The Arterial Switch Operation for Transposition of the Great Arteries

Transcription

1 The Arterial Switch Operation for Transposition of the Great Arteries Jan M. Quaegebeur, M.D., Ph.D. A Journey of 60 Years

2 Transposition of the Great Arteries First description: M. BAILLIE The morbid anatomy of some of the more important parts of the human body London (1797) The term Transposition of the aorta and pulmonary artery : J.R. FARRE On malformations of the human heart London (1814)

3 First attempts at TGA repair directed at the arterial level 1954 MUSTARD (2 patients) transfeer of LCA description of 3 coronary pattern 1954 BJÖRK and BOUCKAERT (Karolinska) experimental switch-over anastomosis systemic LV pressure 1954 BAILEY operated on one patient with TGA + VSD who survived 30 hours 1955 KAY & CROSS 1961 IDRISS 1960 BAFFES: concept of coronary buttons ( triangulation )

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5 TRANSPOSITION of GREAT VESSELS 34 cases

6 Fig. 4 Diagram of coronary artery variations in transposition from William Mustard s 1954 report [19] 123

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10 The Arterial Switch Operation for TGA 1976 A. JATENE: first successful ASO TRUSLER, ROSS, YACOUB, BROM: series of ASO for complex TGA HAZAN (Paris): series of primary ASO for simple TGA (100% mortality) YACOUB: staged ASO (shunt ± PA banding) for TGA and intact ventricular septum 1983 CASTAÑEDA, QUAEGEBEUR: neonatal ASO for simple TGA DAMUS, KAY, STANSEL (DKS) procedure: to avoid coronary transfer

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12 Arterial Switch Operation

13 Arterial Switch Operation

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18 Arterial Switch Option

19 Arterial Switch Operation

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21 Coronary Artery Branching Patterns 70% 14% 4.5% 3% 7% 1.5% Quaegebeur 1986

22 Single Coronary Artery Anatomy Jonas- Ped Cardiac Surgery Annual 2001

23 Intramural Coronary Arteries Traverse aortic wall High in sinus Juxtacommissural Quaegebeur 1986

24 Intramural Coronary Arteries

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26 German Heart Centre Munich Atrial/Arterial Switch Volume

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28 Arterial Switch Operation ( ) Incremental risk factors for death Lower birth weight Large PDA Morphology other than simple TGA Intra-mural coronary artery Longer myocardial ischemic time Earlier date of operation

29 Arterial Switch for TGA CHONY (N=555) N Death % Simple TGA TGA, VSD Taussig-Bing Univentricular IAA, VSD, TAPVR 1 1 Various 4 1 Total:

30 Arterial Switch for TGA and Aortic Arch Obstruction ( ) Total N Death % Simple TGA TGA, VSD * Taussig-Bing* Total: * 1 and 5 had IAA

31 Arterial Switch for TGA ( ) Mode of Death (N=18) Acute Cardiac Failure 14 * Premature- ECMO 1 Preop ECMO (Mecon. Asp.) 1 Acute Pulmonary Hemorrhage 1 Pulmonary Hypertension 1 * I IUGR (l000g) in one 5 with Intramural Coron.

32 Arterial Switch for TGA ( ) Coronary Morphology and Death Simple TGA VSD TB 1LCx- 2r L- 2CxR Unusual ** Intramural 11 3* * Bilateral Intramural in one ** Acute Pulmonary Hemorrhage

33 Risk Factors for Death after ASO for TGA±VSD (n=513, 92 deaths) - CHSS Patient p-value LCA, LAD or Cx from Sinus 2: with intramural 0.07 no intramural Multiple VSDs Non-cardiac anomalies 0.14 PA Banding > 1 month 0.4 Older age 0.7 simple TGA 0.5 Support Longer circulatory arrest time 0.03 Longer aortic cross-clamp time 0.03 Institutions 1 institution with better MR 10 High Risk institutions from Kirklin et al, Circulation Nov 1992

34 Risk factors for death after the ASO Conclusions Risk of death after ASO for TGA±VSD with unusual coronary pattern is very low (<1%) In several institutions, a single independent risk factor for death after ASO cannot be identified any longer Unusual CAP is possibly associated with increased risk, although most experienced centers have neutralized this factor

35 Risk factors for death after the ASO Conclusions Aortic arch obstruction, multiple VSD s and possibly low birth weight continue to impact outcomes negatively A combination of variables (although N is small) can complicate the ASO in any form of TGA Institutional differences in Volume and Experience can be associated with differences in outcomes, irrespective of patient variables

36 Arterial Switch for TGA ( ) Late Mortality (N=3) Simple TGA *7m ths, no info * 5.5yrs. OB s/p H Lung Tx TGA, VSD Taussig-Bing 42 1 * 6m ths Pneumonia/ Sepsis

37 Survival after the ASO (Leiden ) Independent risk factors for early death Cross-clamp time (coronary problems at ASO) No Lecompte (earlier date of ASO) Independent risk factor for late death Coronary problems at ASO Pacemaker implantation

38 Arterial Switch : Late Reoperations and Cardiac Interventions Simple TGA (300) TGA, VSD (210) TB (45) Supravalv PS Coarc Supravalv PS 2 & Coarc Subvalve, Valve PS HLTx 1 PPM 1 Ao V Replace. 1 6/17 PA Interventions Needed Reoperation

39 Reoperations after the ASO (Leiden ) Independent risk factors Older age at ASO Ao Arch Anomalies Coronary problems at ASO Duration of P.O. Ventilation

40 Supravalvar Pulmonary Stenosis Incidence <10% (CHSS) Etiology Small neo-pulmonary root Inadequate PA mobilization Pursestring effect Inappropriate Lecompte? Patch material Reintervention rate -0.5% /yr

41 Cause of Reoperation in 756 survivors after ASO (Angeli, Eur. JCTS 2008) Early ( 1yr) Coronary obstruction 4 18 Ao Coarctation 4 - RVOTO 2 11 LVOTO - 3 Tracheal Compression - 1 Pulmon.Hypertension - 2 Pacemaker 1 - Late (mean 6.5 yrs) Total = 46

42 Coronary Artery Obstruction After the Arterial Switch Operation for Transposition of the Great Arteries in Newborns Bonhoeffer et al, JACC patients had coronary angioplasty 2 wks 15 yrs after arterial switch Coronary Obstruction N n % Evidence of myocardial ischemia % Prospective (Nl ECG, ECHO) % Single ostium technique %

43 Aortic Root and LV 20 years after the ASO (Vandekerckhove et al. Eur. JCTS 2009) LVESD and LVEDD were normal Septal and posterior wall thickness normal Mild decrease in SF in 10% No coronary obstruction

44 Aortic Root and LV 20 years after the ASO (Vandekerckhove et al. Eur. JCTS 2009) AR: None-Trivial 28 72% Mild 5 13% Mod 6 15% AVR in 1 patient 10 yrs post ASO -had discrete Sub AS Larger diameter of SV, STJ when mild or moderate AR Reinterventions in 7 pts * Supravalv PS 3 * Left PA stenosis 1 * Subvalv AS, AVR 1 * Balloon Ao Coarc 2

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50 Ao Root dilation (2 3) develops over time after ASO Not progressive in late follow- up Considerable overlaps between Z-values of Ao Root and degree of AR Risk factors for ARD: -Previous PA Band -Technical factors 2.4% had neo-aortic valve surgery from Schwartz et al. Circ 2004

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