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Can an operation provide superior outcomes for corrected transposition of the great arteries with left ventricular
Rui Liu1, Kai Luo2, Xinxin Chen3
1Department of Cardiovascular Surgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, China.
Insights
Operative repair for congenitally corrected transposition of the great arteries with left ventricular outflow tract obstruction (CCTGA/LVOTO) does not improve long-term outcomes. Anatomical repair increases mortality, except in patients with moderate or worse tricuspid regurgitation.
Area of Science:
- Congenital Heart Surgery
- Pediatric Cardiology
- Cardiovascular Outcomes Research
Background:
- Congenitally corrected transposition of the great arteries with left ventricular outflow tract obstruction (CCTGA/LVOTO) presents complex therapeutic challenges.
- Evaluating the long-term efficacy of operative versus non-operative management strategies is crucial for patient care.
- Risk-adjusted analyses are essential to compare treatment outcomes in this specific patient population.
Purpose of the Study:
- To assess the risk-adjusted long-term effects of operative and non-operative repair in patients with CCTGA/LVOTO.
- To compare outcomes between anatomical and non-anatomical operative repair strategies.
- To identify specific subgroups that may benefit from different treatment approaches.
Main Methods:
- Retrospective review of 391 patients with CCTGA/LVOTO from 2001-2020 across three Chinese centers.
- Comparison of operative (n=282) and non-operative (n=109) groups, with operative subdivided into anatomical (n=73) and non-anatomical (n=209) repairs.
- Utilized inverse probability of treatment weighted-adjusted Cox regression and Kaplan-Meier analysis for long-term outcome evaluation over a median 8.5-year follow-up.
Main Results:
- Operative repair did not reduce mortality or improve New York Heart Association functional class but increased pulmonary valve regurgitation.
- Anatomical repair was associated with significantly higher rates of death and pulmonary valve regurgitation compared to non-operative management.
- In patients with CCTGA/LVOTO and moderate or worse tricuspid regurgitation, anatomical repair significantly reduced the hazard ratio for death.
Conclusions:
- Operative repair for CCTGA/LVOTO does not confer superior long-term outcomes compared to non-operative management.
- Anatomical repair is associated with increased mortality, but offers a survival benefit in specific subgroups with significant tricuspid regurgitation.
- Treatment decisions for CCTGA/LVOTO should consider individual patient factors, particularly the severity of tricuspid regurgitation.
Objectives:
Our goal was to evaluate the risk-adjusted effects of operative and non-operative repair on long-term outcomes in patients with congenitally corrected transposition of the great arteries and left ventricular outflow tract obstruction (CCTGA/LVOTO).
Methods:
We retrospectively reviewed 391 patients with CCTGA/LVOTO from 2001 to 2020 (operative group, 282; non-operative group, 109) in 3 centres in China. The operative group included 73 patients who underwent anatomical repair and 209 patients who underwent non-anatomical repair. The median follow-up time was 8.5 years. The inverse probability of treatment weighted-adjusted Cox regression and a Kaplan-Meier analysis were used to evaluate long-term outcomes.
Results:
Operative repair did not reduce the hazard ratio (HR) of death, tricuspid regurgitation or New York Heart Association functional class III/IV, but a significantly increased HR was observed for pulmonary valve regurgitation [HR, 2.84; 95% confidence interval (CI), 1.10-7.33; P = 0.031]. Compared with that in the non-operative group, anatomical repair resulted in significantly increased HRs for death (HR, 2.94; 95% CI, 1.10-7.87; P = 0.032) and pulmonary valve regurgitation (HR, 9.71; 95% CI, 3.66-25.77; P < 0.001). Subgroup analysis showed that in patients with CCTGA/LVOTO with moderate or worse tricuspid regurgitation (≥ moderate), anatomical repair significantly reduced the HR of death. An inverse probability of treatment weighting-adjusted Kaplan-Meier analysis showed that the survival rates at 5 and 10 days postoperatively were 88.2 ± 4.0% and 79.0 ± 7.9%, respectively, in the anatomical repair group; these rates were significantly lower than the rates in the non-operative group (95.4 ± 2.0% and 91.8 ± 2.8%; P = 0.032).
Conclusions:
For patients with CCTGA/LVOTO, operative repair does not provide superior long-term outcomes, and anatomical repair results in a higher incidence of death. However, in patients with CCTGA/LVOTO with tricuspid regurgitation ≥ moderate, anatomical repair can reduce the risk of death in the long term.
