The arterial switch operation in Europe for transposition of the great arteries: a multi-institutional study from the European Congenital Heart Surgeons Association

Impact of Bedside Balloon Atrial Septostomy in Neonates with Transposition of the Great Arteries in a Neonatal Intensive Care Unit in Romania

(1) Background: Transposition of the great arteries (TGA) is the most common congenital heart disease, accounting for 5-7% of all cardiac anomalies, with a prevalence of 0.2-0.3 per 1000 live births. (2) Aim: Our main objectives were to evaluate the clinical safety of balloon atrial septostomy in neonates and the possible complications. Furthermore, we tried to establish whether the procedure should be performed in all TGA patients with small atrial septal defects, regardless of oxygen saturation, within a center where corrective surgery cannot be performed on an emergency basis due to the lack of a permanent cardiac surgery team for arterial switch surgery. (2) Methods: We conducted an observational, retrospective, single tertiary-care center study between January 2008 and April 2022, which included 92 neonates with TGA transferred to our institution for specialized treatment. (3) Results: The median age at the time of the Rashkind procedure was four days. The rate of immediate complications after balloon atrial septostomy (BAS) was high (34.3%), but most were transient (metabolic acidosis and arterial hypotension-21.8%). Twenty patients with TGA managed in our hospital underwent definitive and corrective surgical intervention (arterial switch operation) at a median age of 13 days. Most patients (82.6%) were term neonates, but 16 were born preterm. (4) Conclusions: Urgent balloon atrial septostomy is often the only solution to restore adequate systemic perfusion. Bedside balloon atrial septostomy is a safe, effective, and initial palliative intervention in neonates with TGA, which can be performed in the neonatal unit.

Post-operative troponin levels and left ventricular function in patients with d-transposition of the great arteries following the arterial switch operation

The aim of this study was to assess the significance of post-operative troponin levels as a surrogate for left ventricular (LV) dysfunction measured by global longitudinal strain (GLS) in patients with dextro-transposition of the great arteries (d-TGA) who undergo an arterial switch operation (ASO), and to explore the LV GLS recovery in the mid-term follow-up period. Seventy-eight neonates were included, of whom 41 had troponin-I measurements and 37 had troponin-T measurements. The primary outcome of LV GLS was assessed and compared with healthy controls at the pre-operative stage and time of discharge, 3 months, 6 months and 12 months of age. Secondary outcomes included deaths or transplantations and other clinical markers such as length of hospital stay. D-TGA patients had worse LV GLS post-operatively compared to age-matched controls (p < 0.01) which improved by 12 months of age (p = 0.53). No association was found between changes in troponin-I or troponin-T levels and LV GLS at the time of discharge (r = 0.4, p = 0.64 and r = -0.5, p = 0.91, respectively). In addition, there were no deaths or transplantations in this cohort over a period of 12 months. LV GLS appears to worsen in the early post-operative period for d-TGA patients who undergo neonatal ASO but this recovers through the first post-operative year. Troponin levels have limited value in predicting early or midterm LV dysfunction and recovery.

Techniques and pitfalls of coronary arterial reimplantation in anatomical correction of transposition

BACKGROUND AND AIM

We assessed the anatomical variations in coronary arterial patterns relative to the techniques of reimplantation in the setting of the arterial switch operation, relating the variations to influences on outcomes.

METHODS

We reviewed pertinent published investigations, assessing events reported following varied surgical techniques for reimplantation of the coronary arteries in the setting of the arterial switch procedure.

RESULTS

The prevalence of reported adverse events, subsequent to reimplantation, varied from 2% to 11%, with a bimodal presentation of high early and low late incidence. The intramural pattern continues to contribute to mortality, with some reports of 28% fatality. The presence of abnormal course relative to the arterial pedicles in the setting of single sinus origin was associated with a three-fold increase in mortality. Abnormal looping with bisinusal origin of arteries was not associated with increased risk.

CONCLUSION

The techniques of transfer of the coronary arteries can be individually adapted to cater for the anatomical variations. Cardiac surgeons, therefore, need to be familiar with the myriad creative options available to achieve successful repair when there is challenging anatomy. Long-term follow-up will be required to affirm the superiority of any specific individual technique. Detailed multiplanar computed-tomographic scanning can now reveal all the variants, and elucidate the mechanisms of late complications. Coronary angioplasty or surgical revascularization may be considered in selected cases subsequent to the switch procedure.

