Related Experiment Video
Updated: Nov 7, 2025
Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement
Published on: December 11, 2017
Long-term outcome after the arterial switch operation: 43 years of experience
Roel L F van der Palen1, Nico A Blom1,2, Irene M Kuipers2
1Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands.
Insights
Arterial switch operation (ASO) for transposition of the great arteries (TGA) shows good long-term outcomes. However, reoperations are common, particularly for right ventricular outflow tract obstruction and neoaortic valve issues, with specific TGA subtypes and aortic arch repair increasing risk.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Congenital Heart Disease
Background:
- Transposition of the great arteries (TGA) is a critical congenital heart defect.
- The arterial switch operation (ASO) is a primary surgical repair for TGA.
- Long-term outcomes and risk factors for reintervention after ASO require ongoing evaluation.
Purpose of the Study:
- To evaluate the 43-year experience with arterial switch operation (ASO) for transposition of the great arteries (TGA).
- To analyze cardiac outcomes including mortality, reoperations, and interventions.
- To identify risk factors associated with reoperation and catheter interventions post-ASO.
Main Methods:
- Retrospective analysis of 490 patients undergoing ASO for TGA between 1977 and 2020.
- Kaplan-Meier method for estimating reoperation and catheter intervention rates.
- Multivariate Cox regression analysis to identify risk factors for reoperation and intervention.
Main Results:
- Hospital mortality was 8.8% and late death was 2.9%.
- Reoperations were performed in 18% of patients, most commonly for right ventricular outflow tract obstruction (60.2%) and neoaortic valve regurgitation (18.1%).
- Risk factors for reoperation included TGA subtype, associated aortic arch repair, and non-usual coronary anatomy; aortic arch repair was also a risk factor for catheter intervention.
Conclusions:
- Patients undergoing ASO for TGA generally experience good long-term outcomes.
- Reoperations and interventions remain necessary, with increasing need for neoaortic valve and root surgery anticipated.
- Understanding risk factors aids in optimizing surgical strategies and long-term management.
Objectives:
The objective of this study was to assess our 43-year experience with arterial switch operation (ASO) for transposition of the great arteries (TGA) by analysing cardiac outcome measures (hospital and late mortality, reoperations and catheter interventions, significant coronary artery obstruction) and to identify risk factors for reoperation and catheter interventions.
Methods:
A total of 490 patients who underwent ASO for TGA from 1977 to 2020 were included in this retrospective, single-centre study. Data on reoperation and catheter intervention of hospital survivors were estimated by the Kaplan-Meier method and compared using a long-rank test. Risk factors for reoperation and/or catheter intervention were assessed by multivariate Cox regression analysis.
Results:
Hospital mortality occurred in 43 patients (8.8%), late death in 12 patients (2.9%) and 43 patients were lost to follow-up. Median follow-up time of 413 hospital survivors was 15.6 (interquartile range 7.0-22.4) years. Reoperations were performed in 83 patients (117 reoperations). Neoaortic valve regurgitation with root dilatation was the second most common indication for reoperation (15/83 patients, 18.1%) after right ventricular outflow tract obstruction (50/83 patients, 60.2%). Risk factors for any reoperation on multivariable analysis were: TGA morphological subtype [TGA with ventricular septal defect: hazard ratio (HR) = 1.99, 95% confidence interval (CI) 1.18-3.36; P = 0.010 and Taussig-Bing: HR = 2.17, 95% CI 1.02-4.64; P = 0.045], aortic arch repair associated with ASO (HR = 3.03, 95% CI 1.62-5.69; P = 0.001) and a non-usual coronary artery anatomy (HR = 2.41, 95% CI 1.45-4.00; P = 0.001). One hundred and one catheter interventions were performed in 54 patients, usually for relief of supravalvular pulmonary stenosis (44/54 patients, 81.5%) or arch obstruction (10/54 patients, 18.5%). Main risk factor for catheter intervention on multivariable analysis was aortic arch repair associated with ASO (HR = 2.95, 95% CI 1.37-6.36; P = 0.006). Significant coronary artery stenosis was relatively uncommon (9/413 patients, 2.2%) but may be underrepresented.
Conclusions:
Patients after ASO typically have good long-term clinical outcomes but reoperations and interventions remain necessary in some patients. Neoaortic valve regurgitation with root dilatation is the second most common indication for reoperation after right ventricular outflow tract obstruction and an increasing need for neoaortic valve and root redo surgery in future is to be expected.
