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Abruzzo AR, Beroukhim RS, Campos S, Ghelani S, Baird CW, Feins EN, Del Nido PJ, Emani SM. Reverse double switch operation for the borderline left ventricle. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00769-4. [PMID: 39218145 DOI: 10.1016/j.jtcvs.2024.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 08/02/2024] [Accepted: 08/21/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE(S) This study investigates outcomes of the reverse double switch operation (R-DSO) and ventricular switch, novel approaches for patients with D-looped borderline left hearts that utilize the morphologic right ventricle as the systemic ventricle and the hypoplastic left ventricle as the subpulmonary ventricle. METHODS This retrospective review analyzed early outcomes of children who underwent R-DSO/ventricular switch at a single institution between 2015 and 2023. Our primary end points were right ventricular (RV) function and tricuspid regurgitation. Secondary outcomes included mortality, reoperation, and perioperative complications. RESULTS Twenty-eight patients underwent either R-DSO (n = 19) or ventricular switch (n = 9). In 19 patients, a decompressing bidirectional cavopulmonary shunt was utilized, creating a reverse 1.5 switch. Median age at R-DSO/ventricular switch was 3.1 years (range, 9 months-12 years). At a median follow-up of 1.0 year (range, 38 days-7.2 years), no mortalities or heart transplants had occurred. Mild-moderate or greater RV dysfunction was detected in 4 patients, and mild-moderate or worse tricuspid regurgitation was also detected in 4 patients. Three patients required reoperations. Preoperative RV ejection fraction <55% was associated with higher incidence of postoperative RV dysfunction. CONCLUSIONS The R-DSO/VS strategy is an alternative to single-ventricle palliation or anatomic biventricular repair in the borderline left heart. Concerns for RV dysfunction and tricuspid regurgitation mandate close monitoring. Patients with preoperative RV dysfunction may be at risk for postoperative RV dysfunction. Further studies with longer follow-up are needed to delineate outcomes in comparison to the Fontan pathway and identify optimal candidates for this novel strategy.
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Affiliation(s)
| | - Rebecca S Beroukhim
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Sarah Campos
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Sunil Ghelani
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Eric N Feins
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
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Duong SQ, Ho D, Punn R, Sganga D, Mainwaring R, Ma M, Hanley FL, Lee KJ, Maskatia SA. Echocardiographic Predictors of Readiness for Double Switch Operation and Postoperative Ejection Fraction in Patients With Congenitally Corrected Transposition of the Great Arteries Undergoing Left Ventricular Retraining. J Am Soc Echocardiogr 2024:S0894-7317(24)00438-3. [PMID: 39218369 DOI: 10.1016/j.echo.2024.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 08/14/2024] [Accepted: 08/16/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND In patients with congenitally corrected transposition of the great arteries (ccTGA), assessment of readiness for the double switch operation (DSO) after pulmonary arterial band (PAB) placement involves cardiac magnetic resonance imaging (cMRI) to measure left ventricular ejection fraction (LVEF) and mass and cardiac catheterization (catheterization) to assess the ratio of left ventricular to right ventricular pressure (LV:RVp). The aims of this study were to describe the relationships between echocardiographic and catheterization and cMRI measures of readiness for DSO and to develop risk factors for left ventricular (LV) dysfunction after DSO on the basis of echocardiographic measures of ventricular-arterial coupling (VAC). METHODS Patients with ccTGA undergoing LV retraining at a DSO referral center were reviewed. LVEF measured by echocardiography was compared with that measured by cMRI, and LV:RVp measured by echocardiography was compared with that measured by catheterization using Bland-Altman analysis. The relationship between preoperative VAC markers and postoperative echocardiography was analyzed using ventricular end-systolic elastance (EES) and a novel marker consisting of the product of LVEF and LV:RVp (EFPR). RESULTS Thirty-one patients with 56 evaluations for DSO were included, 24 of whom underwent DSO. Echocardiographic LVEF correlated well with cMRI LVEF (r = 0.79), and Bland-Altman analysis slightly overestimated cMRI LVEF (mean difference, +3%). Echocardiographic LVEF had a moderate ability to