Mortality analysis of arterial switch operation for transposition of the great arteries with and without ventricular septal defect

OBJECTIVES

We aimed to evaluate the 90-day mortality and effect of rescue or urgent coronary revascularization in children undergoing arterial switch operation for transposition of the great arteries with and without ventricular septal defect.

METHODS

The 90-day mortality, risk factors for mortality and outcome of rescue or urgent coronary revascularization were analysed using 8 years of data from the Japan Cardiovascular Surgical Database. We only included patients with full data for all analyses.

RESULTS

A total of 1084 patients (median weight: 3.0 kg; interquartile range: 2.8-3.3) underwent arterial switch operation at a median age of 10 days (interquartile range: 7-14). The 90-day mortality (5.2%, n = 56) was ∼1.6-fold higher than 30-day mortality (3.2%, n = 35). The cause was cardiac origin in 84% of non-survivors. Fifty-nine of the 1034 patients (5.7%) required extracorporeal membrane oxygenation (ECMO), with successful weaning in 44% (n = 26). Univariable or multivariable analyses revealed the following risk factors for mortality: body weight at operation <2.5 kg, aortic cross-clamp time, cardiac events and ECMO (P < 0.005-0.001). Ventricular septal defect was not a risk factor.Thirteen patients (1.2%) had either rescue or urgent coronary revascularization with salvage rates of 25% (2/8) and 100% (5/5), respectively. Only 5 ECMO patients (8%) underwent coronary revascularization with 1 survivor.

CONCLUSIONS

The 90-day mortality represented perioperative outcomes better than 30-day mortality. Patients on ECMO, which extended the survival time, had 56% 90-day mortality. Coronary revascularization showed a salvaging effect, although the case number was small.Subj collection: 116, 137, 141.

Myocardial performance after coronary re-implantation in pediatric patients assessed with conventional echocardiographic and 2D-speckle tracking analysis: a case-control study

Introduction

reduced exercise capacity, coronary artery abnormalities and reversible myocardial ischemia have been demonstrated after arterial switch operation (ASO) and coronary reimplantation. Despite this, indices of systolic function, assessed by standard and Doppler echocardiography, are within the normal range. The aim of this study was to highlight the long-term changes in myocardial function following coronary reimplantation using Doppler and speckle-tracking imaging (STI) echocardiography.

Methods

this observational case control study included 36 patients and 20 gender and age-matched healthy controls. A group study was performed using patients who were followed for at least 6 months after the operation and who visited the pediatric cardiology outpatient between October 2015 and May 2016. Systolic and diastolic parameters, left ventricle (LV) and right ventricle (RV) myocardial performance were assessed in each group.

Results

the LV global peak strain parameters revealed a significant decrease in the longitudinal and circumferential strain components. The LV global longitudinal strain (GLS) values were lower in both groups of operated patients than controls (-19.9 ± 2.2% (group 1) versus -20.9 ± 1.6% (group 2) versus -22.9 ± 2.3% (group 3), p<0.001). The patients with coronary reimplantation had the lowest values. The LV global circumferential strain was also decreased in the group 1 patients as compared with the 2 other groups (-16.6 ± 4.1% (group 1) versus -19.4 ± 3.9% (group 2) versus -19.8 ± 4.0% (group 3), p<0.001).

Conclusion

although global LV function, assessed with conventional echocardiographic parameters, was normal, the 2D-STI analysis showed slight but significant decrease in the global and segmental longitudinal and circumferential LV strain during the long-term follow-up after coronary arteries reimplantation.

Transposition of the Great Arteries-Are We Doing Better? Correlating Outcome to Change in Renal Function Over 2 Decades of Arterial Switch Operation

OBJECTIVES

It is believed that management of neonates with dextro-transposition of the great arteries is constantly improving. Renal function may play a role in the prognosis of patients after congenital heart surgery. The aim of this study was to describe the outcome of neonates who underwent arterial switch operation during the past 2 decades using renal function as a surrogate marker for morbidity and mortality.

DESIGN

Retrospective cohort study.

SETTING

Dedicated cardiac ICU of a university-affiliated pediatric medical center.

