Neoaortic outcomes after the arterial switch operation: A systematic review and meta-analysis

The arterial switch operation has become the treatment of choice for neonates with transposition of great arteries.

This systematic review and meta-analysis aimed to summarize the current evidence regarding neoaortic root dilatation and aortic valve insufficiency as long-term outcomes after the arterial switch operation, and to identify associated risk factors.

A systematic search of PubMed, EMBASE and Cochrane databases was conducted for human studies published in English or French until May 2024.

Out of 1480 identified records, 80 studies were included in the final analysis. The total incidence of moderate-to-severe aortic insufficiency was 588 out of 20,338 patients (2.89%). The total number of neoaortic reinterventions was 306 in 11,291 patients (2.71%). The total number of neoaortic reinterventions for aortic insufficiency was 78 in 4757 patients (1.63%). Distensibility of both the aortic root and the ascending aorta in patients after the arterial switch operation was significantly lower than in the normal population. Several factors were significantly associated with an increased risk of moderate-to-severe aortic insufficiency: ventricular septal defect (P<0.001); pulmonary artery banding (P=0.007); aortopulmonary mismatch (P<0.001); and neoaortic root dilatation (P<0.001). Coronary anomalies showed a borderline association (P=0.055), and the trapdoor technique was significant in one study (P=0.0005). Distensibility of both the aortic root and the ascending aorta was found to be significantly reduced in patients after the arterial switch operation compared with healthy controls, reflecting increased vascular stiffness.

Significant neoaortic valve insufficiency and reintervention remain relatively rare after the arterial switch operation. However, measurable risk factors-including ventricular septal defect, pulmonary artery banding, aortopulmonary mismatch and coronary anomalies-are associated with an increased long-term risk of valve dysfunction or surgical reintervention.