identify normal cMRI LVEF (area under the curve, 0.80) and at an optimal cut point of echocardiographic LVEF threshold of 61%, there was 71% sensitivity and 76% specificity to detect cMRI LVEF ≥ 55%. Echocardiographic LV:RVp correlated well with LV/RVp by catheterization (r = 0.77) and slightly underestimated the catheterization value (mean difference, -0.11). Echocardiographic LV:RVp had a good ability to identify adequate LV:RVp by catheterization (area under the curve, 0.95) and at an optimal echocardiography cut point of 0.75 had 100% sensitivity and 85% specificity to detect a catheterization LV:RVp >0.9. Echocardiography-based criteria for DSO readiness (echocardiographic LVEF of 61% and LV:RVp of 0.75) demonstrated specificity of 97% and positive predictive value of 96% for published criteria of DSO readiness (cMRI LVEF of 55% and catheterization LV:RVp of 0.9). EES and EFPR correlated with post-DSO LVEF (ρ = 0.72 and ρ = 0.60, respectively). EFPR of 0.51 demonstrated 78% sensitivity and 100% specificity for post-DSO LV dysfunction (LVEF < 55%). Age at first PAB also strongly correlated with post-DSO LVEF (ρ = 0.75). No patient with first PAB at <1 year of age exhibited post-DSO LV dysfunction. CONCLUSIONS Echocardiographic measures of LVEF and LV:RVp are reliable indicators of reference standard modalities and can guide management during retraining. The preoperative VAC markers EES and EFPR may be useful markers of post-DSO LV dysfunction. Values of echocardiographic LV:RVp >0.75 are likely to meet pressure-generation criteria for DSO and should be considered for referral to catheterization and cMRI evaluation for DSO. PAB placement before 1 year of life may optimize LV outcomes in patients considered for DSO.
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Affiliation(s)
- Son Q Duong
- Division of Pediatric Cardiology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Deborah Ho
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Betty Irene Moore Heart Center, Palo Alto, California
| | - Rajesh Punn
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Betty Irene Moore Heart Center, Palo Alto, California
| | - Danielle Sganga
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard School of Medicine, Boston, Massachusetts
| | - Richard Mainwaring
- Division of Congenital Heart Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Betty Irene Moore Heart Center, Palo Alto, California
| | - Michael Ma
- Division of Congenital Heart Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Betty Irene Moore Heart Center, Palo Alto, California
| | - Frank L Hanley
- Division of Congenital Heart Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Betty Irene Moore Heart Center, Palo Alto, California
| | - Kyong-Jin Lee
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Betty Irene Moore Heart Center, Palo Alto, California
| | - Shiraz A Maskatia
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Betty Irene Moore Heart Center, Palo Alto, California
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DeWeert KJ, Lancaster T, Dorfman AL. Congenitally corrected transposition: not correct at all. Curr Opin Cardiol 2023; 38:358-363. [PMID: 37016955 DOI: 10.1097/hco.0000000000001052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
PURPOSE OF REVIEW Congenitally corrected transposition of the great arteries is a rare congenital defect with several management options. Disagreement continues on strategies, such as anatomic repair, physiologic repair or observation-only. This review discusses recent data that provide further guidance for clinical decision-making. RECENT FINDINGS New data provide greater insights into practice patterns and outcomes. Recent data from high-volume centers show progressively high rates of systemic right ventricle dysfunction over time with lower rates of systemic left ventricle dysfunction following anatomic repair; there is a statistical trend towards better survival of anatomic repair patients. Data comparing anatomic repair to observation showed that anatomic repair patients had a lower hazard of reaching a composite adverse outcome. These complex operations are predominantly performed at a small subset of congenital heart surgery centers. SUMMARY Anatomic repair compared with physiologic repair may have better outcomes, although there are relatively high rates of morbidity for both approaches. In the patient without associated lesions, nonsurgical management can have excellent outcomes but is complicated by right ventricular failure over time. Multicenter research will help determine risk factors for bad outcomes; management at high volume, experienced centers will probably be beneficial for this complex patient population.
