surgical management of transposition of the great arteries ... · surgical management of...
TRANSCRIPT
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Surgical Management of
Transposition of the Great
Arteries (TGA)
Max B. Mitchell, MD
Professor of Surgery
University of Colorado
and
Children’s Hospital Colorado
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Disclosure: No Conflicts of Interest
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Objectives
• Discuss surgical approach to the repair of D-
TGA
• Discuss outcomes of surgery for D-TGA in the
modern era
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Scope of discussion
• D-TGA with intact ventricular septum
• Not discussed:
• Associated lesions accompanying D-TGA
• VSD
• Arch obstruction
• LVOTO
• Corrected transposition (L-TGA)
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Anatomy: Ventricular-Arterial Discordance
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Normal D-TGA
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Physiology of TGA
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Normal: Circulation in series TGA: Circulation in parallel
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Surgical solutions for D-TGA
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Normal D-TGA
Re-route outflow
Re-route inflow
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Atrial Switch for D-TGA
• Senning operation (1957)
• Mustard operation (1963)
• Problems:
• Pathway obstruction with growth
• Atrial dysrythmias
• Late RV (systemic) failure
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Arterial Switch Operation for D-TGA
• Returns LV to the systemic circulation with
minimal atrial impact
• Rate limiting factor was coronary transfer
• First successful arterial switch done by Jatene,
reported in 1975 (staged following PA band +
shunt)
• First neonatal switch was performed by
Castaneda at Boston Children’s (1983)
• By the late 1980s neonatal arterial switch
operation became the gold standard 9
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Coronary artery classifications
• Yacoub classification:
• Does not describe all variants
• Leiden classification:
• Good for common nomenclature
• Does not guide surgical principles
• Marie Lannelongue “French” classification:
• Simple and guides coronary transfer
techniques
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Leiden classification of “usual / normal”
coronary pattern in D-TGA (1AD,Cx; 2R)
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Usual coronary artery course (1 AD, Cx; 2 R)
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Leiden TGA coronary artery classification
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Marie Lannelongue anatomic coronary
artery classification in TGA
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• “Normal” or usual course
• Looping course
• Intramural course
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“Normal” (Usual) coronary course
• 60% cases
• L ostium: AD, Cx
• R ostium: RCA
• No coronaries cross
in front or behind
great vessels
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Looping coronary artery course
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• 35% involve looping courses
• 3 variations:
• Posterior looping (20%)
• Anterior looping (1%)
• Double looping (14%)
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Posterior looping course
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• 2 variations (20%): • Posterior Cx branching
from RCA (19%)
• Single coronary from R sinus with posterior looping LMCA (1%)
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Anterior looping course
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• 3 variations (1%)
• Great vessels oriented
side-by-side
• 2 involve single coronary
artery anatomy
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Double looping course (14%)
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• Usually Aorta and PA are more side-side
• Cx posterior loop, RCA anterior loop, (5%)
• LMCA posterior, RCA anterior(8%)
• Single coronary with Cx posterior and AD anterior (1%)
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Intramural coronary artery course
• 5% of cases
• LMCA courses in the
posterior aortic wall
above or behind the
posterior commissure
• Close proximity to
commissure
intramural course
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Uniform technique for the Arterial Switch
Operation
• LeCompte maneuver
• Coronary origin and path determines transfer
site
• Arterial switch is aortic surgery – not coronary
surgery
• PA reconstruction with autologous pericardium
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Great Vessel division and Lecompte
maneuver
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Relative position of Aorta and PA in TGA
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Coronary button harvest
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Coronary transfer
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Pulmonary artery reconstruction
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Early outcome of ASO for D-TGA,IVS
• Single institution reports with < 1%
• STS database 20011-2014: 1.8%
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Early outcome of ASO for D-TGA
• Children’s Hospital Colorado (2003-2011)
• N=101 (52 simple DTGA , 49 complex DTGA)
• Operative mortality 0%
• Major morbidity 23%
• Survival: 99% at 49±27 months
Stoica et al. Ann Thorac Surg 2012
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Early survival for ASO in D-TGA/IVS: effect
of center volume
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Karamalou, Ann Thorac Surg 2014
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Early outcome of ASO for D-TGA,IVS:
effect of surgeon volume
Karamalou Ann Thorac Surg 2014
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Risk factors for early mortality of ASO for
D-TGA
• Surgeon volume
• Center volume
• Complicated coronary anatomy:
• Intra-mural coronary artery
• Single coronary artery with inter-arterial course
• Posterior looping course
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High risk coronary artery patterns
• Intra-mural coronary artery course
• Single coronary with inter-arterial coronary
artery course
• Posterior looping courses
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Intra-mural coronary artery
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Intra-mural coronary artery with
interarterial course
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Single coronary from right sinus with
Inter-arterial course
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Posterior looping risks positive feedback
loop
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Minor stretching or kink of
posterior looping coronary
LV Ischemia
LV distension
PA pressure
RV Distension
Hypotension
stretch
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Long-term issues following ASO
• Re-intervention ranges from 5-25%
• Pulmonary stenosis is most common factor
requiring re-intervention
• Coronary artery stenosis:
• Most common early (3 months)
• Can be assymptomatic
• Neoaortic root dilation
• Neoaortic insufficiency (1-3% reoperation at 20
yrs) 37
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Long-term outcome for D-TGA
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Vejlstrup, et al Circulation 2015 Fricke, et al Ann Thorac Surg 2012
Atrial Switch Arterial Switch
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Conclusions
• D-TGA is a technically demanding surgical
challenge
• Standardization of techniques and experience
have led to excellent early survival
• Long-term outcomes are very good but late re-
operations are not uncommon
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