XLI Cong re s s o Nazionale de lla Socie tà Italiana di Cardiolog ia Pe diatrica Bari, Ottobre

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Eileen Jefferson
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1 European Journal of Cardio-t horacic Surgery 38 (2010) www. el sevier. com/ locat e/ ej ct s E. ANGELI, MD

2 TGA population 137 arterial switch operations (ASO) Pathology pts IAAo TGA simple 84 1 TGA + VSD/DORV 52 8 Other 1 0 Early mortality 2.9% Late mortality 0.7%

3 Study population 119 out of 132 late survivors underwent coronary angiographic evaluation 5 % 2 % 2 % 2 % Study group Unavailable Denied Waiting list Lost F.U 8 9 %

4 Population characteristics Mean time at cardiac catheterization 2.9± 1.9 yrs Coronary arteries anatomy Simple Complex 90 pts 29 pts

5 Surgical variables Coronary reimplantation techniques: Punch reimplantation technique 37 (31%) Trap-door technique 82 (69%) Since 2005: myocardial protection is performed using a single dose of crystalloid cardioplegia to avoid repeated selective cannulation of the coronary arteries Single dose cold crystalloid cardioplegia 29 (24%) All the others 90 (76%)

6 Follow up protocol Non invasive evaluation months after surgery: Clinical Electrocardiographic Echocardiographic Routine cardiac cathe te rization be tw e e n m onths afte r s urge ry Further coronary function investigations Exercise stress test Dobutamine stress echocardiography

7 Results 8 / 1 19 (6.7 % ) e vide nce of coronary arte ry s te nos is Type of TGA Native coronary anatom y Type of coronary reimplantation Type of lesion TGA + VSD Type D Punch Comple te occlus ion of LAD Simple TGA Type E Trap-door Ste nos is of LAD Simple TGA Type B single Trap-door Ste nos is of the third proximal s e gment of RCA TGA+VSD Type B Single Trap-door Mode rate s te nos is of RCA TGA+VSD Type A Punch Se ve re s te nos is of LMCA Simple TGA Type A Trap-door Comple te occlus ion of LMCA. TGA+VSD Type A Trap-door Comple te occlus ion of LMCA TGA+VSD situs inversus Type A Trap-door Se ve re s te nos is of RCA

8 Results No evidence of myocardial ischemia at non invasive evaluations 7/8 (87%) asymptomatic patients Type of TGA Type of lesion Sym ptom s Instrum ental evidence of m yocardial ischem ia Echostress TGA + VSD Complete occlusion of LAD Ne gative Simple TGA Stenosis of LAD Ne gative Simple TGA Stenosis of the third proximal segment of RCA Ne gative TGA+VSD Moderate stenosis of RCA Che s t pain T w ave inve rs ion Ne gative TGA+VSD Severe stenosis of LMCA Ne gative Simple TGA Complete occlusion of LMCA. Ne gative TGA+VSD Complete occlusion of LMCA Ne gative TGA+VSD situs inversus Severe stenosis of RCA Ne gative

9 Results 1 / 8 pts. unde rw e nt s urg e ry LMCA stenosis LMCA patch repair

Results 4 / 8 pts re ce ive d no proce dure No interventional treatment if: Complete occlusion with vessel hypoplasia Very small main coronary trunk Dobutamine

10 Results 4 / 8 pts re ce ive d no proce dure No interventional treatment if: Complete occlusion with vessel hypoplasia Very small main coronary trunk Dobutamine echo negative for myocardial wall motion abnormalities Close follow-up and monitoring for signs of silent or effort ischemia (exercise stress test every 12 months)

11 Results 3 / 8 pts re ce ive d coronary s te nt implantation Before procedure After procedure

12 Results Statis tical inve s tig ation: Variable Complex native coronary anatomy Punch reimplantation technique Pts. w ithout coronary arte ry dis e as e Pts. w ith coronary arte ry dis e as e Univa ria te p Multiva ria te p 24/111 (22%) 5/8 (62%) /111 (31.5%) 2/8 (25%)

13 Conclusions Non invasive follow up protocols may fail in tracking down the onset of progressive coronary obstruction Severe stenosis or occlusion may lead to hypoplasia of the main vessel and hamper any further attempt of surgical/interventional revascularization.

14 Conclusions A policy of systematic angiographic evaluation of the coronary arteries within the first 2 years after repair is warranted in order to: Minimize impaired vessel growth Maximize potential for revascularization procedures

15 Discussion Coronary trans location tools : Accurate mobilization of the vessels Sacrifice of small conal branches Relation between the great vessels and proximal segment of the coronary arteries

16 Discussion Coronary trans location tools : Accurate mobilization of the vessels Sacrifice of small conal branches Relation between the great vessels and proximal segment of the coronary arteries

17 Points of discussion Avoiding selective cardioplegic infusion into the coronary ostia may help in reducing damage to arterial wall ASA therapy until the first angiographic evaluation

18 Discussion Follow up e valuation: Common non-invasive follow up protocols are inadequate to monitor: Tension Torsion Kinking Growth of the coronary arteries after ASO

19 Surgical variables Coronary reimplantation techniques: Punch reimplantation technique 37 (31%) Trap-door technique 82 (69%) Since 2005: myocardial protection is performed using a single dose of crystalloid cardioplegia to avoid repeated selective cannulation of the coronary arteries

TGA Surgical techniques: tips & tricks (Arterial switch operation)

TGA Surgical techniques: tips & tricks (Arterial switch operation) Seoul National University Children s Hospital Woong-Han Kim Surgical History 1951 Blalock and Hanlon, atrial septectomy 1954 Mustard et