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Affiliation(s)
| | | | - Adam L Dorfman
- University of Michigan Congenital Heart Center, Department of Pediatrics
- University of Michigan Department of Radiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Miller JR, Sebastian V, Eghtesady P. Management Options for Congenitally Corrected Transposition: Which, When, and for Whom? Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2022; 25:38-47. [PMID: 35835515 DOI: 10.1053/j.pcsu.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 02/03/2022] [Accepted: 04/04/2022] [Indexed: 11/11/2022]
Abstract
Management strategies for congenitally corrected transposition of the great arteries (ccTGA) historically consisted of a physiologic repair, resulting in the morphologic right ventricle (mRV) supporting systemic circulation. This strategy persisted despite the development of heart failure by middle age because of the reasonable short-term outcomes, and the natural history of some patients with favorable anatomy (felt to demonstrate the mRV's ability to function in the long-term), and due to the less-than-optimal outcomes associated with anatomical repair. As outcomes with anatomical repair improved, and the long-term risk of systemic mRV dysfunction became apparent, more have begun to realize its advantages. In addition to the decision on whether or not to pursue anatomical repair, and the optimal timing, studies demonstrating the nuance to morphologic left ventricle retraining have demonstrated its feasibility. Further considerations in ccTGA have begun to be better understood, including: the management of a poorly functioning mRV, systemic tricuspid valve regurgitation, the utility of morphologic left ventricle outflow tract obstruction (native or surgically created) and pacing strategies. While some considerations are apparent: biventricular pacing is superior to univentricular, tricuspid regurgitation must be managed early with either progression towards anatomical repair (pulmonary artery banding if needed for retraining) or tricuspid replacement (not repair) based on the patient's age; others remain to be completely elucidated. Overall, the heterogeneity of ccTGA, as well as the unique presentation with each patient regarding ventricular and valvular function and center-to-center variability in management strategies has made the interpretation of published data difficult. That said, more recent long-term outcomes favor anatomical repair in most situations.
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Affiliation(s)
- Jacob R Miller
- Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, Missouri
| | - Vinod Sebastian
- Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, Missouri
| | - Pirooz Eghtesady
- Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, Missouri.
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Ma K, Qi L, Ren L, Zhang B, Liu R, Yang Y, Wang G, Zhang S, Li S. Impact of electrophysiological features acquired after anatomical repair of congenital corrected transposition of the great arteries on late mortality and ventricular dysfunction. Eur J Cardiothorac Surg 2021; 59:839-846. [PMID: 33313849 DOI: 10.1093/ejcts/ezaa433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 10/07/2020] [Accepted: 10/18/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES In patients with anatomically repaired congenitally corrected transposition of the great arteries, the impact of electrophysiological features on postoperative ventricular dysfunction remains less well known. Our goal was to investigate the role of fragmented QRS and QRS duration in mortality and systemic ventricular dysfunction after anatomical repair of corrected transposed great arteries. METHODS Consecutive patients who underwent anatomical repair in our institution from January 2005 to December 2017 were enrolled in this retrospective analysis. Fragmented QRS was defined as ≥1 discontinuous deflections in narrow QRS complexes, and ≥2 in wide QRS complexes, in 2 contiguous electrocardiogram leads. The primary end point was a composite of all-cause mortality and systemic ventricular dysfunction. RESULTS A total of 74 patients were included. Among them, 30, 15 and 29 underwent the Senning arterial switch, the Senning Rastelli and the hemi-Mustard/bidirectional Glenn/Rastelli procedures, respectively. The primary end point occurred in 9 (12.2%) patients and included 7 late deaths and 2 cases of late-onset systemic ventricular dysfunction. Fragmented QRS and QRS prolongation were noted in 19 (25.7%) and 21 (28.4%) patients, respectively. In patients with the primary end point, QRS fragmentation (6/9 vs 10/65; P < 0.001) and QRS prolongation (6/9 vs 15/65; P = 0.013) were noted more frequently than in patients without the primary end point. No statistical differences in these electrocardiogram findings were found among patients treated with 3 surgical strategies. CONCLUSIONS Appearance of QRS fragmentation or QRS prolongation is associated with death or ventricular dysfunction in anatomically repaired corrected transposition of the great arteries. Although there is a trend that QRS fragmentation and QRS prolongation appear more frequently in patients who had the Senning-arterial switch operation, there is no statistically significant difference associated with these electrocardiogram features among varied procedures.
