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Jacquemyn X, Van den Eynde J, Schuermans A, van der Palen RL, Budts W, Danford DA, Ravekes WJ, Kutty S. Neoaortic Regurgitation Detected by Echocardiography After Arterial Switch Operation: A Systematic Review and Meta-Analysis. JACC. ADVANCES 2024; 3:100878. [PMID: 38939665 PMCID: PMC11198711 DOI: 10.1016/j.jacadv.2024.100878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/18/2023] [Accepted: 01/04/2024] [Indexed: 06/29/2024]
Abstract
Background Neoaortic root dilatation (NeoARD) and neoaortic regurgitation (NeoAR) are common sequelae following the arterial switch operation (ASO) for transposition of the great arteries. Objectives The authors aimed to estimate the cumulative incidence of NeoAR, assess whether larger neoaortic root dimensions were associated with NeoAR, and evaluate factors associated with the development of NeoAR during long-term follow-up. Methods Electronic databases were systematically searched for articles that assessed NeoAR and NeoARD after ASO, published before November 2022. The primary outcome was NeoAR, classified based on severity categories (trace, mild, moderate, and severe). Cumulative incidence was estimated from Kaplan-Meier curves, neoaortic root dimensions using Z-scores, and risk factors were evaluated using random-effects meta-analysis. Results Thirty publications, comprising a total of 6,169 patients, were included in this review. Pooled estimated cumulative incidence of ≥mild NeoAR and ≥moderate NeoAR at 30-year follow-up were 67.5% and 21.4%, respectively. At last follow-up, neoaortic Z-scores were larger at the annulus (mean difference [MD]: 1.17, 95% CI: 0.52-1.82, P < 0.001; MD: 1.38, 95% CI: 0.46-2.30, P = 0.003) and root (MD: 1.83, 95% CI: 1.16-2.49, P < 0.001; MD: 1.84, 95% CI: 1.07-2.60, P < 0.001) in patients with ≥mild and ≥moderate NeoAR, respectively, compared to those without NeoAR. Risk factors for the development of any NeoAR included prior pulmonary artery banding, presence of a ventricular septal defect, aorto-pulmonary mismatch, a bicuspid pulmonary valve, and NeoAR at discharge. Conclusions The risks of NeoARD and NeoAR increase over time following ASO surgery. Identified risk factors for NeoAR may alert the clinician that closer follow-up is needed. (Risk factors for neoaortic valve regurgitation after arterial switch operation: a meta-analysis; CRD42022373214).
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Affiliation(s)
- Xander Jacquemyn
- Department of Pediatrics, Helen B. Taussig Heart Center, Johns Hopkins Hospital, Baltimore, Maryland, USA
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Jef Van den Eynde
- Department of Pediatrics, Helen B. Taussig Heart Center, Johns Hopkins Hospital, Baltimore, Maryland, USA
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Art Schuermans
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, Massachusetts, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Roel L.F. van der Palen
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Werner Budts
- Congenital and Structural Cardiology, Department of Cardiovascular Sciences, UZ Leuven, KU Leuven, Leuven, Belgium
| | - David A. Danford
- Department of Pediatrics, Helen B. Taussig Heart Center, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - William J. Ravekes
- Department of Pediatrics, Helen B. Taussig Heart Center, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Shelby Kutty
- Department of Pediatrics, Helen B. Taussig Heart Center, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Jonas K, Jakutis V, Sudikienė R, Lebetkevičius V, Baliulis G, Tarutis V. Early and Late Outcomes after Arterial Switch Operation: A 40-Year Journey in a Single Low Case Volume Center. MEDICINA-LITHUANIA 2021; 57:medicina57090906. [PMID: 34577829 PMCID: PMC8469545 DOI: 10.3390/medicina57090906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/26/2021] [Accepted: 08/26/2021] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Karolis Jonas
- Center of Cardiothoracic Surgery, Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Vilnius University Faculty of Medicine, Santariskiu St. 2, LT-08661 Vilnius, Lithuania; (R.S.); (V.L.); (V.T.)
