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Published on: July 18, 2014
The arterial switch operation in transposition of the great arteries: anatomic indications and contraindications
1Department of Pathology, Children's Hospital, Boston, Massachusetts.
Insights
The arterial switch procedure is the preferred surgical option for D-transposition of the great arteries, offering a low mortality rate. Anatomical differences between the left and right ventricles support the left ventricle as a superior systemic pump, favoring this surgical approach.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Congenital Heart Disease
Background:
- D-transposition of the great arteries (TGA) is a critical congenital heart defect.
- The arterial switch procedure has become the standard surgical treatment for typical D-TGA.
- Understanding ventricular anatomy is crucial for surgical decision-making.
Purpose of the Study:
- To review the anatomical factors favoring the morphologically left ventricle (LV) as a systemic pump over the morphologically right ventricle (RV).
- To support the arterial switch procedure over atrial switch operations in typical D-TGA based on ventricular morphology.
- To outline current anatomic contraindications for the arterial switch operation.
Main Methods:
- Review of anatomical characteristics of the left and right ventricles relevant to pump function.
- Comparison of ventricular structure, coronary circulation, myocardial composition, valvular suitability, papillary muscle arrangement, and conduction systems.
- Analysis of established contraindications for the arterial switch procedure in D-TGA.
Main Results:
- The LV demonstrates superior characteristics for systemic circulation, including a more developed pumping portion, phylogenetic history, dual coronary supply, compact myocardium, and favorable papillary muscle structure.
- The RV has a larger infundibular component primarily for preventing regurgitation and a less advantageous papillary muscle arrangement.
- Specific anatomical anomalies such as unprepared LV, coronary artery anomalies, outflow tract obstructions, valve atresias, and venous anomalies are contraindications to the arterial switch procedure.
Conclusions:
- The anatomical evidence strongly supports the LV as the optimal systemic ventricle, reinforcing the arterial switch procedure as the preferred surgical option for typical D-TGA.
- Careful preoperative assessment for contraindications is essential for successful surgical outcomes.
- Continued research into ventricular function and surgical techniques is vital for improving outcomes in congenital heart disease.
Abstract:
1. The arterial switch procedure is now the operation of choice for typical D-transposition of the great arteries at The Children's Hospital, Boston, USA, the operative mortality rate since 1985 being 3%. 2. There are many anatomic considerations suggesting the morphologically left ventricle (LV) may well be a better systemic pump than the morphologically right ventricle (RV) which, if true, would favor the arterial switch procedure as opposed to an atrial switch operation: (1) The LV consists almost entirely of the sinus or pumping portion, and has only a minimal distal infundibular (conal) component. The RV, by contrast, has a relatively much larger infundibular component, the primary function of which is to prevent regurgitation rather than to pump. (2) Phylogenetically, the LV is the ancient "professional" pump. By contrast, the RV is a comparatively recent modification of the bulbus cordis. (3) The LV is a two-coronary ventricle, whereas the RV is a one-coronary ventricle. (4) The LV has relatively much more compact myocardium (stratum compactum) than does the RV. (5) The mitral valve leaflets are better designed to occlude a circular systemic atrioventricular orifice than are the tricuspid valve leaflets. (6) The papillary muscles of the LV are large, paired, well balanced, and both arise from the same ventricular wall--the LV free wall. By contrast, the papillary muscles of the RV are comparatively small, numerous, unbalanced, and arise from both ventricular septal and free walls. Hence, dilatation of the LV does not pull the LV papillary muscles apart, whereas dilatation of the RV does pull the RV muscles apart, favoring the development or exacerbation of tricuspid regurgitation. (7) The LV has two conduction system radiations, whereas the RV has only one. 3. The current anatomic contraindications to the arterial switch operation in typical D-TGA include the following: (1) an unprepared LV; (2) an aortic intramural left coronary artery arising from the right coronary sinus of Valsalva; (3) pulmonary outflow tract stenosis (with small annulus and subvalvar obstruction) or atresia; (4) aortic outflow tract stenosis (with small annulus and subvalvar obstruction) with tubular hypoplasia of the aortic arch and preductal coarctation; (5) tricuspid or mitral atresia; (6) marked underdevelopment or absence of either the RV sinus or the LV sinus; and; (7) 2 major anomaly of the systemic and/or pulmonary veins, as in the heterotaxy syndrome with asplenia.(ABSTRACT TRUNCATED AT 400 WORDS)