PATIENTS

Infants who underwent arterial switch surgery in 1993-2015.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The cohort included 336 infants who underwent arterial switch operation for dextro-transposition of the great arteries (n = 169, 50%), transposition of the great arteries/ventricular septal defect (n = 133, 40%), or Taussig-Bing anomaly (n = 34, 10%). Between 1993-1998 and 2012-2015, the mean minimal postoperative estimated glomerular filtration rate rose from 30 mL/min/1.73 m to 40 mL/min/1.73 m (p < 0.05), and the proportion of patients with estimated glomerular filtration rate less than 30 mL/min/1.73 m decreased from 56% to 23% (p < 0.05). The daily furosemide dosage decreased from 4 mg/kg/d to 0.5 mg/kg/d (p < 0.05). Urinary output on operative day 0 decreased over time, but urinary output on operative day 2 significantly increased. Maximal lactate levels and time to lactate normalization decreased steadily. Dialysis was performed in only a few patients in the early periods, and in none in the last 6 years. The mean mortality rate of patients with dextro-transposition of the great arteries and transposition of the great arteries/ventricular septal defect decreased to 2.7% in the last 6 years. The odds ratio of a prolonged hospital stay (≥ 28 d) in a patient with estimated glomerular filtration rate less than 30 mL/min/1.73 m was 18.79, and in a patient with transposition of the great arteries/ventricular septal defect, 3.39. The odds ratio of dying after Rashkind atrial septostomy was 4.42.

CONCLUSIONS

During the past 2 decades, there has been significant improvement in outcome of patients undergoing transposition of the great arteries repair. Renal function was found to be a good prognostic marker of morbidity and mortality.

Transposition of the great vessels and intact ventricular septum: is there an age limit for the arterial switch? Personal experience and review of the literature

OBJECTIVE

Prognosis of the transposition of the great arteries has completely changed since the introduction of the arterial switch. Time limit to perform this intervention is still controversial. The aim of this study is to demonstrate the early and late outcome of primary arterial switch operation beyond the age of months.

METHODS

We included all patients with the diagnosis of transposition of the great arteries with intact ventricular septum beyond the age of 8 weeks who underwent primary arterial switch operation. The procedures were performed by the same surgeon, in two different institutes. Patients who had transposition of the great arteries and associated anomalies (except atrial septal defect and persistent arterial duct) were excluded. Ventricular shape, geometry, and mass were not considered during the decision on procedure type.

RESULTS

In the study, 11 patients with the diagnosis of simple d-transposition of the great arteries beyond 8 weeks were undergone primary arterial switch operation with a mean age of 90.63 days (60-137 days), and 7 patients had a Rashkind procedure. All patients had squashed left ventricle shape with preserved function. The sternum was left open in 10 patients. Extracorporeal membrane oxygenation support was necessary in 45.45% of cases. The mean mechanical ventilation time was 7.27 days (1-16 days). No mortality was recorded until now. Post-operatory left ventricular function was preserved in 90.9% of the patients. Only one patient had mild myocardial dysfunction at the time of discharge.

CONCLUSIONS

Primary arterial switch procedure can still be the best surgical option in patients with the diagnosis of transposition of the great arteries with intact ventricular septum beyond 8 weeks of age, providing that mechanical circulatory support and an expert cardiac intensive care unit service are available.

Late Arterial Switch Surgery Under ECMO Support in a Patient with Transposition of the Great Arteries with Intact Ventricular Septum: a Case Report

A 30-month-old male patient with transposition of the great arteries with intact ventricular septum (TGA/IVS) is presented. Arterial switch operation (ASO) was performed in the light of echocardiographic and angiographic findings. The patient remained under extracorporeal membrane oxygenation support for seven days postoperatively, and his cardiac functions returned to normal at the postoperative 10^th day. He was discharged at the postoperative 20^th day. The present case, which presents one of the most advanced ages at operation for TGA/IVS among previously reported cases, is used to discuss late ASO in this study.

Twenty-Three-Year Experience With the Arterial Switch Operation: Expectations and Long-Term Outcomes

We aimed to describe the short- and long-term outcomes of patients after an arterial switch operation (ASO) at a single institution during a 23-year period. A retrospective chart review of all patients <18 months of age who underwent an ASO between January 1995 and March 2018 at Texas Children's Hospital, Houston, TX was performed. Primary endpoints include mortality and reintervention. Perioperative mortality was defined as mortality occurring in-hospital and/or <30 days after surgery. Survival and freedom-from-reintervention were analyzed using Kaplan-Meier method, log-rank tests, and Cox regression models. The cohort included 394 patients. Diagnoses included 204 patients (52%) with intact ventricular septum, 137 (35%) with a ventricular septal defect, 17 (4%) with a ventricular septal defect and left ventricular outflow tract obstruction (LVOTO), and 36 (9%) with Taussig-Bing anomaly. Median age at surgery was 8 days (range: 1 day to 17 months) and median weight was 3.4 (range: 0.8-12.0) kg. Overall perioperative mortality was 1.3% (n = 5), 0.3% (n = 1) since 1999. Overall survival at 5, 10, and 15 years was 98.2%, 97.8%, and 97.8%, respectively. Perioperative morality was associated with prematurity (P = 0.012), <2.5 kg (P< 0.001), and longer circulatory arrest (P = 0.024) after univariate analysis. Reintervention was associated with a longer cross-clamp time (P < 0.001), <2.5 kg (P = 0.009), LVOTO resection (P = 0.047), and genetic syndrome (P= 0.011) after multivariable analysis. Current ASO expectations should include a perioperative mortality risk of <1% and good long-term survival. Reinterventions are more frequent in patients <2.5 kg, concomitant LVOTO resection, a genetic syndrome, and longer cross-clamp time.