- Correspondence:
| | - Virginijus Jakutis
- Clinic of Anesthesiology and Intensive Care, Institute of Clinical Medicine, Vilnius University Faculty of Medicine, Santariskiu St. 2, LT-08661 Vilnius, Lithuania;
| | - Rita Sudikienė
- Center of Cardiothoracic Surgery, Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Vilnius University Faculty of Medicine, Santariskiu St. 2, LT-08661 Vilnius, Lithuania; (R.S.); (V.L.); (V.T.)
| | - Virgilijus Lebetkevičius
- Center of Cardiothoracic Surgery, Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Vilnius University Faculty of Medicine, Santariskiu St. 2, LT-08661 Vilnius, Lithuania; (R.S.); (V.L.); (V.T.)
| | - Giedrius Baliulis
- Department of Cardiac Surgery, University Hospital Southampton NHS Foundation Trust, Trenona Road, Southampton SO16 6YD, UK;
| | - Virgilijus Tarutis
- Center of Cardiothoracic Surgery, Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Vilnius University Faculty of Medicine, Santariskiu St. 2, LT-08661 Vilnius, Lithuania; (R.S.); (V.L.); (V.T.)
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Progresión y predictores de insuficiencia valvular neoaórtica y dilatación de la raíz neoaórtica en adultos jóvenes tras cirugía de switch arterial. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.01.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Vera F, Sarria E, Ortiz A, Ruiz E. Cirugía de la transposición de las grandes arterias en periodo neonatal. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Rueda Soriano J, Rodríguez Puras MJ, Buendía Fuentes F, Wals Rodríguez A, Osa Sáez A, Pulido I, Agüero Ramón-Llin J, Manso García B, Insa Albert B, Navarro S, Martínez-Dolz L, Gallego P. Time course and predictors for neoaortic root dilatation and neoaortic valve regurgitation during adult life after arterial switch operation. ACTA ACUST UNITED AC 2020; 74:329-336. [PMID: 32402686 DOI: 10.1016/j.rec.2020.01.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 01/31/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION AND OBJECTIVES There are limited data on the long-term development of neoaortic root dilatation (NRD) and neoaortic valve regurgitation (AR) after arterial switch operation (ASO) for transposition of the great arteries during adult life. METHODS We performed a retrospective longitudinal analysis of 152 patients older than 15 years who underwent ASO for transposition of the great arteries and who were followed-up for 4.9±3.3 years in 2 referral centers. Sequential changes in body surface-adjusted aortic root dimensions and progression to moderate/severe AR were determined in patients with 2 or more echocardiographic examinations. Risk factors for dilatation were tested by Cox regression to identify predictors of AR progression. RESULTS At baseline, moderate AR was present in 9 patients (5.9%) and severe AR in 4 (2.6%), of whom 3 had required aortic valve surgery. Initially, the median neoaortic root dimension was 20.05±2.4mm/m2, which increased significantly to 20.73±2.8mm/m2 (P <.001) at the end of follow-up. The mean change over time was 0.14mm/m2/y (95%CI, 0.07-0.2). Progressive AR was observed in 20 patients (13.5%) and 6 patients (4%) required aortic valve surgery. Progressive AR was associated with bicuspid valve, AR at baseline, NRD at baseline, and neoaortic root enlargement. Independent predictors were bicuspid valve (HR, 3.3; 95%CI, 1.1-15.2; P=.037), AR at baseline (HR, 5.9; 95%CI, 1.6-59.2; P=.006) and increase in NRD (HR, 4.1 95%CI, 2-13.5; P=.023). CONCLUSIONS In adult life, NRD and AR progress over time after ASO. Predictors of progressive AR are bicuspid valve, AR at baseline, and increase in NRD.
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Affiliation(s)
- Joaquín Rueda Soriano
- Unidad de Cardiopatías Congénitas del Adulto, Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, CIBERCV, Valencia, Spain.
