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†

Outcomes After Anatomic Versus Physiologic Repair of Congenitally Corrected Transposition of the Great Arteries: A Systematic Review and Meta-Analysis

Surgical treatment for congenitally corrected transposition of the great arteries is widely debated, with both physiologic repair and anatomic repair holding advantages and disadvantages. This meta-analysis, which includes 44 total studies consisting of 1857 patients, compares mortality at different time points (operative, in-hospital, and post-discharge), reoperation rates, and postoperative ventricular dysfunction between these two categories of procedures. Although anatomic and physiologic repair had similar operative and in-hospital mortality, anatomic repair patients had significantly less post-discharge mortality (6.1% vs 9.7%; P = .006), lower reoperation rates (17.9% vs 20.6%; P < .001), and less postoperative ventricular dysfunction (16% vs 43%; P < .001). When anatomic repair patients were subdivided into those who had atrial and arterial switch versus those who had atrial switch with Rastelli, the double switch group had significantly lower in-hospital mortality (4.3% vs 7.6%; P = .026) and reoperation rates (15.6% vs 25.9%; P < .001). The results of this meta-analysis suggest a protective benefit of favoring anatomic repair over physiologic repair.

Congenitally corrected transposition with left ventricular outflow obstruction and cardiac malposition: One-and-a-half ventricular repair vs. Fontan pathway?

Objectives

This study was to assess the mid-term results of the one-and-a-half ventricular repair (hemi-Mustard and bidirectional Glenn procedures combined with the Rastelli procedure) and Fontan pathway for correcting congenitally corrected transposition of great artery (ccTGA) patients with left ventricular outflow tract obstruction (LVOTO) and cardiac malposition.

Methods

In this retrospective study, 74 consecutive ccTGA with LVOTO and cardiac malposition underwent the one-and-a-half ventricular repair (group A; 33 cases) and Fontan operation (group B; 41 cases) between October 2011 and March 2018. The Median follow-up time was 49 (20–84) and 42 (7–85) months in groups A and B, respectively. To estimate excise tolerance the 6-min walk test (MWT) was performed.

Results

No in-hospital death. Compared with group A, group B have significantly less CPB, mechanical ventilation time, and intensive care unit stay, but prolonged pleural effusions developed more frequently in Group B. The survival probability was 90.2% (95% CI, 80.2–100%) and 97.2% (95% CI, 92–100%) at 7 years (p = 0.300) in group A and B. The probability of freedom from re-intervention were 80.6% (95% CI, 66.5–97.6%) and 97.2% (95% CI, 92–100%) at 7 years (p = 0.110). Longitudinal repeated measured echo data at every follow-up time shows that group A has more systemic ventricular EF% (p < 0.001) and less moderate systemic ventricular valve regurgitation (p < 0.001) compared with group B. Estimated by 6 MWT, group A has better outcomes for 6-min walk distance.

Conclusions

For correction of ccTGA with LVOTO and cardiac malposition, the one-and-a-half ventricular repair had superior midterm heart function and excise tolerance.

One and One-Half Ventricle Repair: Role for Restricting Antegrade Pulmonary Blood Flow

BACKGROUND

In patients with hypoplastic subpulmonary ventricles, the one and one-half ventricle (1.5V) repair is an alternative to the Fontan procedure. However, in 1.5V-treated patients with pulsatile pulmonary blood flow, superior vena cava (SVC) hypertension or right atrial hypertension may develop. This study aimed to (1) describe patient outcomes after 1.5V repair and (2) determine whether pulmonary artery septation at 1.5V repair confers a lower risk of SVC or right atrial hypertension.

METHODS

This study retrospectively reviewed patients who underwent a 1.5V repair between 1989 and 2020. The primary outcome was transplant-free survival. Secondary outcomes were postoperative SVC hypertension (defined by mean Glenn pressures greater than 17 mm Hg, SVC flow reversal or pulsatility, venovenous collateral vessels, or SVC syndrome) and right atrial hypertension (defined as mean right atrial pressures greater than 10 mm Hg with inferior vena cava and hepatic vein dilation or flow reversal).

RESULTS

A total of 74 patients underwent 1.5V repair at a median age of 29.6 months (interquartile range, 8.9 to 45.5 months). Median follow-up time was 39.9 months (interquartile range, 11.4 to 178.1 months). Transplant-free survival at 10 years was 92.4%. Among survivors, 12% (8 of 69) had right atrial hypertension and 39% (27 of 69) had SVC hypertension on follow-up. Survivors with unseptated pulmonary arteries had a greater risk of SVC hypertension compared with patients with septated pulmonary arteries (44% vs 10%; P = .04). No difference was found in right atrial hypertension between the 2 groups.

