Outcomes of Patients After Arterial Switch Operation: 18 Years of Experience in a Single Medium-Volume Center

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.

Recurrent neoaortic insufficiency after the switch back operation with previous repair of transposition with ventricular septal defect and aortic arch hypoplasia

Neoaortic insufficiency is not uncommon after the arterial switch operation (ASO) for d-Transposition, yet surgery is rarely required. In a patient with worsening neoaortic regurgitation post-arterial switch and ventricular septal defect (VSD) closure, we performed a successful "switch back" operation with documented aortic valve competence on discharge echocardiography. However, recurrent severe aortic insufficiency required valve replacement, and histopathology of the excised valve indicated abnormal leaflet/vascular wall structure. We question whether the switch back operation is a viable option for neoaortic insufficiency after an ASO in patients with previous d-Transposition and VSD, when the native pulmonary valve may have structural deficiencies.