| | - María José Rodríguez Puras
- Unidad de Cardiopatías Congénitas del Adulto, Servicio de Cardiología, Hospital Universitario Virgen del Rocío, Instituto BioMedicina (IBIS), CIBERCV, Sevilla, Spain
| | - Francisco Buendía Fuentes
- Unidad de Cardiopatías Congénitas del Adulto, Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, CIBERCV, Valencia, Spain
| | - Amadeo Wals Rodríguez
- Unidad de Cardiopatías Congénitas del Adulto, Servicio de Cardiología, Hospital Universitario Virgen del Rocío, Instituto BioMedicina (IBIS), CIBERCV, Sevilla, Spain
| | - Ana Osa Sáez
- Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, CIBERCV, Valencia, Spain
| | - Ildefonso Pulido
- Unidad de Cardiopatías Congénitas del Adulto, Servicio de Radiodiagnóstico, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Jaime Agüero Ramón-Llin
- Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, CIBERCV, Valencia, Spain; Área de Fisiopatología del Miocardio, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
| | - Begoña Manso García
- Unidad de Cardiopatías Congénitas del Adulto, Sección de Cardiología Pediátrica, Hospital Infantil Virgen del Rocío, Sevilla, Spain
| | - Beatriz Insa Albert
- Sección de Cardiología Pediátrica, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Silvia Navarro
- Unidad de Cardiopatías Congénitas del Adulto, Servicio de Radiodiagnóstico, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Luis Martínez-Dolz
- Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, CIBERCV, Valencia, Spain
| | - Pastora Gallego
- Unidad de Cardiopatías Congénitas del Adulto, Servicio de Cardiología, Hospital Universitario Virgen del Rocío, Instituto BioMedicina (IBIS), CIBERCV, Sevilla, Spain
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Left ventricular function and exercise capacity after arterial switch operation for transposition of the great arteries: a systematic review and meta-analysis. Cardiol Young 2018; 28:895-902. [PMID: 29848397 DOI: 10.1017/s1047951117001032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The arterial switch operation for transposition of the great arteries was initially believed to be an anatomical correction. Recent evidence shows reduced exercise capacity and left ventricular function in varying degrees in the long term after an arterial switch operation. OBJECTIVE To perform a meta-analysis on long-term exercise capacity and left ventricular ejection fraction after an arterial switch operation. METHODS A literature search was performed to cover all studies on patients who had undergone a minimum of 6 years of follow-up that reported either left ventricular ejection fraction, peak oxygen uptake, peak workload, and/or peak heart rate. A meta-analysis was performed if more than three studies reported the outcome of interest. RESULTS A total of 21 studies reported on the outcomes of interest. Oxygen uptake was consistently lower in patients who had undergone an arterial switch operation compared with healthy controls, with a pooled average peak oxygen uptake of 87.5±2.9% of predicted. The peak heart rate was also lower compared with that of controls, at 92±2% of predicted. Peak workload was significantly reduced in two studies. Pooled left ventricular ejection fraction was normal at 60.7±7.2%. CONCLUSION Exercise capacity is reduced and left ventricular ejection fraction is preserved in the long term after an arterial switch operation for transposition of the great arteries.
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Sarris GE, Balmer C, Bonou P, Comas JV, da Cruz E, Chiara LD, Di Donato RM, Fragata J, Jokinen TE, Kirvassilis G, Lytrivi I, Milojevic M, Sharland G, Siepe M, Stein J, Büchel EV, Vouhé PR. Clinical guidelines for the management of patients with transposition of the great arteries with intact ventricular septum. Eur J Cardiothorac Surg 2017; 51:e1-e32. [DOI: 10.1093/ejcts/ezw360] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Wasmer K, Eckardt L. Management of supraventricular arrhythmias in adults with congenital heart disease. Heart 2016; 102:1614-9. [PMID: 27312002 DOI: 10.1136/heartjnl-2015-309068] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/23/2016] [Indexed: 01/21/2023] Open
Abstract
Supraventricular arrhythmias are a frequent complication in adults with congenital heart disease (ACHD). The prevalence increases with time since surgery, complexity of the underlying defect, type of repair and older age at surgery. Arrhythmias are the most frequent reason for hospital admission and along with heart failure the leading cause of death. The arrhythmia-associated increase in morbidity and mortality makes their management a key task in patients with ACHD. Intra-atrial re-entry is the most frequent arrhythmia mechanism. Less common arrhythmia mechanisms are supraventricular tachycardias in the presence of an accessory pathway, atrioventricular nodal re-entrant tachycardia or focal tachycardias. Patient management includes stroke prevention, acute termination and prevention of arrhythmia recurrence. Acute treatment depends on patients' symptoms. In cases of haemodynamic instability, immediate cardioversion is warranted. For stable patients, acute treatment includes rate control and termination by antiarrhythmic drugs or electrical cardioversion. Following a symptomatic arrhythmia, catheter ablation or treatment with antiarrhythmic drugs is recommended to prevent recurrences. Advances in mapping and ablation technology are now associated with high success rates of catheter ablation. In patients with a complex substrate recurrence rates of 50% remain high. However, in the presence of side effects and complications associated with long-term antiarrhythmic drug therapy, redo procedures are encouraged by current guidelines.
