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Reoperation after the arterial switch operation for transposition of the great arteries
A Serraf1, D Roux, F Lacour-Gayet
1Department of Pediatric Cardiac Surgery, Marie-Lannelongue Hospital, Le Plessis-Robinson, France.
Insights
Reoperations after arterial switch operations for transposition of the great arteries are uncommon but necessary for specific complications. This study details the causes and outcomes of these crucial interventions in pediatric cardiac surgery.
Area of Science:
- Pediatric Cardiac Surgery
- Congenital Heart Disease Management
- Cardiovascular Reconstructive Surgery
Background:
- Arterial switch operation (ASO) is standard for transposition of the great arteries (TGA).
- While most patients achieve normal outcomes, some require reoperation due to residual or new complications.
- Understanding reoperation indications and outcomes is vital for optimizing pediatric cardiac surgical care.
Purpose of the Study:
- To analyze the incidence, causes, and outcomes of reoperations following ASO for TGA over a 10-year period.
- To identify specific complications necessitating early or late reinterventions.
- To evaluate the effectiveness of surgical and interventional procedures for managing these complications.
Main Methods:
- Retrospective review of 753 patients undergoing ASO for TGA between [Start Year] and [End Year].
- Analysis of 75 reoperations performed on 68 patients, categorizing them into early (<30 days) and late (>30 days).
- Detailed review of reoperation indications, surgical techniques, and patient outcomes, including mortality.
Main Results:
- 9.3% of patients (68/753) required 75 reoperations.
- Common causes included supravalvular pulmonic stenosis (n=16), superior vena cava thrombosis (n=9), and residual ventricular septal defects (n=8).
- Six intraoperative (8.8%) and two late deaths occurred, with all early deaths associated with early reoperations.
Conclusions:
- Reoperations after ASO for TGA, though infrequent, are essential for managing specific critical complications.
- Supravalvular pulmonic stenosis and superior vena cava thrombosis are significant indications for reintervention.
- While surgical interventions can successfully address these issues, early reoperations carry a higher mortality risk.
Abstract:
Although most children after an arterial switch operation for transposition of the great arteries have normal development and cardiac function, a few require reoperation. During the last 10 years, 68 of 753 patients who underwent arterial switch operations (9.3%) underwent 75 reoperations. Thirty underwent early reoperation (< 30 days or during the same hospital stay) and 38 underwent late reoperation. Causes for reoperation included pacemaker insertion (n = 5), left diaphragm plication (n = 4), revision for hemostasis (n = 1), mediastinitis (n = 2), superior vena cava thrombosis (n = 9), subvalvular pulmonic stenosis (n = 5), supravalvular pulmonic stenosis (n = 16), residual atrial (n = 2) or ventricular (n = 8) septal defects, isolated mitral valve insufficiency (n = 2), aortic valve insufficiency (either isolated [n = 1] or in association with mitral incompetence [n = 1] or stenosis [n = 1]), left coronary artery ostial stenosis (n = 1), and recurrent aortic (n = 6) or neoaortic (n = 4) aortic coarctation. In all but 27 patients, the residual defects were already present immediately after the completion of the arterial switch operation; however, only patients with critical lesions were reoperated on early. Interventional catheterization procedures were performed when indicated; however, they only postponed inevitable reoperation. Successful relief of superior vena cava thrombosis was achieved by atriojugular bypass grafting in two patients, by early open thrombectomy in six patients, and by direct patch angioplasty of the superior vena cava once. Patch plasty for subvalvular or supravalvular pulmonic stenosis was carried out in 21 patients, septal defect closure was carried out in nine patients, and pulmonary artery banding was performed in one patient with criss-cross atrioventricular relationship and multiple ventricular septal defects. Valve repair was performed in all five patients with either isolated or combined aortic and mitral valve dysfunction. One patient with left coronary ostial stenosis underwent a patch enlargement of this ostium. Recoarctation was repaired by end-to-end anastomosis in eight patients and by a subclavian flap and a patch angioplasty in one patient each. Seven patients underwent a second reoperation for supravalvular pulmonary stenosis (n = 3), mitral valve replacement (n = 1), ventricular septal defect closure (n = 1), and recurrent coarctation (n = 2). There were six intraoperative (8.8%) and two late deaths. All early deaths occurred after early reoperations.(ABSTRACT TRUNCATED AT 400 WORDS)