Association Between Variation in Preoperative Care Before Arterial Switch Operation and Outcomes in Patients With Transposition of the Great Arteries

BACKGROUND

The arterial switch operation (ASO) is the gold standard operative correction of neonates with transposition of the great arteries and intact ventricular septum, with excellent operative survival. The associations between patient and surgeon characteristics and outcomes are well understood, but the associations between variation in preoperative care and outcomes are less well studied.

METHODS

A multicenter retrospective cohort study of infants undergoing neonatal ASO between January 2010 and September 2015 at hospitals contributing data to the Pediatric Health Information Systems database was performed. The association between preoperative care (timing of ASO, preoperative use of balloon atrial septostomy, prostaglandin infusion, mechanical ventilation, and vasoactive agents) and operative outcomes (mortality, length of stay, and cost) was studied with multivariable mixed-effects models.

RESULTS

Over the study period, 2159 neonates at 40 hospitals were evaluated. Perioperative mortality was 2.8%. Between hospitals, the use of adjuvant therapies and timing of ASO varied broadly. At the subject level, older age at ASO was associated with higher mortality risk (age >6 days: odds ratio, 1.90; 95% CI, 1.11-3.26; P=0.02), cost, and length of stay. Receipt of a balloon atrial septostomy was associated with lower mortality risk (odds ratio, 0.32; 95% CI, 0.17-0.59; P<0.001), cost, and length of stay. Later hospital median age at ASO was associated with higher odds of mortality (odds ratio, 1.15 per day; 95% CI, 1.02-1.29; P=0.03), longer length of stay ( P<0.004), and higher cost ( P<0.001). Other hospital factors were not independently associated with the outcomes of interest.

CONCLUSIONS

There was significant variation in preoperative care between hospitals. Some potentially modifiable aspects of perioperative care (timing of ASO and septostomy) were significantly associated with mortality, length of stay, and cost. Further research on the perioperative care of neonates is necessary to determine whether modifying practice on the basis of the observed associations translates into improved outcomes.

Surgical Age and Morbidity After Arterial Switch for Transposition of the Great Arteries

BACKGROUND

Transposition of the great arteries (TGA) is a complex congenital heart disease that requires early diagnosis as well as advanced surgical repair and postoperative support. This study sought to investigate the impact of surgical timing on early postoperative morbidity.

METHODS

This study reviewed all patients with TGA repaired at a single institution (Skåne University Hospital, Lund, Sweden) by arterial switch operation (ASO) between June 2001 and June 2017. Major postoperative morbidity (MPM) and death within 30 days after ASOs were documented. Patients with double-outlet right ventricle, chromosomal abnormalities, and noncardiac diseases were excluded. MPM was defined as the presence of at least 1 of the following: delayed sternum closure, reoperation, prolonged mechanical ventilation, noninvasive ventilation after extubation, peritoneal dialysis, extracorporeal membrane oxygenation, and readmission.

RESULTS

A total of 241 patients were included, with medians for birth weight, gestational week, and age at surgery of 3.5 kg, 39 weeks, and 5 days, respectively. MPM was encountered in 32.3% of patients. Prematurity (P = .001) and need for aortic arch repair at the time of ASO (P = .04) were associated with a significant increase in MPM. Non-A coronary anatomy, associated ventricular septal defect requiring surgical closure, and fetal diagnosis of TGA had no significant impact on MPM (P = .35, .08, and .21, respectively). There was no significant difference in MPM among the surgical groups (P = .49).

CONCLUSIONS

Early complications after ASO do occur and are mostly associated with prematurity and the need for aortic arch repair. Timing of surgical repair does not seem to influence the rate of these complications.

