Surgical repair of complete transposition of the great arteries with pulmonary stenosis

Long-term surgical results of transposition of the great arteries with left ventricular outflow tract obstruction

Objective

The objective of this study was to evaluate the long-term surgical results of transposition of the great arteries with left ventricular outflow tract obstruction.

Methods

We conducted a retrospective study of patients with transposition of the great arteries or double outlet right ventricle with left ventricular outflow tract obstruction undergoing biventricular repair between 1980 and 2017.

Results

One hundred and eleven patients were enrolled and classified into five groups: atrial switch (n = 20), arterial switch (n = 12), Nikaidoh (n = 7), Rastelli (n = 48), and REV operation groups (n = 24). Early mortality was highest in Nikaidoh group (29%). Median follow-up was 18.2 years. Long-term survival was by far lowest in Nikaidoh group and comparable among the other 4 groups. Freedom from reoperation at 20 years was lowest in Rastelli group (32.1%) due to right ventricular outflow tract-related reoperations. While having no recurrence of left ventricular outflow tract obstruction, the arterial switch operation group had a high proportion of substantial neo-aortic regurgitation (29%).

Conclusions

The long-term survival was satisfactory regardless of the surgical technique except Nikaidoh group. The surgical option for transposition of the great arteries with left ventricular outflow tract obstruction should be selected based on the features of the respective procedures.

Aortic Root Translocation Plus Arterial Switch for Transposition of the Great Arteries With Left Ventricular Outflow Tract Obstruction

OBJECTIVES

The goal of our study was to report our intermediate-term results with aortic root translocation plus arterial switch for d-transposition of the great arteries with left ventricular outflow tract obstruction.

BACKGROUND

A d-transposition of the great arteries with left ventricular outflow tract obstruction represents a difficult surgical problem. The Rastelli procedure is the usual approach to this condition. However, recurrent left ventricular outflow tract obstruction and early conduit obstruction as well as arrhythmias and troublesome late mortality are significant limitations.

METHODS

From 1993 to 2005, 11 children (8 male, 3 female) ages 1 month to 11 years (median age 7 months) have undergone aortic root autograft translocation plus arterial switch to correct d-transposition of the great arteries with left ventricular outflow tract obstruction. The native aortic root was excised from the right ventricle infundibulum and inserted into the left ventricular outflow, enlarging the outflow tract by resecting the outlet septum and an appropriate-size ventricular septal defect patch. After coronary artery reimplantation, right ventricular outflow reconstruction was achieved with a homograft.

RESULTS

There were no early or late deaths. With a median follow-up of 59 months (range 2 to 137 months), 5 patients required 6 conduit replacement procedures at a median time of 53 months. Two patients required an implantable defibrillator for ventricular arrhythmias. None of the patients have developed left ventricular outflow tract obstruction.

CONCLUSIONS

Aortic root autograft plus arterial switch procedure is a good option for the surgical management of infants and children with d-transposition of the great arteries and left ventricular outflow tract obstruction and results in a more anatomic repair compared with Rastelli operation. Intermediate-term results indicate good relief of left ventricular outflow tract obstruction and need for conduit replacement compares favorably with the Rastelli procedure for this lesion.

Twenty-five-year experience with rastelli repair for transposition of the great arteries

OBJECTIVE

Our purpose was to describe the outcome of the Rastelli repair in D -transposition of the great arteries and to determine the risk factors associated with unfavorable events.

METHODS

From March 1973 to April 1998, 101 patients with D -transposition of the great arteries and ventricular septal defect underwent a Rastelli type of repair. Median age and weight were 3.1 years (10th to 90th percentiles 0.3-9.9 years) and 12.8 kg (5.9-28.2). Pulmonary stenosis was present in 73 patients and pulmonary atresia in 18; 10 patients had no left ventricular outflow tract obstruction.

RESULTS

There were 7 early deaths (7%) and no operative deaths in the last 7 years of the study. Risk factors for early death, by univariable analysis, included straddling tricuspid valve (P =.04) and longer aortic crossclamping times (P =.04). At a median follow-up of 8.5 years, there were 17 late deaths and 1 patient had undergone heart transplantation. Forty-four patients had reoperations for conduit stenosis, 11 for left ventricular outflow tract obstruction, and 28 had interventional catheterization to relieve conduit stenosis. Nine patients had late arrhythmias, and there were 5 sudden deaths. Overall freedom from death or transplantation (Kaplan-Meier) was 82%, 80%, 68%, and 52% at 5, 10, 15, and 20 years, respectively. Freedom from death or reintervention (catheterization or surgical treatment) was 53%, 24%, and 21% at 5, 10, and 15 years of follow-up, respectively.

