Complete transposition of the great vessels in infancy with reference to palliative surgery

Interruption of the aortic arch with complete transposition of the great arteries. Clinical and angiocardiographic diagnosis at the age of one day

The association of complete transportation of the great arteries and complete interruption of the aortic arch is very rare. This combined lesion was diagnosed clinically in a 1-day-old infant in whom it caused cyanosis of the upper half of the body. The diagnosis was confirmed angiocardiographically. We believe this is the youngest patient in whom this diagnosis was made in vivo.

Atrial defect size after Blalock-Hanlon atrioseptectomy

In transposition of the great arteries, a Blalock-Hanlon closed atrial septectomy is performed to improve intracardiac mixing at the atrial level. Although the Blalock-Hanlon septectomy is a common surgical procedure in cyanotic congenital heart disease, it has not been adequately assessed pathologically. In 14 heart specimens from patients (aged 3 days to 19 years) with transposition of the great arteries and Blalock-Hanlon septectomy, the margins of the septectomy, fossa ovalis and atrial septum were identified. The total area of the septum and its defects was calculated using planimetry. The ratio of defect size to atrial septal area was expressed as percent communication, which ranged from 5 to 39 (mean 18) percent in eight specimens with intact limbus of the foramen ovale and 26 to 57 (mean 42) percent in six specimens in which the limbus had been excised. The finding that specimens in which the Blalock-Hanlon defect extended into the fossa ovalis had the largest total communication emphasizes that to obtain optimal bidirectional atrial mixing the surgeon should extend the Blalock-Hanlon procedure across the limbus into the foramen ovale.

Transposition of the great arteries. Results of treatment with early palliation and late intracardiac repair

A longitudinal study was made of 62 patients with dextro-transposition of the great arteries. The patients were managed with balloon atrial septostomy (BAS), palliative surgery if any operation was needed in the first year of life, and Mustard intra-atrial baffle repair after one year of age. Of the 47 patients with intact ventricular septum (IVS) treated in this manner, 41 (87 percent) were living at three months of age, 36 (77 percent) at one year, and 31 (66 percent) at two years of age. Survival rates were lower at each age for patients with associated ventricular septal defect (VSD). In relation to therapeutic interventions in the 62 patients, there were six medical deaths within one week of BAS, three deaths during palliative operations, and eight deaths associated with 31 Mustard procedures. Three patients with IVS and five with VSD developed pulmonary vascular obstructive disease, and two patients suffered strokes. In view of the relatively low mortality rate after the neonatal period and our good results with palliative surgery, we continue to defer the Mustard procedure to the second year of life. This is in contrast to the policy of some centers which now advocate elective intracardiac repair in the first year of life.

Balloon atrial septostomy in complete transposition of great arteries in infancy

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Transposition of the great arteries. Results of palliation by balloon atrioseptostomy in thirty-one infants

A nonsurgical method of creating atrial septal defects using a balloon catheter has been reviewed, and important procedural and technical details have been presented. The results of balloon atrioseptostomy in 31 infants with transposition of the great arteries have been reported and compared with those from the surgical creation of atrial septal defects. All 31 patients survived balloon atrioseptostomy without complications; 26 of them (84%) had effective immediate palliation, and 22 (71%) are long-term survivors. These results demonstrate that effective palliation of transposition of the great arteries, with or without associated ventricular septal defect, can be provided rapidly and safely by balloon atrioseptostomy. All patients with transposition and a large ventricular septal defect should have balloon atrioseptostomy and may also need pulmonary artery banding. For some of these patients banding may be postponed safely for many months, may occur spontaneously, or may be avoided completely.

Atrioseptostomy by the balloon catheter technique requires neither sedation nor general anesthesia, and obviates the need for thoracotomy and cardiotomy. The rapidity with which it can be performed makes it particularly advantageous for the desperately hypoxic newborn with transposition of the great arteries who may be considered too sick to withstand major surgery.

Disturbances in atrial rhythm and conduction following the surgical creation of an atrial septal defect by the Blalock-Hanlon technique

Disturbances in atrial conduction or rhythm, or both, were found in 16 of 27 patients undergoing the surgical creation of an atrial septal defect by the Blalock-Hanlon technique. These included P-wave aberrations of intra-atrial block and ectopic atrial rhythm, A-V rhythm, A-V dissociation, sinus bradycardia, atrial flutter, escape-capture bigeminy, and atrial premature beats. Some of these were transient and occurred within 2 weeks after surgery. It seems likely that tissue trauma engendered by the clamp and resection of the atrial septum with possible injury to the internodal conducting pathways may be the genesis of these early postoperative disturbances. Of the eight cases with transient disturbances, six occurred in this period. Later changes, such as intra-atrial block, sinus bradycardia, and atrial flutter, may be attributed to changes in atrial size secondary to the postoperative pathophysiology. Digitalis intoxication and congestive heart failure cannot be excluded as contributory factors in either the early or the late disturbances. It was not possible to correlate the incidence and nature of these disturbances with morbidity and mortality. In such severely ill, cyanotic infants, irregularities, however slight, may have altered cardiac function significantly and contributed to their deaths.