No difference found in safety or efficacy of balloon atrial septostomy performed at the bedside versus the catheterisation laboratory

BACKGROUND

Balloon atrial septostomy is performed in infants with dextro-transposition of the great arteries to improve oxygenation before surgery. It is performed in the catheterisation laboratory with fluoroscopy or at the bedside using echocardiography. It is unclear whether procedural safety and efficacy is superior in one location versus the other, although the bedside procedure may improve resource utilisation and present an opportunity for reducing cost. This study compares safety and efficacy of atrial septostomy performed at the patient's bedside versus the catheterisation laboratory.

METHODS

Neonates with dextro-transposition of the great arteries who underwent balloon atrial septostomy from October, 2000 to January, 2014 were included. Medical and procedural records, echocardiograms, and catheterisation data were reviewed. Comparisons between the two procedural locations included patient demographics, pre- and post-procedure oxygen saturations, and outcomes. Complications reviewed included bleeding, arrhythmia, cardiac trauma, stroke, and death. Coronary artery evaluations were recorded. T-tests were used for continuous variables, and Fisher's exact tests were used for all categorical variables. Wilcoxon rank sum and analysis of covariance modelling were used for time variables and oxygen saturation, respectively.

RESULTS

A total of 88 infants met the inclusion criteria. Among them, 53 underwent septostomy at the bedside and 35 underwent septostomy in the catheterisation laboratory. No safety or outcome benefit was identified between the two procedural locations.

CONCLUSION

Septostomy performed at the bedside and in the catheterisation laboratory had similar outcomes and efficacy. Further, bedside septostomy has the advantage of no radiation exposure, and obviating risks with patient transfer from the ICU to the catheterisation laboratory.

Risk factor analysis for a complicated postoperative course after neonatal arterial switch operation: The role of troponin T

OBJECTIVE

To find risk factors for a complicated early postoperative course after arterial switch operation (ASO) in neonates with d-transposition of the great arteries (dTGA). In addition to anatomical and surgical parameters, the predictive value of early postoperative troponin T (TnT) values in correlation to the early postoperative course after ASO is analyzed.

METHODS

Seventy-nine neonates (57 (72%) male) with simple dTGA treated by ASO between 2009 and 2016 were included in the analysis. A complicated early postoperative course (30 days) was defined by one of the following criteria: (A) moderate to severe cardiac dysfunction without rhythm disturbances, (B) rhythm disturbances causing hemodynamic instability with the need for medical treatment, (C) signs for ischemia in ECG, (D) need for surgical or catheter interventional reinterventions other than diagnostic, or (E) other reasons.

RESULTS

Forty of 79 patients (51%) showed a complicated early postoperative course after ASO, with 2 patients dying after 13 and 16 days. Patients with a complicated early postoperative course had a longer PICU stay (P < .001), needed longer mechanical ventilator support (P = .001) and longer inotropic support (P = .03), and more reinterventions (surgical or catheter interventional) were necessary (P = .001). Only the presence of a VSD (P = .001) and longer surgery duration (P = .026) were associated to a complicated postoperative course. TnT values only showed a trend toward higher values in patients with a complicated postoperative course (P = .06). A secondary rise in TnT was seen in 10 patients, ranging from 11.6% to 410.2%, of whom 7 could be classified in the complicated postoperative group.

CONCLUSIONS

The postoperative course after ASO in dTGA neonates is influenced by other cardiac comorbidities like a VSD with the need for surgical treatment, influencing surgery duration. Postoperative higher TnT values reflect a longer and more vulnerable intraoperative course with limited predictive value on the early postoperative course.

Population trends in prenatal detection of transposition of great arteries: impact of obstetric screening ultrasound guidelines

OBJECTIVES

Dextro-transposition of the great arteries (d-TGA) is one of the most common critical neonatal heart defects, with a low detection rate antenatally. We sought to evaluate trends in the prenatal detection of d-TGA with or without ventricular septal defect (VSD) in Alberta over the past 13 years, examining the potential impact of ultrasound guidelines incorporating screening of cardiac outflow tracts, updated in 2009-2010 and in 2013, and factors affecting detection of the condition.

METHODS

All fetuses and neonates with d-TGA, with or without VSD, encountered between 2003 and 2015 in the province of Alberta, were identified retrospectively. Clinical records including obstetric ultrasound reports were reviewed. Pregnancy outcome, common referral indications and associated maternal and fetal pathology in affected pregnancies were assessed.

RESULTS

From 2003 to 2015, 127 cases with d-TGA were encountered in Alberta, of which 47 (37%) were detected prenatally. Prenatal detection improved over the study period, from 14% in 2003-2010, to 50% in 2011-2013, and to 77% in 2014-2015. Of the 47 fetuses with a prenatal diagnosis of d-TGA, an indication for fetal echocardiography included abnormal or poorly visualized cardiac outflows with normal four-chamber view in 46 (98%). Comorbidities were identified in 12 mothers, only five of which represented an additional reason for fetal echocardiography referral, and four fetuses had extracardiac pathology.

