The Arterial Switch Operation

for Transposition of the Great

Arteries

A Journey of 60 Years

Jan M. Quaegebeur, M.D., Ph.D.

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)

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”)

TRANSPOSITION of GREAT VESSELS – 34 cases

Fig. 4 Diagram of

coronary artery

variations in

transposition from

William Mustard’s 1954

report [19]

123

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

Arterial Switch Operation

Arterial Switch Operation

Arterial Switch Operation

Arterial Switch Operation

Arterial Switch Operation

Arterial Switch Operation

Arterial Switch Option

Arterial Switch Operation

Quaegebeur 1986

70% 14%

3%

4.5%

7% 1.5%

Coronary Artery Branching Patterns

Jonas- Ped Cardiac Surgery Annual 2001

Single Coronary Artery Anatomy

Quaegebeur 1986

Intramural Coronary Arteries

Traverse aortic wall

High in sinus

Juxtacommissural

Intramural Coronary Arteries

German Heart Centre – Munich

Atrial/Arterial Switch Volume

Arterial Switch Operation (1978-1994)

Incremental risk factors for

death

1985 1988 1994

Lower birth weight

Large PDA

Morphology other than simple TGA

Intra-mural coronary artery

Longer myocardial ischemic time

Earlier date of operation

Arterial Switch for TGA 1990-2011

CHONY (N=555)

N Death %

Simple TGA 300 4 1.3

TGA, VSD 210 7 3.3

Taussig-Bing 45 3 6.6

Univentricular 14 2 14

IAA, VSD, TAPVR 1 1

Various 4 1

Total: 574 18 3.3

Arterial Switch for TGA

and Aortic Arch Obstruction (1990-2011)

Total N Death %

Simple TGA 300 7 0 0

TGA, VSD * 210 37 1 2.7

Taussig-Bing* 45 35 3 8.5

Total: 555 79 4 5

* 1 and 5 had IAA

Arterial Switch for TGA (1990-2011)

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.

Arterial Switch for TGA (1990-2011)

Coronary Morphology and Death

Simple TGA VSD TB

1LCx- 2r 188 0 147 3 14 0

1L- 2CxR 55 0 15 1 4 0

Unusual 37 1 45 2 20 1**

Intramural 11 3* 4 2 2 2

* Bilateral Intramural in one

** Acute Pulmonary Hemorrhage

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 0.009

Multiple VSDs 0.001

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

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

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

Arterial Switch for TGA (1990-2011)

Late Mortality (N=3)

Simple TGA 296 2 *7mths, no info

* 5.5yrs. OB

s/p H Lung Tx

TGA, VSD 203 0

Taussig-Bing 42 1 * 6mths

Pneumonia/

Sepsis

Survival after the ASO (Leiden 1977-2007)

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

Arterial Switch : Late Reoperations and Cardiac Interventions

Simple TGA (300) TGA, VSD (210) TB (45)

Supravalv PS 9 8 2 3 3 6

Coarc 1 - - 1 2 4

Supravalv PS

& Coarc

2

Subvalve,

Valve PS

1 2 4

HLTx 1

PPM 1

Ao V Replace. 1

6/17 PA Interventions Needed Reoperation

Reoperations after the ASO

(Leiden 1977-2007)

Independent risk factors • Older age at ASO

• Ao Arch Anomalies

• Coronary problems at ASO

• Duration of P.O. Ventilation

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

Cause of Reoperation in 756 survivors

after ASO (Angeli, Eur. JCTS 2008)

Early ( ≤ 1yr) Late (mean 6.5 yrs)

Coronary obstruction 4 18

Ao Coarctation 4 -

RVOTO 2 11

LVOTO - 3

Tracheal

Compression

- 1

Pulmon.Hypertension - 2

Pacemaker 1 -

Total = 46

Coronary Artery Obstruction After the Arterial Switch Operation

for Transposition of the Great Arteries in Newborns

Bonhoeffer et al, JACC 1997

165 patients had coronary angioplasty

2 wks – 15 yrs after arterial switch

Coronary Obstruction

N n° %

Evidence of myocardial ischemia 25 13 52%

Prospective (Nl ECG, ECHO) 105 6 5.7%

“Single ostium” technique 35 11 31%

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

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

• 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