The influence of coronary artery anatomy on mortality after the arterial switch operation

Outcomes of the Arterial Switch Operation in Patients With Dextrocardia

BACKGROUND

Patients with dextrocardia and d-transposition of the great arteries (d-TGA) present a technical challenge when performing the arterial switch operation (ASO). We sought to determine the long-term outcomes of this rare presentation.

METHODS

All patients who underwent the ASO with d-TGA and dextrocardia were identified from the hospital database.

RESULTS

There were four patients with dextrocardia (4 of 844, 0.5%) patients; two patients had situs solitus and two patients had situs inversus. Three patients had a ventricular septal defect. Left ventricular outflow tract obstruction was present in one patient and one patient had a hypoplastic arch with severe coarctation of aorta. Anomalous coronary anatomy occurred in two patients. There was one early mortality and the cause of death was sepsis. One patient required late reoperation for severe neo-pulmonary valve regurgitation at 23 years after the ASO. At last follow-up, all three surviving patients were in New York Heart Association Class I.

CONCLUSIONS

Patients with d-TGA and dextrocardia who undergo the ASO are extremely rare and require challenging operative management.

Tubular Pouch Technique Using Aortic Tissues for Single Coronary Artery Transfer

A single coronary artery with a single ostium from sinus 2 (2 R L Cx) is rare and difficult to transfer. A 6-day-old male neonate was diagnosed with dextro-transposition of the great arteries with an intact ventricular septum at birth. Computed tomography revealed the presence of a single coronary artery with a single ostium from sinus 2 (2 R L Cx). We performed a new coronary transfer technique involving a tubular pouch using the original aortic tissue for this single coronary artery. The postoperative course was uneventful, and postoperative computed tomography revealed a smooth coronary route with no stenosis.

Exercise electrocardiogram for risk-based screening of severe residual coronary lesion in children after coronary surgery

BACKGROUND

Residual severe coronary artery (CA) lesion (SCL) in children after cardiac surgery involving the CA is a major concern.

AIM

To evaluate the value of exercise electrocardiogram (eECG) for risk-based screening of SCL.

METHODS

We analysed 135 maximal eECG from 115 children (mean age 13.6±3.7 years) who underwent concomitant CA imaging. SCL was defined as a stenosis exceeding 50%.

RESULTS

Underlying congenital heart diseases were transposition of the great arteries (TGA) (n = 116), CA pathway anomaly (n = 13) and left CA from the pulmonary artery (n = 6). Eleven SCLs were identified in 10 patients, of which 3 had a known untreated non-severe lesion and 4 had no lesions on previous imaging. In multivariable analysis, risks markers for SCL were effort chest pain (OR: 4.72, 95% CI: 1.23-18.17; P=0.024), intramural pathway (OR: 4.37, 95% CI: 1.14-16.81; P=0.032). Yacoubs C-type CA was added as a risk marker for patients with TGA (P=0.0009). All patients with SCL had a positive eECG (sensitivity: 100%, 95% CI: 72-100). Specificity was 81% (95% CI: 73-87). In the low-risk group (0 risk markers), 3/95 patients had SCL (3%), and the post-test probability of SCL with positive eECG (PPr+) was 15% (95% CI: 8-21). In the high-risk group (≥1 risk marker) comprising 8/40 SCLs (20%), PPr+ was 53% (95% CI: 35-67).

CONCLUSIONS

Most SCL tended to develop gradually, years after surgery. Provided it is near maximal, a negative eECG appears sufficient to exclude SCL. In the high-risk group, PPr+ exceeded 50%.

Exercise Capacity After Arterial Switch Operation in Patients with D-Transposition of Great Arteries: Does the Coronary Artery Anatomy Matter?