CONCLUSION

Substantial improvement in the prenatal detection of d-TGA has been observed in Alberta over the past few years, owing to improved screening of cardiac outflow tracts on routine obstetric ultrasound examination in otherwise healthy pregnancies, and has been temporally associated with updated obstetric ultrasound guidelines suggesting that these contributed to optimized screening of affected pregnancies. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Differences in clinical outcomes and cost between complex and simple arterial switches

BACKGROUND

This study evaluates the morbidity, mortality, and cost differences between patients who underwent either a simple or a complex arterial switch operation.

METHODS

A retrospective study of patients undergoing an arterial switch operation at a single institution was performed. Simple cases were defined as patients with d-transposition of the great arteries with usual coronary anatomy or circumflex artery originating from the right with either intact ventricular septum or ventricular septal defect. Complex cases included all other forms of coronary anatomy, aortic coarctation or arch hypoplasia, and Taussig-Bing anomalies. Costs were acquired using an institutional activity-based accounting system.

RESULTS

A total of 98 patients were identified, 68 patients in the simple group and 30 in the complex group. The mortality rate was 2% for the simple and 7% for the complex group, p=0.23. Major morbidities including cardiac arrest, extracorporeal membrane oxygenation, a major coronary event, surgical or catheter-based re-intervention, stroke, or permanent pacemaker placement, non-cardiac surgical procedures, mediastinitis, and sepsis did not differ between the simple and complex groups (16 versus 27%, p=0.16). The complex group had increased bleeding requiring re-exploration (0 versus 10%, p=0.04). Hospital and ICU length of stay did not differ. Complex patients had higher overall hospital costs (simple $80,749 versus complex $97,387, p=0.01) and higher postoperative costs (simple $60,192 versus complex $70,132, p=0.02). The operating room and supplies accounted for the majority of the cost difference.

CONCLUSION

Complex arterial switches can be safely performed with low rates of morbidity and mortality but at an increased cost.

Preoperative Coronary Anatomy Assessment with Echocardiography and Morbidity After Arterial Switch Operation of Transposition of the Great Arteries

In transposition of the great arteries (TGA), certain coronary patterns have been associated with major adverse events early after the arterial switch operation (ASO). We sought to determine the impact of preoperative echocardiographic (ECHO) diagnosis on the intra- and postoperative morbidity. All patients with TGA born between June 2001 and June 2017 and who underwent ASO were reviewed. Data on presumed coronary anatomy (CA) preoperatively were obtained from the preoperative ECHO report. Intraoperative CA was categorized according to Yacoub classification. Major postoperative morbidity included at least one of the following: delayed sternal closure (DSC), prolonged (> 72 h) mechanical ventilation, reintubation, peritoneal dialysis (PD), ECMO, reoperation, and readmission within 30 days after surgery. 240 patients with median age of 5 days (range 1-614) and mean weight at surgery was 3.6 kg (1.8-8.4) were included. Preoperative ECHO assessment of CA was available in 228 patients. Intraoperatively, 181 patients (75%) were found to have type A, 25 patients had type B or C or intramural (B-C-IM; 10%), and 34 patients had type D or E (D-E; 14%). Patients with types B, C, and intramural coronary (B-C-IM) had increased risk for delayed sternum closure (9/25 vs. 20/181 in type A and 8/34 in type D-E; p = 0.04), peritoneal dialysis (4/25 vs. 8/181 and 1/34; p = 0.04), and ECMO (2/25 vs. 1/131 and 1/34; p = 0.02). Within the B-C-IM group, preoperative ECHO raised suspicion of type A in 13 patients (i.e., incorrect diagnosis, ID; 52%), whereas non-A CA was suspected in 12 patients (i.e., correct diagnosis, CD; 48%). With the exception of reoperation, which was seen only in the ID subgroup (4/12 vs. 0/10 in the CD subgroup; p = 0.04), the intraoperative (cardiopulmonary bypass time and cross-clamp time) and postoperative morbidity indices were comparable in both ID and CD subgroups (p > 0.1). Although there is a significant risk for early postoperative morbidity in TGA patients with single, interarterial, and intramural CA, there seems to be relatively limited influence of preoperative ECHO assessment of coronary anatomy on this morbidity burden.