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Affiliation(s)
- Kai Ma
- Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Lei Qi
- Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Lan Ren
- Department of Cardiology, Beijing Jishuitan Hospital, Beijing, China
| | - Benqing Zhang
- Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Rui Liu
- Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yang Yang
- Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Guanxi Wang
- Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Sen Zhang
- Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Shoujun Li
- Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Luo Q, Xu X, He X, Wang S, Sun Q, Zheng J. Pulmonary Hypoplasia Resulting from Pulmonary Artery Banding in Infancy: A Neonatal Rat Model Study. Pediatr Cardiol 2021; 42:397-407. [PMID: 33151352 DOI: 10.1007/s00246-020-02495-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/30/2020] [Indexed: 10/23/2022]
Abstract
The aim of this study was to establish a neonatal rat model of decreased pulmonary blood flow (PBF) for studying pulmonary pathophysiological changes in newborn lung development with reduced PBF. Horizontal thoracotomy surgery with banding of the main pulmonary artery (PA) was performed on 30 rats in the PA banding (PAB) group and without banding on another 30 rats in the sham group within 6 h after birth. The body growth and mortality were recorded. Constriction of PA was checked by echocardiography on postnatal day 7 (P7). Lung morphology was assessed with computed tomography scanning and three-dimensional reconstruction. Histological differences of two groups were evaluated using hematoxylin and eosin (H&E) staining, Masson's trichrome staining, TdT-mediated dUTP nick-end labeling assay, and CD31 labeling with microscopic examination. PA ultrasound confirmed the establishment of constriction on P7. Relative to the sham group, the neonates' physical growth, survival fraction, and lung geometry volume were decreased in the PAB group over time (p < 0.05). Histologic appearance with reduced PBF characterized a markedly simplified alveolarization with noted lower radial alveolar count and alveolar septal thickness in the PAB group (p < 0.0001), pulmonary arteries with thinner/uneven membranous layers and smaller lumina. The deficient alveolar capillary bed, enhanced pulmonary collagen deposition, and increased apoptotic alveolar epithelium were significant in the PAB group compared to the sham group (p < 0.0001). A neonatal rat PAB model demonstrated that PBF reduction during early infancy impairs alveolarization and pulmonary microvasculature.
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Affiliation(s)
- Qiancheng Luo
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Rd., Shanghai, 200127, China
| | - Xiuxia Xu
- Department of Radiology, Huangpu Branch, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 58 Puyu East Rd., Shanghai, 200011, China
| | - Xiaomin He
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Rd., Shanghai, 200127, China
| | - Shoubao Wang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai, 200011, China
| | - Qi Sun
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Rd., Shanghai, 200127, China.
| | - Jinghao Zheng
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Rd., Shanghai, 200127, China.