Variant coronary anatomy (VarCA) is frequent in D-Transposition of the great arteries (d-TGA). There are a paucity of data on the effect of the VarCA on the exercise capacity (XC) in patients with repaired d-TGA. This retrospective study included patients with d-TGA who underwent an arterial switch operation (ASO) and had at least one cardiopulmonary exercise test (CPET). Data from the treadmill CPET and simultaneously performed spirometry were collected. The parameters of CPET were compared between patients with usual anatomy vs. VarCA. Longitudinal changes in XC in patients with ASO were also analyzed. A total of 44 patients with either usual coronary anatomy (n = 27, 61%) or VarCA (n = 17, 39%) met inclusion criteria. There was no significant difference in oxygen consumption (%VO₂) at initial CPET (104 vs. 100%, p = 0.53) between the two groups. Abnormal %VO₂ (< 85%) was uncommon in both groups (n = 2, 7.4% vs. n = 4; 23.5%; p = ns). For longitudinal changes, there was no significant decline in %VO₂ in either group: (i) usual coronary anatomy (n = 15, median follow-up 4.8 years, %VO₂ 111 vs. 108%; p = 0.306) and (ii) VarCA (n = 10, median follow-up 6.6 years, %VO₂ 106 vs. 92%; p = 0.441). Spirometry was abnormal in 25 (59.5%) patients [restrictive (n = 8, 19.0%), obstructive (n = 15, 35.7%), and mixed (n = 2, 4.8%)] butabnormal spirometry had no impact on the XC. Patients with d-TGA who underwent neonatal ASO uniformly exhibited good XC without any longitudinal decline on medium-term follow-up, regardless of coronary artery anatomy. Although frequent (60%), abnormal spirometry was not associated with reduced exercise capacity.

Nuclear Imaging in Pediatric Cardiology: Principles and Applications

Nuclear imaging plays a unique role within diagnostic imaging since it focuses on cellular and molecular processes. Using different radiotracers and detection techniques such as the single photon emission scintigraphy or the positron emission tomography, specific parameters can be assessed: myocardial perfusion and viability, pulmonary perfusion, ventricular function, flow and shunt quantification, and detection of inflammatory processes. In pediatric and congenital cardiology, nuclear imaging can add complementary information compared to other imaging modalities such as echocardiography or magnetic resonance imaging. In this state-of-the-art paper, we appraise the different techniques in pediatric nuclear imaging, evaluate their advantages and disadvantages, and discuss the current clinical applications.

Canadian Cardiovascular Society 2022 Guidelines for Cardiovascular Interventions in Adults With Congenital Heart Disease

Interventions in adults with congenital heart disease (ACHD) focus on surgical and percutaneous interventions in light of rapidly evolving ACHD clinical practice. To bring rigour to our process and amplify the cumulative nature of evidence ACHD care we used the ADAPTE process; we systematically adjudicated, updated, and adapted existing guidelines by Canadian, American, and European cardiac societies from 2010 to 2020. We applied this to interventions related to right and left ventricular outflow obstruction, tetralogy of Fallot, coarctation, aortopathy associated with bicuspid aortic valve, atrioventricular canal defects, Ebstein anomaly, complete and congenitally corrected transposition, and patients with the Fontan operation. In addition to tables indexed to evidence, clinical flow diagrams are included for each lesion to facilitate a practical approach to clinical decision-making. Excluded are recommendations for pacemakers, defibrillators, and arrhythmia-directed interventions covered in separate designated documents. Similarly, where overlap occurs with other guidelines for valvular interventions, reference is made to parallel publications. There is a paucity of high-level quality of evidence in the form of randomized clinical trials to support guidelines in ACHD. We accounted for this in the wording of the strength of recommendations put forth by our national and international experts. As data grow on long-term follow-up, we expect that the evidence driving clinical practice will become increasingly granular. These recommendations are meant to be used to guide dialogue between clinicians, interventional cardiologists, surgeons, and patients making complex decisions relative to ACHD interventions.

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.

Mortality analysis of arterial switch operation for transposition of the great arteries with and without ventricular septal defect

OBJECTIVES

We aimed to evaluate the 90-day mortality and effect of rescue or urgent coronary revascularization in children undergoing arterial switch operation for transposition of the great arteries with and without ventricular septal defect.

METHODS

The 90-day mortality, risk factors for mortality and outcome of rescue or urgent coronary revascularization were analysed using 8 years of data from the Japan Cardiovascular Surgical Database. We only included patients with full data for all analyses.