Management of late presentation congenital heart disease

In many parts of the world, mostly low- and middle-income countries, timely diagnosis and repair of congenital heart diseases (CHDs) is not feasible for a variety of reasons. In these regions, economic growth has enabled the development of cardiac units that manage patients with CHD presenting later than would be ideal, often after the window for early stabilisation - transposition of the great arteries, coarctation of the aorta - or for lower-risk surgery in infancy - left-to-right shunts or cyanotic conditions. As a result, patients may have suffered organ dysfunction, manifest signs of pulmonary vascular disease, or the sequelae of profound cyanosis and polycythaemia. Late presentation poses unique clinical and ethical challenges in decision making regarding operability or surgical candidacy, surgical strategy, and perioperative intensive care management.

Transposition of the Great Arteries in the Developing World: Surgery and Outcomes

BACKGROUND

Little has been published regarding surgery for transposition of the great arteries (TGA) in the developing world.

OBJECTIVES

This study sought to identify patient characteristics, surgical interventions, institutional characteristics, risk factors for mortality, and outcomes among patients undergoing surgery for TGA in this setting.

METHODS

Developing world congenital heart surgical programs submitted de-identified data to a novel international collaborative database as part of a quality improvement project. We conducted a retrospective cohort study that included all cases of TGA with intact ventricular septum and TGA with ventricular septal defect performed from 2010 to 2013. Demographic, surgical, and institutional characteristics and their associations with in-hospital mortality were identified.

RESULTS

There were 778 TGA operations performed at 26 centers, 480 (62%) for TGA with intact ventricular septum and 298 (38%) for TGA with ventricular septal defect. Most (80%) were single-stage arterial switch operations, but 20% were atrial baffling procedures (atrial switch operation) or 2-stage repairs (pulmonary artery band followed by arterial switch operation). Age at operation was >30 days in one-half of the cases and did not vary significantly with operation type. Survival was 85% and did not significantly vary with age at operation or operation type. Preceding septostomy was infrequently reported (16%) and was not associated with surgical mortality. Mortality was associated with lower World Health Organization weight/body mass index-for-age percentile and lower institutional volume of TGA repair.

CONCLUSIONS

Surgical repair of TGA performed in the developing world is associated with an early survival of 85%. Type of surgical repair and age at operation varied considerably, but no associations with mortality were identified. In contrast, poor nutrition and small surgical volume were most strongly associated with mortality. Multicenter collaborative quality improvement efforts may benefit patients with TGA in the developing world.

Transposition of Great Arteries with Complex Coronary Artery Variants: Time-Related Events Following Arterial Switch Operation

Coronary artery anatomy represents a challenging and, often, determining predictor of outcome in an arterial switch operation (ASO). Impact of specific coronary artery variants, such as single, intramural and inverted, on time-related events following ASO, is, yet, to be determined. We sought to compare early and late outcomes within the group of nonstandard coronary artery variants. Patients who underwent ASO from January 1995 to October 2010 were reviewed. Patients with coronary artery variants other than L1Cx1R2 ("standard" by Leiden classification) were included. Patients with single, intramural and inverted coronary artery variants incorporated in group A. All other nonstandard coronary variants incorporated in group B. Demographics, perioperative variables, early and late outcomes were assessed. Of the 123 ASO, 24 patients (19.5%) with nonstandard coronary variant were studied. Thirteen were in group A and 11 in group B. There were two early deaths (1 in group A and 1 in group B) (p > 0.05). There is one death early after hospital discharge (group A). Mean follow-up was 59.4 ± 55.1 months. There was no structural coronary artery failure after hospital discharge following ASO. Freedom from any reintervention at 8 years was (78.3 ± 9.6%) (p 0.55) with no late neo-aortic or mitral valve intervention. ASO with single, intramural or inverted coronary artery course carries no added longitudinal risk for structural or flow impairment within the group of nonstandard coronary artery variants. There is an early hazard period with no late survival attrition. Aortic arch repair as part of staged strategy prior to ASO might influence early and late outcome.

Transposition of the great arteries: Rationale for tailored preoperative management

As preoperative morbi-mortality remains significant, care of newborns with transposition of the great arteries is still challenging. In this review of the literature, we discuss the different treatments that could improve the patient's condition into the preoperative period. Instead of a standardized management, we advocate personalized care of these neonates. Considering the deleterious effects of hypoxia, special attention is given to the use of non-invasive technologies to assess oxygenation of the tissues. As a prolonged preoperative time with low cerebral oxygenation is associated with cerebral injuries, distinguishing neonates who should undergo early surgery from those who could wait longer is crucial and requires full expertise in the management of neonatal congenital heart disease. Finally, to treat these newborns as soon as possible, we support a planned delivery policy for foetuses with transposition of the great arteries.