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Commentary: Building evidence to support empiric observations—Molecular cross talk, or simply crossed wires? J Thorac Cardiovasc Surg 2019; 157:2429-2430. [DOI: 10.1016/j.jtcvs.2019.02.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 02/11/2019] [Indexed: 11/23/2022]
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Ma K, Qi L, Hua Z, Yang K, Zhang H, Li S, Zhang S, He F, Wang G, Feng Z. Surgical Outcomes of Anatomical Repair for Congenitally Corrected Transposed Great Arteries. Heart Lung Circ 2019; 29:772-779. [PMID: 31085133 DOI: 10.1016/j.hlc.2019.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 01/14/2019] [Accepted: 01/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The outcomes of anatomical repair for patients with congenitally corrected transposed great arteries remain unclear and the indications for different procedures are poorly understood. METHODS From January 2005 to February 2016, consecutive corrected transposition patients who underwent anatomical repair at the current institution were enrolled in this retrospective study. Varied types of anatomical repair were individually customised. RESULTS A total of 85 patients were included. Fifty-one (51) and 35 patients presented with left ventricular outflow tract obstruction and cardiac malposition, respectively. Thirty-nine (39) patients presented with moderate-to-severe tricuspid regurgitation. Thirty-four (34), 19, and 32 patients underwent Senning arterial switch operations, Senning-Rastelli, and hemi-Mustard-Rastelli-bidirectional Glenn, respectively. Early after repair, there were five in-hospital deaths and nine re-operations. During 4.6 years (range, 0.5-10.3) of follow-up, seven late deaths were documented. Estimated overall survival rate after anatomical repair was 89.3%, 85.0%, and 85.0% at 1 year, 3 years, and 5 years, respectively. Instead of Senning-Rastelli, most (75.0%) early left ventricular dysfunctions were noted in patients who underwent Senning arterial switch procedures. However, all the late left ventricular dysfunctions were found in patients who underwent previous left ventricular retraining. In patients with left ventricular outflow tract obstruction, the hemi-Mustard-Rastelli-bidirectional Glenn shunt provided a lower early mortality (0% vs 15.8%, p = 0.047). CONCLUSIONS Favourable outcomes can be achieved for anatomical repair of corrected transposition. Left ventricular dysfunction was a significant postoperative issue. Hemi-Mustard-bidirectional Glenn-Rastelli procedure may provide benefits for patients with associated left ventricular outflow tract obstruction and cardiac malposition. Each procedure has its own advantages in varied anatomy.
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Affiliation(s)
- Kai Ma
- Pediatric Cardiac Surgery Center, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Lei Qi
- Pediatric Cardiac Surgery Center, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Zhongdong Hua
- Pediatric Cardiac Surgery Center, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Keming Yang
- Pediatric Cardiac Surgery Center, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Hao Zhang
- Pediatric Cardiac Surgery Center, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Shoujun Li
- Pediatric Cardiac Surgery Center, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China.
| | - Sen Zhang
- Pediatric Cardiac Surgery Center, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Fengpu He
- Pediatric Cardiac Surgery Center, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Guanxi Wang
- Pediatric Cardiac Surgery Center, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Zicong Feng
- Pediatric Cardiac Surgery Center, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
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Smood B, Kirklin JK, Pavnica J, Tresler M, Johnson WH, Cleveland DC, Mauchley DC, Dabal RJ. Congenitally Corrected Transposition Presenting in the First Year of Life: Survival and Fate of the Systemic Right Ventricle. World J Pediatr Congenit Heart Surg 2019; 10:42-49. [DOI: 10.1177/2150135118813125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Knowledge gaps exist in the life expectancy and functional outcome of patients with congenitally corrected transposition (ccTGA) presenting early in life, which is relevant in the evaluation of early anatomic repair. Methods: In a single-center analysis, 91 patients with ccTGA were identified over 25 years, of which 31 presented with biventricular anatomy in the first year of life and formed the study cohort. End points for analysis included survival, moderate or worse tricuspid valve regurgitation, and systemic right ventricle (RV) dysfunction. Median follow-up was 4.9 years (range: 7 days to 20 years). Results: Among 31 patients presenting in the first year of life, 9 (29%) never received cardiac surgery, while 22 (71%) underwent 36 cardiac operations. Overall freedom from moderate or severe systemic RV dysfunction was 75% at 10 years. Overall survival was 82% at 10 years. Surgical mortality was 5.6% (2/36). Among survivors with a systemic RV, 23 (100%) of 23 were Ross or NYHA class I or II at last follow-up. Conclusions: Congenitally corrected transposition presenting in the first year of life and maintaining a systemic RV can expect (1) long-term survival of more than 80% at 10 years, (2) low expected surgical mortality (overall 6%), and (3) 75% late freedom from major RV dysfunction at 10 years. Pending multi-institutional analyses, this experience with a systemic RV in ccTGA provides an initial benchmark for comparison when considering early elective anatomic correction.
