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Hemodynamic function after the Mustard operation for transposition of the great arteries
Insights
The Mustard operation for transposition of the great arteries (TGA) can lead to venous obstruction, but modifications and spontaneous regression of left ventricular outflow obstruction improve outcomes. Careful surgical planning is key.
Area of Science:
- Cardiology
- Pediatric Cardiac Surgery
- Medical Imaging
Background:
- The Mustard operation is a palliative procedure for transposition of the great arteries (TGA).
- Long-term outcomes and potential complications require thorough investigation.
- Associated cardiac lesions can influence surgical approach and outcomes.
Purpose of the Study:
- To evaluate the long-term hemodynamic consequences of the Mustard operation.
- To identify the incidence and impact of systemic and pulmonary venous obstruction.
- To assess the resolution of preoperative left ventricular outflow obstruction.
Main Methods:
- Review of pre- and postoperative cardiac catheterization and cinenangiocardiogram data from 82 TGA survivors.
- Analysis of venous obstruction, tricuspid regurgitation, and left ventricular outflow tract gradients.
- Comparison of outcomes before and after modifications to the Mustard operation.
Main Results:
- 13% of patients experienced significant systemic venous obstruction, with 6 requiring reoperation.
- Pulmonary venous obstruction occurred in 6%, often asymptomatic but with radiographic evidence.
- Left ventricular outflow obstruction improved spontaneously in most patients postoperatively.
- Tricuspid regurgitation was uncommon, associated with ventricular septal defect closure.
Conclusions:
- While venous obstruction can occur after the Mustard operation, it is often well-tolerated.
- Modifications to the procedure, including pulmonary venous atrium enlargement, reduced obstruction incidence.
- Spontaneous regression of left ventricular outflow obstruction is common, but surgical relief is effective for localized lesions.
Abstract:
Pre- and postoperative cardiac catheterization data and cinenangiocardiograms of 82 patients who survived the Mustard operation for transposition of the great arteries (TGA) were reviewed. The post-operative catheterizations were performed 20 days to 10 years after operation (mean 2.5 years). Forty-six patients (56%) had no or insignificant associated cardiac lesions, whereas 36 (44%) had ventricular septal defect, pulmonary stenosis, or both, and required surgical intervention at the time of the Mustard operation. Postoperatively, 11 patients (13%) had significant systemic venous obstruction. Of the 11 patients, 6 required reoperation, and 2 patients had evidence of restenosis or complete obstruction in the superior vena cava after reoperation. In most patients, superior vena caval obstruction was well tolerated even in the presence of high pressure in the superior vena cava. Pulmonary venous obstruction occurred in 5 patients (6%), 3 of whom had no clinical symptoms despite severe pulmonary venous obstruction, although all had radiographic evidence of pulmonary venous congestion. The incidence of obstruction was drastically reduced after the Mustard operation was modified to include routine enlargement of the pulmonary venous atrium. Tricuspid regurgitation was uncommon (10%), but did occur in patients who had transatrial closure of a ventricular septal defect. Preoperatively, left ventricular outflow obstruction occurred in 38%. In 12 patients an attempt was made to relieve the obstruction at surgery. The 6 patients who had localized obstruction had a good result, but patients with more diffuse narrowing of left ventricular outflow had little or no relief of obstruction. Mild to moderate left ventricular outflow gradients regressed spontaneously in most patients after the Mustard operation.