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

Evaluation of the cyanotic newborn

In this article, the determinants of hypoxemia and cyanosis are analyzed and discussed. The pathophysiology, clinical presentation, diagnostic evaluation, and treatment of major cyanotic forms of congenital heart disease also are reviewed.

Survival after balloon atrial septostomy for complete transposition of great arteries

Mortality before surgery must be taken into account when comparing the surgical mortality of atrial redirection procedures (Mustard's or Senning's operation) and the arterial switch operation for patients with complete transposition. This is because the switch operation is usually performed within the neonatal period or early infancy but Mustard's or Senning's operation usually after 4 months of age. The outcome of balloon atrial septostomy was therefore assessed in all 102 infants with transposition of the great arteries (plus or minus associated anomalies) who underwent the procedure at our hospital in the 10 years from January 1975 to December 1984. We considered the procedure to have been unsuccessful if the patient died from any cause (including other surgical procedures) between the septostomy and subsequent interatrial repair (Mustard's operation) or arterial switch operation. Eighteen patients died, although in only two was this as a direct result of the septostomy. Statistical analysis showed that low weight, presence of a persistent arterial duct, and coarctation of the aorta were significant risk factors. Early survival of infants with transposition of the great arteries has been dramatically improved after the introduction of balloon atrial septostomy. Nevertheless, there is considerable attrition before definitive repair, which must be included in the prediction of overall outcome.

Late results of the Mustard procedure in transposition of the great arteries

Thirty-five patients were discharged from the hospital after a Mustard procedure and have been followed a mean of 4.5 years. Thirty remain in a stable atrial or sinus rhythm, 3 have required hospitalization and medication to control atrial dysrhythmias, 1 is in a junctional rhythm, and 1 requires a pacemaker. In no patient has there been clinical evidence of systemic or pulmonary venous baffle obstruction. Twenty-two patients have had an elective postoperative cardiac catheterization, which has confirmed the absence of baffle obstruction. We attribute the lack of baffle obstruction and the low incidence of atrial dysrhythmias to several technical points in the operation including: direct high cannulation of the superior vena cava, aggressive resection of the atrial septum except in the region of the atrioventricular node, an extremely large pericardial baffle trimmed in the manner of Brom, sharp divergence of the upper and lower limbs of the inferior suture line away from one another and toward the caval orifices once they enter the right atrium, and very superficial endocardial bites of the baffle suture line in the region of the sinoatrial and atrioventricular nodes.

Transcatheter blade atrial septostomy

Six infants, four with transposition of the great arteries and one each with mitral atresia and tricuspid atresia, who did not improve following balloon atrial septostomy are presented. Each patient underwent transcatheter blade atrial septostomy with resultant improvement of interatrial mixing (immediate improvement in three transposition patients and delayed improvement in one) or interatrial obstruction (in the mitral and tricuspid atresia patients). It is suggested that blade atrial septostomy is a safe and effective technique for nonsurgical palliation of congenital heart defects to enlarge a restrictive interatrial communication, especially if balloon atrial septostomy has not been successful.

Factors influencing survival after balloon atrial septostomy for complete transposition of great arteries

Despite balloon atrial septostomy within the first days of life, some patients with complete transposition of the great arteries die before reaching elective definitive surgery in the second six months of life. To discover why, we analysed the fate of 144 patients who had balloon atrial septostomy after 1966, using a modified logrank survival test with multivariate capability. Patients were withdrawn "alive" on reaching definitive surgery. The following largely independent factors were associated with a statistically significant excess mortality: pulmonary hypertension, the presence and size of a ventricular septal defect of persistent ductus arteriosus, relative anaemia, absence of left ventricular outflow tract obstruction, low arterial oxygen saturation, aortic stenosis and coarctation, and balloon atrial septostomy between 1 week and 1 month of life. Those of the above factors which can be determined at balloon atrial septostomy or at routine cardiac catheterisation at 3 months of age were then introduced into discriminant function analysis on survival to 6 months. Hence the probability of any individual patient dying in the first six months was calculated, allowing for these factors. This prediction was correct in 76 per cent of the patients studied. By offering earlier definitive correction to patients thus identified as being at high risk of premature death, it should prove possible to reduce overall mortality in transposition of the great arteries.