RESULTS

A total of 1084 patients (median weight: 3.0 kg; interquartile range: 2.8-3.3) underwent arterial switch operation at a median age of 10 days (interquartile range: 7-14). The 90-day mortality (5.2%, n = 56) was ∼1.6-fold higher than 30-day mortality (3.2%, n = 35). The cause was cardiac origin in 84% of non-survivors. Fifty-nine of the 1034 patients (5.7%) required extracorporeal membrane oxygenation (ECMO), with successful weaning in 44% (n = 26). Univariable or multivariable analyses revealed the following risk factors for mortality: body weight at operation <2.5 kg, aortic cross-clamp time, cardiac events and ECMO (P < 0.005-0.001). Ventricular septal defect was not a risk factor.Thirteen patients (1.2%) had either rescue or urgent coronary revascularization with salvage rates of 25% (2/8) and 100% (5/5), respectively. Only 5 ECMO patients (8%) underwent coronary revascularization with 1 survivor.

CONCLUSIONS

The 90-day mortality represented perioperative outcomes better than 30-day mortality. Patients on ECMO, which extended the survival time, had 56% 90-day mortality. Coronary revascularization showed a salvaging effect, although the case number was small.Subj collection: 116, 137, 141.

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.

Long-Term Survival and Freedom From Coronary Artery Reintervention After Arterial Switch Operation for Transposition of the Great Arteries: A Population-Based Nationwide Study

Background The aim of this study was to evaluate long-term survival and freedom from coronary artery reintervention after the arterial switch operation (ASO). Methods and Results This single-center nationwide retrospective study included consecutive children who underwent ASO between 1990 and 2016 (n=605). Long-term outcomes were obtained by cross-mapping individual data with the National Death Registry and the National Registry of Cardiovascular Interventions for adults. A control group was randomly retrieved at a 1:10 ratio from the National Birth and Death Registries. Early mortality was 3.3% and late mortality was 1.7% during a median follow-up of 10 (interquartile range, 5-16) years. The probability of overall survival at 20 years after ASO was 94.9% compared with 99.5% in the background population (hazard ratio [HR] 15.6; 95% CI, 8.9-27.5, P<0.001). Independent multivariable predictors of worse survival were an intramural coronary artery (HR, 5.2; 95% CI, 1.8-15.2, P=0.002) and period of ASO 1990 to 1999 (HR, 4.6; 95% CI, 1.5-13.6, P<0.001). Fourteen patients (2.3%) required 16 coronary artery reoperations. Freedom from coronary artery reintervention at 20 years after ASO was 96%. The only independent multivariable predictor associated with a higher hazard for coronary artery reintervention was an intramural coronary artery (HR, 33.9; 95% CI, 11.8-97.5, P<0.001). Conclusions Long-term survival after ASO is excellent. Coronary artery reinterventions are rare. An intramural coronary artery was an independent predictor associated with a higher risk for coronary artery reintervention and death, regardless of the surgical period.

Long-term outcomes of the arterial switch operation

OBJECTIVES

The arterial switch operation (ASO) has excellent early outcomes in the modern era. We sought to determine the long-term outcomes in patients who underwent an ASO at a single institution.

METHODS

Patients who underwent an ASO between 1983 and 2015 were identified from the hospital database and retrospectively reviewed using hospital records.

RESULTS

From 1983 to 2015, 844 patients with a biventricular circulation underwent an ASO. There were 28 (3.3%, 28/844) early deaths. Follow-up was available for 94% (729/774) of local patients after hospital discharge. Median follow-up was 15 years (interquartile range, 8-20 years). There were 187 (26%, 187/729) patients with more than 20 years of follow-up and 95 (13%, 95/729) patients with more than 25 years of follow-up. Overall survival was 95% (95% confidence interval [CI], 94%-97%) at 10 and 25 years after the ASO. At 25 years after ASO, freedom from overall reintervention was 77% (95% CI, 73%-81%), freedom from reoperation on the neoaortic root or neoaortic valve was 92% (95% CI, 88%-95%), and freedom from coronary reoperation was 99% (95% CI, 98%-99.7%). Left ventricular (LV) systolic function was normal in 595 of 609 (98%) of patients who had LV function quantified at latest follow-up. Of the 95 patients with more than 25 years of follow-up after ASO, 6 (6.3%) had at least moderate neoaortic valve regurgitation (AR) and 8 (8.4%) had undergone replacement of the neoaortic valve.

CONCLUSIONS

Overall, survivors of ASO have excellent late survival and normal LV systolic function into adult life. However, AR and reoperation on the neoaortic valve remains an issue for older patients.