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Affiliation(s)
- Benjamin Smood
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - James K. Kirklin
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Surgery, James and John Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jozef Pavnica
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Margaret Tresler
- Department of Surgery, James and John Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Walter H. Johnson
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
- Division of Cardiovascular Services, Children’s of Alabama, Birmingham, AL, USA
| | - David C. Cleveland
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Cardiovascular Services, Children’s of Alabama, Birmingham, AL, USA
| | - David C. Mauchley
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Cardiovascular Services, Children’s of Alabama, Birmingham, AL, USA
| | - Robert J. Dabal
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Cardiovascular Services, Children’s of Alabama, Birmingham, AL, USA
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Spigel Z, Binsalamah ZM, Caldarone C. Congenitally Corrected Transposition of the Great Arteries: Anatomic, Physiologic Repair, and Palliation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2019; 22:32-42. [PMID: 31027562 DOI: 10.1053/j.pcsu.2019.02.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 02/26/2019] [Indexed: 06/09/2023]
Abstract
Congenitally corrected transposition of the great arteries (ccTGA) is a lesion that rarely occurs in isolation. The presenting physiology of ccTGA is predominantly secondary to the concurrent cardiac lesions; however, as the child ages, unrepaired ccTGA results in progressive failure of the morphologic right ventricle under the strain of maintaining a systemic pressure. Repair of ccTGA was initially focused on rectification of the underlying physiologic aberrations, but in recent years, the focus of repair has shifted toward anatomic correction to avoid failure of the morphologic right ventricle. This anatomic repair is commonly associated with improved long-term mortality at the cost of increased short-term mortality. Key preoperative considerations such as morphologic left ventricular pressure, tricuspid valve competency, and out flow tract obstructions can assist in determining the optimal repair for individual patients. An alternative, single ventricle, pathway has been proposed for any patient without optimal preoperative anatomy to improve long-term survival. Adjunctive repair options including pulmonary artery banding and one-and-a-half ventricle repairs have also been proposed to augment the survival curves.
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Affiliation(s)
- Zachary Spigel
- Congenital Heart Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Ziyad M Binsalamah
- Congenital Heart Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas.
| | - Christopher Caldarone
- Pediatric Congenital Heart Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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Cohen MS, Dagincourt N, Zak V, Baffa JM, Bartz P, Dragulescu A, Dudlani G, Henderson H, Krawczeski CD, Lai WW, Levine JC, Lewis AB, McCandless RT, Ohye RG, Owens ST, Schwartz SM, Slesnick TC, Taylor CL, Frommelt PC. The Impact of the Left Ventricle on Right Ventricular Function and Clinical Outcomes in Infants with Single-Right Ventricle Anomalies up to 14 Months of Age. J Am Soc Echocardiogr 2018; 31:1151-1157. [PMID: 29980396 PMCID: PMC6475580 DOI: 10.1016/j.echo.2018.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Children with single-right ventricle anomalies such as hypoplastic left heart syndrome (HLHS) have left ventricles of variable size and function. The impact of the left ventricle on the performance of the right ventricle and on survival remains unclear. The aim of this study was to identify whether left ventricular (LV) size and function influence right ventricular (RV) function and clinical outcome after staged palliation for single-right ventricle anomalies. METHODS In the Single Ventricle Reconstruction trial, echocardiography-derived measures of LV size and function were compared with measures of RV systolic and diastolic function, tricuspid regurgitation, and outcomes (death and/or heart transplantation) at baseline (preoperatively), early after Norwood palliation, before stage 2 palliation, and at 14 months of age. RESULTS Of the 522 subjects who met the study inclusion criteria, 381 (73%) had measurable left ventricles. The HLHS subtype of aortic atresia/mitral atresia was significantly less likely to have a measurable left ventricle (41%) compared with the other HLHS subtypes: aortic stenosis/mitral stenosis (100%), aortic atresia/mitral stenosis (96%), and those without HLHS (83%). RV end-diastolic and end-systolic volumes were significantly larger, while diastolic indices suggested better diastolic properties in those subjects with no left ventricles compared with those with measurable left ventricles. However, RV ejection fraction was not different on the basis of LV size and function after staged palliation. Moreover, there was no difference in transplantation-free survival to Norwood discharge, through the interstage period, or at 14 months of age between those subjects who had measurable left ventricles compared with those who did not. CONCLUSIONS LV size varies by anatomic subtype in infants with single-right ventricle anomalies. Although indices of RV size and diastolic function were influenced by the presence of a left ventricle, there was no difference in RV systolic function or transplantation-free survival on the basis of LV measures.