CONCLUSIONS

The Rastelli repair can be performed with low early mortality. However, substantial late morbidity and mortality are associated with conduit obstruction, left ventricular outflow tract obstruction, and arrhythmia.

Arterial switch in hearts with left ventricular outflow and pulmonary valve abnormalities

BACKGROUND

Pulmonary valve and left ventricular outflow tract abnormalities (LVOT) may not be absolute contraindications to arterial switch operation (ASO).

METHODS

In this study we analyze long-term outcome for 26 such transposition patients (6.3% of our ASO cohort). Median age and weight were 69 days (7 to 3,631 days) and 4.5 kg (2.6 to 34 kg). Pulmonary valve abnormalities included bicuspid valve (n = 4) and dysplastic valve (n = 5). The LVOT abnormalities (n = 17) included accessory atrioventricular valve/endocardial cushion tissue, fibromuscular ring, anomalous muscle bands, and septal malalignment. Patients with dynamic LVOT obstruction were excluded. The median preoperative left ventricular to pulmonary artery peak systolic pressure gradient was 30 mm (0 to 93 mm), or 50 mm (16 to 93 mm) if patients with isolated valve abnormalities are excluded. The ASO was performed according to our standard technique with or without LVOT resection or pulmonary valvotomy as required.

RESULTS

There were two perioperative deaths (7.7%; 95% confidence interval, 0.9% to 25%), and no late deaths during 1,934 patient-months of follow-up time. Actuarial freedom from reoperation for neoaortic valve or LVOT problems is 87% (+/- 7) at 130 months, representing two reoperations. One was performed for neoaortic insufficiency plus LVOT obstruction, and the other for isolated LVOT obstruction. One patient currently has significant neoaortic insufficiency, and median gradient at last follow-up is 0 mm Hg (range, 0 to 35 mm Hg).

CONCLUSIONS

The ASO can be performed in selected patients with transposition of the great arteries and with LVOT abnormalities with early and late survival and functional status similar to that of matched patients with normal pulmonary valves and LVOT (p > 0.05), but with a greater hazard for reoperation (p < 0.05). Selection for ASO should be based on anatomic criteria rather than left ventricular to pulmonary artery gradient alone, to avoid assigning these patients with transposition of the great arteries to treatment strategies less satisfactory than ASO.

Accuracy of prospective two-dimensional echocardiographic evaluation of left ventricular outflow tract in complete transposition of the great arteries

Thirty-two consecutive infants with transposition of the great arteries (TGA) and ventricular septal defect underwent subxiphoid 2-dimensional echocardiography (2-D echo). Two independent observers prospectively evaluated each echocardiogram for the presence or absence of left ventricular (LV) outflow tract obstruction, whether outflow obstruction was dynamic or fixed, or both, and the precise anatomic type of fixed obstruction. Compared with the LV-to-pulmonary artery gradient determined at cardiac catheterization, 2-D echo yielded low false-negative (7 to 13%) and false-positive (0 to 6%) rates for diagnosing the presence or absence of LV outflow tract obstruction. Moreover, the false-negative cases were only minor errors, because the measured LV-pulmonary artery gradients proved to be less than 25 mm Hg. Compared with the long-axial oblique LV angiogram, 2-D echo yielded no false-negative results in detection of outflow tract obstruction, which was at least partly fixed. Compared with autopsy/surgical observation, 2-D echo made no significant errors in delineating the exact anatomic type of fixed obstruction. The diagnostic accuracy of 2-D echo in detecting and characterizing LV outflow tract obstruction limits the need for "routine" cardiac catheterization before repair in infants with TGA and intact ventricular septum. Furthermore, because certain types of fixed LV outflow tract obstruction are difficult for the surgeon to visualize and alleviate, precise knowledge of the anatomic type of fixed obstruction influences the choice among Rastelli, intraatrial baffle and arterial switch procedures in patients with TGA and ventricular septal defect.

Rastelli procedure for transposition of the great arteries, ventricular septal defect, and left ventricular outflow tract obstruction. Early and late results in 41 patients (1971 to 1978)

Forty-one children with transposition of the great arteries, ventricular septal defect, and left ventricular outflow tract obstruction underwent a Rastelli operation between 1971 and 1978. A homograft valve preserved in an antibiotic solution and extended with A dacron tube was the conduit of choice. Alternatively, conduits with porcine heterografts or valves constructed from calf pericardium were used. They were positioned to the left of the aorta whenever possible. The intraventricular tunnel from the left ventricle to the aorta was constructed from Dacron velour. There were four early and seven late deaths. The last 13 consecutive patients have survived. Early deaths were related to unfavourable anatomy, conduit compression, and sepsis. Residual ventricular septal defects and postoperative infection were the main factors contributing to the late deaths.