CONCLUSIONS

Patients with 1.5V repair avoid Fontan-associated complications with favorable transplant-free survival. However, SVC hypertension remains a significant long-term complication. Pulmonary artery septation at 1.5V repair may reduce the risk of SVC hypertension.

Congenitally Corrected Transposition of the Great Arteries: Mid-term Outcomes of Different Surgical Strategies

BACKGROUND

Optimal management for congenitally corrected transposition of the great arteries (ccTGA) is controversial. We applied different surgical strategies based on individual variations in our single-centered practice over 10 years, aming to describe the mid-term results.

METHODS

From January 2008 to June 2021, 90 patients with ccTGA were reviewed and grouped by three different surgical strategies: 41 cases with biventricular correction as biventricular group, 11 cases with 1.5 ventricular correction as 1.5 ventricular group, and 38 cases with Fontan palliation as univentricular group. The mean age at primary surgery was 41.4 ± 22.7 months. Patients were followed for mortality, complications, reoperation, cardiac function, and valve status.

RESULTS

The median follow-up period was 5.1 years (range, 1.5-12.5 years). The overall 10-year survival and freedom from reoperation rate was 86.7 and 82.4%, respectively. There were 3 early deaths and 3 mid-term deaths in the biventricular group, while 2 early deaths and 1 mid-term deaths were reported in the univentricular group. Although 1.5 ventricular group presented no death and the fewest complications, we still found similar mortality (p = 0.340) and morbidity (p = 0.670) among the three groups. The bypass time, aortic-clamp time, and ICU stay length were the longest in the biventricular group, followed by the 1.5 ventricular group (p < 0.001). However, in mid-term follow-up, biventricular and 1.5 ventricular groups both showed excellent cardiac function and obvious improvement of tricuspid regurgitation (p = 0.008 and p = 0.051, respectively). Fontan palliation provided acceptable mid-term outcomes as well, despite a lower ejection fraction.

CONCLUSION

Satisfactory mid-term outcomes could be achieved for highly selected ccTGA patients using the whole spectrum of surgical techniques. Moreover, 1.5 ventricular correction, as a new emerging technique in recent years, might hold great promise in future practice.

Systematic review and meta-analysis of outcomes of anatomic repair in congenitally corrected transposition of great arteries

BACKGROUND

Treatment of congenitally corrected transposition of great arteries (cc-TGA) with anatomic repair strategy has been considered superior due to restoration of the morphologic left ventricle in the systemic circulation. However, data on long term outcomes are limited to single center reports and include small sample sizes.

AIM

To perform a systematic review and meta-analysis for observational studies reporting outcomes on anatomic repair for cc-TGA.

METHODS

MEDLINE and Scopus databases were queried using predefined criteria for reports published till December 31, 2017. Studies reporting anatomic repair of minimum 5 cc-TGA patients with at least a 2 year follow up were included. Meta-analysis was performed using Comprehensive meta-analysis v3.0 software.

RESULTS

Eight hundred and ninety-five patients underwent anatomic repair with a pooled follow-up of 5457.2 patient-years (PY). Pooled estimate for operative mortality was 8.3% [95% confidence interval (CI): 6.0%-11.4%]. 0.2% (CI: 0.1%-0.4%) patients required mechanical circulatory support postoperatively and 1.7% (CI: 1.1%-2.4%) developed post-operative atrioventricular block requiring a pacemaker. Patients surviving initial surgery had a transplant free survival of 92.5% (CI: 89.5%-95.4%) per 100 PY and a low rate of need for pacemaker (0.3/100 PY; CI: 0.1-0.4). 84.7% patients (CI: 79.6%-89.9%) were found to be in New York Heart Association (NYHA) functional class I or II after 100 PY follow up. Total re-intervention rate was 5.3 per 100 PY (CI: 3.8-6.8).

CONCLUSION

Operative mortality with anatomic repair strategy for cc-TGA is high. Despite that, transplant free survival after anatomic repair for cc-TGA patients is highly favorable. Majority of patients maintain NYHA I/II functional class. However, monitoring for burden of re-interventions specific for operation type is very essential.

Surgical Outcomes of Anatomical Repair for Congenitally Corrected Transposed Great Arteries

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.