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Affiliation(s)
- Meryl S Cohen
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | | | - Victor Zak
- New England Research Institutes, Boston, Massachusetts
| | - Jeanne Marie Baffa
- Division of Cardiology, A.I. DuPont Hospital for Children, Wilmington, Delaware
| | - Peter Bartz
- Division of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andreea Dragulescu
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gul Dudlani
- Division of Cardiology, Johns Hopkins All Children's Heart Institute, St. Petersburg, Florida
| | - Heather Henderson
- Division of Pediatric Cardiology, Duke University Medical Center, Raleigh, North Carolina
| | | | - Wyman W Lai
- Division of Cardiology, Morgan Stanley Children's Hospital, New York, New York
| | - Jami C Levine
- Department of Cardiology, Children's Hospital, Boston, Boston, Massachusetts
| | - Alan B Lewis
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, California
| | | | - Richard G Ohye
- Division of Cardiac Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Sonal T Owens
- Division of Pediatric Cardiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Steven M Schwartz
- Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Carolyn L Taylor
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Peter C Frommelt
- Division of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Double switch operations: Should we perform physiologic or anatomic repair in congenitally corrected transposition of the great arteries. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 26:511-518. [PMID: 32082791 DOI: 10.5606/tgkdc.dergisi.2018.15240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 04/25/2018] [Indexed: 11/21/2022]
Abstract
The seeking for the optimal surgical treatment of congenitally corrected transposition of the great arteries (cTGA) is ongoing. Physiologic (conventional) repair approaches, leaving the morphologic right ventricle (MRV) on the systemic circulation side, cause systemic ventricle and tricuspid valve failure, particularly in the long-term. Double Switch operations (anatomic repair) were aimed to convert the morphologic left ventricle to systemic ventricle and MRV to pulmonic ventricle. Gradual improvement in the early and midterm results of double switch operations in the last 20 years rendered anatomic repair to become a preferred procedure. Thanks to the preservation of ventricular functions through anatomic repair, patients with congenitally cTGA may survive longer with normal/near normal functional capacity. However, studies with larger sample size and longer follow-up duration are required to establish a more definite judgement.
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Zhang S, Ma K, Li S, Hua Z, Zhang H, Yan J, Yang K, Pang K, Wang X, Qi L, Chen Q. The hemi-Mustard, bidirectional Glenn and Rastelli procedures for anatomical repair of congenitally corrected transposition of the great arteries/left ventricular outflow tract obstruction with positional heart anomalies†. Eur J Cardiothorac Surg 2018; 51:1058-1062. [PMID: 28329265 DOI: 10.1093/ejcts/ezx033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 01/03/2017] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES The hemi-Mustard and bidirectional Glenn (BDG) procedures combined with the Rastelli procedure have been applied to selected cases of congenitally corrected transposition of the great arteries (ccTGA) for potential benefit over the classic atrial switch procedure. The aim of this study was to analyse our experience with the hemi-Mustard, BDG and Rastelli procedures as an anatomical correction for patients with ccTGA/left ventricular outflow tract obstruction (LVOTO) with positional heart anomalies. METHODS In this retrospective study, 31 consecutive patients with corrected transposition underwent the hemi-Mustard/BDG procedures with the Rastelli operation between 2011 and 2015. The median age was 5.4 (range: 0.75-12) years. Positional anomalies were present in all patients. Eleven patients underwent BDG initially; they then had the second-stage hemi-Mustard and Rastelli procedures; 'one-stage repair' (hemi-Mustard/BDG and the Rastelli procedures) was performed in 20 cases. RESULTS There were no in-hospital deaths, and 3 patients received a pacemaker. One patient had an atrial baffle obstruction that was observed in the early postoperative period; 7 patients had prolonged pleural effusions that developed more frequently in the one-stage repair group (7/20 vs 0/11, P = 0.033). During the mean follow-up of 3.3 years, 1 late death was noted, and no conduit replacements were required. Twenty-five (83.3%) patients are in New York Heart Association classes I and II at the latest follow-up. CONCLUSIONS Hemi-Mustard, BDG and the Rastelli procedures are technically feasible for correction of ccTGA/left ventricular outflow tract obstruction (LVOTO) and cardiac malposition. Nevertheless, postoperative pleural effusion is the most prevalent complication in the one-stage repair. Two-stage repair may reduce the risk of pleural effusion-related complications.