Treatment of d-transposition of the great arteries: management of hypoxemia after balloon atrial septostomy

Between 1975 and 1979, a group of 43 patients with d-transposition of the great arteries were diagnosed and underwent Rashkind balloon atrial septostomy at the time of initial catheterization. Thirty-six (88 percent) survived to the time of intraatrial baffle repair, and 31 (72 percent) are long-term survivors, 2 of them now awaiting repair. Palliative operations were performed in nine patients before definitive surgery; four of these patients are long-term survivors. Prostaglandin E1 infusion improved oxygenation and relieved acidosis in four patients. It is concluded that most patients with d-transposition of the great arteries will survive to elective intraatrial baffle repair between 6 and 12 months without surgical palliation in spite of significant hypoxemia. Prostaglandin E1 infusion may be lifesaving and provide sufficient palliation in patients with persistent hypoxemia and acidosis after balloon atrial septostomy.

A new instrument for surgical creation of an atrial septal defect

An instrument for surgical creation of an atrial septal defect (ASD) was designed and tested in puppies weighing an average of 4.7 kg. Oxygen saturations were obtained in both atria, the superior vena cava, and the inferior vena cava before and after septectomy. The instrument has a cutting cylinder introduced into the right atrium (RA) through the right atrial appendage with a second part (base-plate) inserted into the left atrium (LA) just posterior to the interatrial groove. In 21 animals (Group 1), a single hole was created in dogs killed 48 hours later. In 9 animals (Group 2), an attempt was made to create two adjoining holes. In 14 animals (Group 3), a single hole was created and the dogs were allowed to triple their body weight before they were killed. Group 1 dogs demonstrated a 10% increase in average venae cavae--RA oxygen saturation immediately after septectomy and a 9.4 +/- 0.37 mm diameter of the ASD at death; in Group 2, there was a 14% average step-up and a 12.7 +/- 0.6 mm diameter of the ASD; and in Group 3, the diameter of the ASD was 11.5 +/- 0.4 mm, representing a 50% increase in average area with dog growth compared with that of Group 1. After this experience in the production of ASDs in 44 experimental animals, we find that this instrument seems to be reliable, simple, and safe.

Anatomical correction of transposition of great arteries with persistent ductus arteriosus. One year after operation

The postoperative data are described of a boy who had a 'switch' operation for transposition of the great arteries with persistent ductus arteriosus more than a year before. The child is living a normal active life. Electrocardiography, echocardiography, and angiocardiography show persistent abnormality of structure and function of the right ventricle but no evidence of reduced coronary blood flow, coarctation at the suture lines of the great arteries, or aortic regurgitation. Reference is made to an identical case operated upon 2 1/2 years ago.

Prognosis for the newborn with transposition of the great arteries

To determine the prognosis for the newborn with transposition of the great arteries, the clinical course of 112 consecutive neonates with dextrotransposition was reviewed. Patients were managed with balloon atrial septostomy at initial cardiac catheterization, palliative operation if needed in the 1st year of life and Mustard's intraatrial baffle repair. The 1st month of life was the period of greatest risk (8 percent mortality rate). Between balloon septostomy and baffle repair, 14 of 103 patients at risk (14 percent) either died or had a cerebrovascular accident. The mortality rate at baffle repair was 14 percent (10 deaths in 71 patients), and there were 3 late postoperative deaths. Actuarial analysis of the data indicates that with this plan of management, approximately 50 percent of newborns with transposition of the great arteries will survive 5 years with excellent function and an additional 15 to 20 percent will survive with one or more medical handicaps.

Echocardiographic assessment of left ventricular function during the injection of adriamycin

Echocardiography was used to evaluate left ventricular function in 8 children treated with adriamycin for malignant disease. Preejection period (PEP), left ventricular ejection time (LVET) and percent change in left ventricular internal dimension with systole (delta LVID) were measured before, during and immediately after 22 injections of adriamycin as well as 14 injections of other cytotoxic drugs and physiologic saline. No immediate effects on left ventricular function could be discerned. When functional parameters were evaluated longitudinally in patients with relatively higher cumulative doses of adriamycin, percent change in left ventricular internal dimension with systole showed some tendency to decrease, while the other parameters remained essentially unchanged.

Cyanotic congenital heart disease

This review describes the evolving concepts of diagnosis and management of patients with cyanotic congenital heart disease. Early palliative surgical procedures were followed by reparative operations and are now to a large extent replaced by these operations which are designed to relieve the problem. Collaboration of the team of cardiologists, surgeons, radiologists, anesthesiologists and nurses has made the many developments possible. The teamwork has not only widened the scope of what can be accomplished but has also extended the opportunities for beneficial reparative surgery down to the first weeks and months of life. Precise diagnosis and meticulous operative and perioperative care by the team are essential elements of success. Long-term follow-up and regular analyses of results have led to continuing improvements. Although these patients were born to be blue, their color and their outlook have been changed during these last 3 decades to something close to rosy.