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Affiliation(s)
- Kristina Wasmer
- Division of Clinical and Experimental Electrophysiology, Department of Cardiology and Angiology, University Hospital Münster, Münster, Germany
| | - Lars Eckardt
- Division of Clinical and Experimental Electrophysiology, Department of Cardiology and Angiology, University Hospital Münster, Münster, Germany
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Wasmer K, Köbe J, Diller G, Eckardt L. [Arrhythmia in adults with congenital heart defects : Incidence, substrates, and mechanisms]. Herzschrittmacherther Elektrophysiol 2016; 27:75-80. [PMID: 27216033 DOI: 10.1007/s00399-016-0427-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 03/26/2016] [Indexed: 06/05/2023]
Abstract
Arrhythmia management is one of the main challenges in the treatment of adult patients with congenital heart disease (ACHD). Apart from heart failure, arrhythmias are mainly responsible for morbidity and mortality in these patients. Supraventricular tachycardia is more frequent than ventricular arrhythmias and is not only associated with debilitating symptoms, but is often as threatening as ventricular tachycardia. The incidence depends on the underlying defect, type, and time of repair. For the overall ACHD population the incidence of supraventricular tachycardia is up to 50 % and increases with age and time since surgery. Arrhythmia substrate relates to structural abnormalities due to the congenital defect and most importantly to the amount of incisions and material used for repair. In addition, poor hemodynamic conditions influence substrate through dilatation, hypertrophy, and fibrosis. Both supraventricular and ventricular arrhythmias are due to a macroreentrant mechanism in the vast majority of patients, but focal arrhythmias occasionally occur as well.
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Affiliation(s)
- Kristina Wasmer
- Abteilung für Rhythmologie, Department für Kardiologie und Angiologie, Universitätsklinikum Münster (UKM), Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland.
| | - Julia Köbe
- Abteilung für Rhythmologie, Department für Kardiologie und Angiologie, Universitätsklinikum Münster (UKM), Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Gerhard Diller
- Zentrum für Erwachsene mit angeborenen Herzfehlern, Department für Kardiologie und Angiologie, Universitätsklinikum Münster (UKM), Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Lars Eckardt
- Abteilung für Rhythmologie, Department für Kardiologie und Angiologie, Universitätsklinikum Münster (UKM), Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
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Outcomes of Patients After Arterial Switch Operation: 18 Years of Experience in a Single Medium-Volume Center. Pediatr Cardiol 2015; 36:1657-61. [PMID: 26036352 DOI: 10.1007/s00246-015-1213-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 05/19/2015] [Indexed: 10/23/2022]
Abstract
The objective of this paper was to describe the outcomes in patients submitted to arterial switch operation and to analyze the predictors of in-hospital mortality and further need of re-operation at a single-center institution. Between September 1995 and January 2014, 128 consecutive arterial switch operations were performed. Surgical mortality during this period was analyzed retrospectively, and a follow-up analysis of the survivors was conducted. Surgical era, cardiopulmonary bypass time (p = 0.001), and diagnosis category (p = 0.025) influenced in-hospital mortality. The estimated overall survival for the 91 hospital survivors was 96.8, 96.4, and 96.2 % at 5, 10, and 15 years, respectively. The median follow-up time was 67 months (range 0.71-222 months). Three patients (5 %) presented severe aortic regurgitation. Right ventricle outflow tract systolic gradient by echocardiography was above 60 mmHg in 2 %. Late re-interventions occurred in 12 (13 %) patients with mean time of 64 ± 34 months after the initial procedure. Actuarial freedom from re-interventions at 5, 10, and 15 years was 96.4, 69.7, and 61.9 %, respectively. Arterial switch operation remains the procedure of choice in patients with transposition of great arteries. It can be performed even in middle-volume institutions, leading to the same middle- and long-term outcomes of high-volume institutions. Early high mortality rate may occur due not only to learning curve, but also to cardiopulmonary bypass time and ventricular septal defect closure.
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