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Affiliation(s)
- Sen Zhang
- National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Kai Ma
- National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Shoujun Li
- National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Zhongdong Hua
- National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Hao Zhang
- National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jun Yan
- National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Keming Yang
- National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Kunjing Pang
- National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Xu Wang
- National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Lei Qi
- National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Qiuming Chen
- National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Sachdeva S, Jacobsen RM, Woods RK, Mitchell ME, Cava JR, Ghanayem NS, Frommelt PC, Bartz PJ, Tweddell JS. Anatomic Repair of Congenitally Corrected Transposition of the Great Arteries: Single-Center Intermediate-Term Experience. Pediatr Cardiol 2017; 38:1696-1702. [PMID: 28918529 DOI: 10.1007/s00246-017-1715-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 08/31/2017] [Indexed: 01/15/2023]
Abstract
We present our experience for patients who have undergone an anatomic repair (AR) for congenitally corrected transposition of the great arteries (CCTGA) at the Children's Hospital of Wisconsin. A retrospective chart review of patients who underwent AR for CCTGA from 2001 to 2015 was performed. The cohort consisted of 15 patients (74% male). Median age of anatomic repair was 15 months (range 4.5-45.6 months). Four patients had a bidirectional Glenn (BDG) prior to AR. At the time of AR,-9 (60%) underwent Senning/Rastelli procedure, 4 (26.6%) had double switch operation, and 2 (13.3%) underwent only Senning with VSD closure. Median duration of follow-up was 5.5 years (0.05-14 years). Reoperations prior to discharge included BDG, revision of pulmonary venous baffle, closure of residual VSD, and pacemaker placement. Late reoperations included left ventricular outflow tract obstruction repair, conduit replacement, melody valve placement, and pacemaker implantation. At their most recent follow-up, no patient had heart failure symptoms and only 1 had severely diminished function that improved with cardiac resynchronization therapy. Moderate mitral regurgitation was noted in 15% (2/13), and severe in 7% (1/13). Moderate tricuspid regurgitation was noted in 15% (2/13). One patient, 7% (1/13), developed moderate aortic insufficiency. There was a 100% survival at the time of the most recent follow-up. Patients with CCTGA who have undergone AR have excellent functional status and mid-term survival but reinterventions are common. Longer term studies are needed to determine both the extent and spectrum of reinterventions as well as long term survival.
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Affiliation(s)
| | | | | | | | - Joseph R Cava
- Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | | | | | - Peter J Bartz
- Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - James S Tweddell
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
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Ma K, Li S, Hu S, Hua Z, Yang K, Yan J, Zhang H, Chen Q, Zhang S, Qi L. Neoaortic Valve Regurgitation After Arterial Switch: Ten Years Outcomes From A Single Center. Ann Thorac Surg 2016; 102:636-42. [DOI: 10.1016/j.athoracsur.2016.02.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 02/01/2016] [Accepted: 02/09/2016] [Indexed: 10/21/2022]
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Helsen F, De Meester P, Van Keer J, Gabriels C, Van De Bruaene A, Herijgers P, Rega F, Meyns B, Gewillig M, Troost E, Budts W. Pulmonary outflow obstruction protects against heart failure in adults with congenitally corrected transposition of the great arteries. Int J Cardiol 2015; 196:1-6. [DOI: 10.1016/j.ijcard.2015.05.142] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 05/13/2015] [Accepted: 05/26/2015] [Indexed: 01/04/2023]
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