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[Arterial switch operation in older infants with severe pulmonary hypertension]
Qing-yu Wu1, Xiang-dong Shen, Xiu-bin Yang
1Department of Cardiovascular Surgery, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China.
Insights
The arterial switch operation is effective for treating transposition of great arteries (TGA) in infants over one month old, especially those with severe pulmonary hypertension. This surgical repair shows promising results for complex congenital heart conditions.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Congenital Heart Disease
Context:
- Transposition of great arteries (TGA) and Taussing-Bing anomaly are critical congenital heart defects requiring surgical intervention.
- The arterial switch operation (ASO) is a complex procedure aiming to correct these anomalies.
- Evaluating the efficacy of ASO in a diverse pediatric population is crucial for refining surgical techniques and improving outcomes.
Purpose:
- To assess the clinical effectiveness and outcomes of the arterial switch operation in patients with TGA and related anomalies.
- To analyze the impact of ASO on severe pulmonary hypertension in affected children.
- To report on short-term and medium-term survival and complication rates following ASO.
Summary:
- Thirty pediatric patients underwent ASO for TGA and Taussing-Bing anomaly, with various associated defects including ventricular septal defects (VSD) and patent ductus arteriosus (PDA).
- The study reported a hospital mortality rate of 6.7%, with no deaths directly linked to coronary artery issues. Significant reduction in pulmonary hypertension was observed post-operatively.
- Twenty-eight patients were discharged successfully, with follow-up demonstrating good survival rates and absence of late complications.
Impact:
- The arterial switch procedure demonstrates a satisfactory effect on TGA, particularly in patients older than one month with severe pulmonary hypertension.
- This study contributes valuable data on the safety and efficacy of ASO in a complex pediatric cardiac surgery cohort.
- Findings support ASO as a viable and effective treatment for selected infants and children with TGA and associated hemodynamics.
Objective:
To investigate the clinical efficacy of arterial swith operation on transposition of great artery (TGA) and Tausing-Bing anomaly.
Methods:
Between June 2000 and December 2002, 30 consecutive patients, aged 3 days to 6 years (mean, 9.4 +/- 15 months) with the mean body weight was 6.1 kg +/- 2.7 kg, underwent arterial switch operation. Among the 30 patients 7 suffered from TGA with intact ventricular septum, 19 from TGA with ventricular septal defect (VSD), 3 from Taussing-Bing anomaly, and 1 from corrected TGA; 12 were complicated by atrial septal defect (ASD) and 18 complicated by patent ductus arteriosus (PDA); 23 had severe pulmonary hypertension; 2 had left ventricular outlet stenosis. Coronary type A distribution was recognized in 26 cases, type D in 4, and one of them having the origin of the left descending artery tunneled in the aortic wall. The operation was performed under general anesthesia and extracorporeal circulation with low temperature and low volume blood flow. Prostaglandin 1 was administered pre-operatively in 3 patients, one of which underwent balloon atrial septostomy and one underwent pulmonary banding and systemic to pulmonary shunt pre-operatively. The aorta and pulmonary artery were transected above the valvular commisures, the coronary ostia with all the adjacent sinus of Valsalva were excised and re-implanted to the proximal neo-aorta, and then aortic anastomosis was completed. The proximal neo-pulmonary trunk was reconstructed with a large autologous native pericardium as a posterior patch. The pulmonary anastomosis was completed after the aortic cross-clamp was released. The VSD was repaired through the atrium or proximal aorta with dacron patches.
Results:
Two patients died with a hospital mortality rate of 6.7%. No death was directly related to any coronary artery problem. One 5 day-old neonate with TGA and an intact septum having refractory hypotension, hypoxemia, and acidosis pre-operatively underwent a smooth emergency operation. The patient had a refractory low cardiac output syndrome post-operatively and died 20 hours after the operation. Another patient with chylothorax died of allergy from iodophor 22 days postoperatively. The pulmonary pressure decreases significantly in 22 patients who had severe pulmonary hypertension preoperatively with the mean pressure 46.7 mm Hg preoperatively and 31.3 mm Hg postoperatively. 28 patients were discharged from hospital uneventfully. Follow-up of 1 to 31 months showed survival with no late complications and death.
Conclusion:
The arterial switch procedure has a satisfying effect on TGA for patients older than 1 month with severe pulmonary hypertension.