mean right ventricular [RV] fractional area change, 22.9 ± 7.5%; 31 with pacemakers at baseline) and no histories of heart failure or ventricular tachycardia were prospectively evaluated. Global longitudinal strain (GS), global systolic strain rate (GSRs), and global early diastolic strain rate (GSRe) of the right ventricle were measured using speckle tracking from apical views and compared with standard parameters of RV function (fractional area change, tricuspid annular plane systolic excursion, tissue Doppler velocities, and isovolumic acceleration) for association with and potential prediction of clinical events, defined as incident stage C heart failure or ventricular tachycardia.

RESULTS

Baseline RV GS, GSRs, and GSRe were -12.5 ± 3.0%, -0.59 ± 0.14 sec(-1), and 0.68 ± 0.22 sec(-1), respectively. After a median of 2.4 years (interquartile range, 1.5-4.1 years), 12 patients (19%) presented with clinical events (heart failure in 11 patients, ventricular tachycardia in one patient). In Cox models, RV GS had the strongest association with clinical events (hazard ratio [HR] per 1%, 1.35; 95% confidence interval [CI], 1.14-1.58; P < .001), followed by GSRs (HR per 0.01 sec(-1), 1.06; 95% CI, 1.02-1.11; P = .006), GSRe (HR per -0.01 sec(-1), 1.04; 95% CI, 1.00-1.07; P = .031), and fractional area change (HR per -1%, 1.08; 95% CI, 1.00-1.17; P = .047). Other measures of RV function were not significantly associated with risk for events. In receiver operating characteristic analysis, RV GS ≥ -10% optimally predicted future events (C = 0.83; 95% CI, 0.71-0.91; P < .001).

CONCLUSIONS

Reduced longitudinal GS of the systemic right ventricle is associated with increased risk for clinical events among patients with D-transposition of the great arteries and prior atrial switch.

Late outcome of 132 Senning procedures after 20 years of follow-up

BACKGROUND

Risk factors and rates of reoperation, arrhythmias, systemic right ventricular dysfunction (RVD), and late death after a Senning procedure were investigated.

METHODS

One-hundred thirty-two patients underwent a Senning operation between 1977 and 2004 (105 simple and 27 complex transpositions of the great arteries). Mean follow-up time was 19.5 ± 6.6 years. Surviving patients were evaluated by transthoracic echocardiography and electrocardiography. Right ventricular function was assessed in 70 patients by isotopic ventriculography or magnetic resonance imaging.

RESULTS

Operative and late mortality were 5.3% (7/132) and 9.6% (12/125), respectively. Nine patients were reoperated for left ventricular outflow tract obstruction or baffle stenosis. Survival rate was 91.5%, 91%, 89%, and 88% at 1, 5, 10, and 20 years, respectively. Probability of maintaining permanent sinus rhythm was 80%, 65%, 55%, and 44%. Twelve patients required pacemaker implantation. Probability of no supraventricular tachycardia, atrial flutter/fibrillation or ventricular tachycardia was 95.5%, 91.5%, 88%, and 75%, respectively. These parameters were similar for simple and complex transposition. Probability of right ventricular ejection fraction >40% was 100% at 5 and 10 years, and 98% at 20 years for simple transposition, and 100%, 92%, and 58% for complex transposition. This difference was statistically significant. Risk factors for RVD were complex transposition (p < 0.001), body weight (p = 0.008), no cardioplegia (p < 0.001), and tricuspid valve regurgitation (p = 0.004).

CONCLUSIONS

Senning procedure results in very good long-term survival out to 20 years. Both RVD and baffle stenosis were rare, but there was a concerning incidence of arrhythmia over time suggesting careful long-term surveillance.

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.