Transposition of the great arteries with ventricular septal defect and pulmonary stenosis

A postmortem investigation was carried out of 19 heart specimens with transposition of the great arteries, ventricular septal defect, and congenital subvalvular pulmonary stenosis. Certain types of obstruction appeared to be closely related to other features of the hearts. In cases with malalignment of the infundibular septum, the obstruction was caused by this septum and the anterolateral muscle bundle of the left ventricle. If the infundibular septum was deviated considerably to the left, the pulmonary stenosis was usually severe because the infundibular septum and anterolateral muscle bundle were joined. This junction resulted in a relatively posterior position of the pulmonary orifice in the left ventricle. A less extreme deviation of the infundibular septum resulted in an obstruction by this septum and by the anterolateral muscle bundle, situated at the right and the left sides of the pulmonary orifice respectively. In some cases of paratricuspid ventricular septal defect an anomalously attached and cleft anterior leaflet of the mitral valve was found. This, together with a leftward deviation of the anterior left ventricular part of the ventricular septum, caused the obstruction.

Quanitification of left heart volume and systolic output in transposition of the great arteries

Left heart volume and output were calculated by using cineangiocardiograms from 64 studies in 44 patients with transposition of the great arteries (TGA). The majority of patients who had an intact ventricular septum and were less than 6 months of age showed normal end-diastolic volumes (LVEDV) and systolic output (LVSO), while patients in this hemodynamic group more than 6 months of age had elevated volumes and outputs. The presence of a patent ductus arteriosus (PDA) was associated with an increase in LVEDV and LVSO. Patients with a ventricular septal defect (VSD) and no pulmonary stenosis (PS) had increased volumes and outputs with the average values for LVEDV and LVSO significantly greater for the VSD group than for the intact-septum group. Patients with a VSD and PS showed normal values for LVEDV and LVSO. The ejection fraction was normal in all patients. Left atrial maximal volume (LAMax) was normal in the majority of patients with an intact ventricular septum and no PDA, but was increased in patients with a VSD and no PS. The values for LVEDV, LVSO, and LAMax showed little or no change following balloon atrial septostomy in the majority of patients. Four patients studied before and after corrective surgery demonstrated decreases in LVEDV and LVSO to normal values following successful interatrial venous transposition. Left heart volume variables derived from cineangiocardiograms can aid considerably in hemodynamic evaluation of patients and in estimation of pulmonary blood flow.

Physiologic correction of transposition of the great arteries. Indications for and results of operation in 32 patients

The total management of a group of 32 patients with transposition of the great arteries (TGA) is reported. All but one had required creation of an atrial septal defect in infancy. Eighteen patients had no associated cardiac defects, and physiologic correction was performed between 8 months and 9½ years of age. The only death in this group occurred 9 months after operation. Eight of nine patients with TGA and an associated ventricular septal defect (VSD) had required pulmonary artery banding in infancy. Physiologic correction was performed between 2¼ and 6 years of age. Three of these patients died during the postoperative period, and one died 9 months after operation. Two patients had TGA and pulmonary stenosis (PS). Physiologic correction was performed at 2 1/3 and 3¾ years of age. Both patients have done well. Three patients had TGA, VSD, and PS. Total correction was performed between 2 1/3 and 3½ years of age. All three patients died in the postoperative period. The over-all operative mortality was 19%.

Our present plan of management has evolved from the experience reported above. All infants with TGA have balloon atrioseptostomy. If no VSD is present, physiologic correction is performed between 1 and 2 years of age. Patients with TGA and a VSD are catheterized at 8 months of age, and pulmonary banding is performed if pulmonary artery hypertension is present. Physiologic correction is performed at about 4 years of age. Patients with TGA, VSD, and PS may require systemicpulmonary artery anastomosis. Correction at 5 years of age with the use of a homograft from the right ventricle to the pulmonary artery, as described by Rastelli and his associates, is recommended because of the poor results obtained with an intra-atrial baffle in this group.

Surgical treatment of complex forms of transposition

In spite of the new knowledge developed in recent years surgical treatment for patients with complex forms of transposition of the great arteries remains suboptimal. This is because of the morbidity and mortality that have followed many of the corrective operations, and these are related chiefly to the basic malformation and its secondary effects. This review summarizes information about surgical treatment of such patients and comments upon some of the implications of this experience.