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Complexity stratification of the arterial switch operation: a second learning curve
1Pediatric Cardiac Surgery, Montefiore Children's Hospital, New York, New York 10467, USA. flacour@montefiore.org
Cardiology in the Young
|January 22, 2013
Summary
The arterial switch operation is safer, but complexity factors like coronary patterns still challenge surgeons. Long-term outcomes now focus on morbidity and reoperations, not just mortality.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Congenital Heart Disease Surgery
Background:
- The arterial switch operation (ASO) has evolved into a safer procedure over two decades.
- Peri-operative mortality for ASO is now very low, shifting focus to morbidity and long-term outcomes.
- Certain anatomical and coronary variations continue to present significant surgical challenges.
Purpose of the Study:
- To analyze the evolving complexity of the arterial switch operation.
- To identify factors contributing to ASO complexity and their impact on outcomes.
- To discuss the current assessment of ASO outcomes beyond peri-operative mortality.
Main Methods:
- Review of anatomical features and their classification regarding ASO complexity.
- Application of the Aristotle comprehensive score and a new morbidity score for outcome stratification.
- Analysis of coronary artery patterns and other complex anatomical associations.
Main Results:
- Many previously complex anatomical features are now manageable.
- Approximately 20% of ASO cases remain complex due to associated factors, particularly coronary patterns.
- Complex coronary patterns include double-looping, anterior-looping, intramural courses, and single ostia.
Conclusions:
- While ASO is safer, complex cases require specialized expertise and present a 'second learning curve'.
- Long-term surveillance for rare coronary failures and aortic root dilation is crucial for complex ASO patients.
- The introduction of morbidity scores aids in more accurate outcome assessment in low-mortality ASO procedures.