Transposition of the Great Arteries and Common Variants

OBJECTIVES

The objectives of this review are to discuss the physiology, perioperative management, surgical correction, and outcomes of infants with transposition of the great arteries and common variants undergoing the arterial switch operation.

DATA SOURCE

MEDLINE and PubMed.

CONCLUSION

The widespread adoption of the arterial switch operation for transposition of great arteries has been one of the more gratifying advances in pediatric cardiovascular care, and represents the simultaneous improvements in diagnostics, surgical and bypass techniques, anesthesia in the neonate, improvements in intensive care technology, nursing strategies, and system-wide care delivery. Many of the strategies adopted for the neonate with transposition of the great arteries have been translated to neonatal care for other congenital heart lesions. Continued work is necessary to investigate the effects of perioperative care on long-term neurodevelopmental outcomes, as well as collaboration between centers to spread "best practices" for outcome, cost, and morbidity reduction.

Prenatal diagnosis, hospital characteristics, and mortality in transposition of the great arteries

BACKGROUND

The role of prenatal diagnosis in reducing neonatal mortality from transposition of the great arteries (TGA) is controversial. Factors affected by prenatal diagnosis such as proximity at birth to a cardiac surgical center (CSC) and CSC volume are associated with mortality in congenital heart disease. The purpose of the study was to determine the associations between prenatal diagnosis, distance from birthplace to a CSC, CSC TGA volume, and neonatal mortality in patients with TGA.

METHODS

The Texas Birth Defects Registry was queried for all live born infants with TGA from 1999 to 2007. Four hundred sixty-eight cases of TGA were included.

RESULTS

Forty-eight patients (10.3%) were prenatally diagnosed, and 20 patients died before age 28 days (4.3%). Neither prenatal diagnosis nor close proximity to a CSC at birth (p > 0.05) were associated with decreased mortality. Low CSC TGA volume was associated with increased mortality (p < 0.0002). Mortality at the CSCs with <5 patients per year was 9.6%; CSCs with 5 to 10 patients per year had 0% mortality, and those with >10 patients per year had 2.3% mortality. In multivariable logistic regression, only preterm birth (odds ratio, 7.05; 95% confidence interval, 4.13-12.05) and lower CSC volume (p < 0.001) were associated with neonatal mortality, although prenatal diagnosis attenuated the detrimental association of lower volume CSCs with higher mortality (p for interaction = 0.047).

CONCLUSION

Lower CSC TGA patient volume was associated with higher neonatal mortality. Prenatal diagnosis may improve survival in lower volume CSCs. Birth Defects Research (Part A) 106:739-748, 2016. © 2016 Wiley Periodicals, Inc.

The functional status of neoaortic valve and left ventricular outlet tract after arterial switch operation for transposition of great arteries with left ventricular outlet tract obstruction

OBJECTIVES

To assess the function of the left ventricular outlet tract and neoaortic valve after arterial switch operation for patients with transposition of the great arteries and left ventricular outlet tract obstruction.

METHODS

The data of 40 patients, who underwent arterial switch surgery with transposition of the great arteries with left ventricular outlet tract obstruction and a concomitant left ventricular outlet tract obstruction relieving procedure, were retrospectively analysed. Ultrasonic cardiogram and intraoperative findings, surgical methods and early and follow-up results were also summarized.

RESULTS

Early death occurred in one case. One patient died in follow-up stage and 3 patients were lost during follow-up. In all the 35 patients accepting follow-up, 1 patient had a reoccurring left ventricular outlet tract obstruction, 1 patient had mild neoaortic stenosis, whereas mild and moderate neoaortic regurgitation occurred in 11 and 2 patients, respectively. The median pressure gradient across the left ventricular outlet tract was 6.8 mmHg (range: 2-49 mmHg) during follow-up which was statistically significant compared with that before surgery. We defined death, reintervention and rehospitalization for cardiac reasons as a cardiac event; the survival rate of being free from cardiac event for 1 year and 5 years was 92.8 ± 0.04%, respectively.

CONCLUSIONS

Anatomical features and pressure gradient should be used together to evaluate the severity of obstruction, whereas the mid-term outcomes can be satisfied after arterial switch operation for the appropriate candidates.

Transposition of the Great Arteries in Fetal Life: Accuracy of Diagnosis and Short-Term Outcome

OBJECTIVE

To review our series of prenatally diagnosed transposition of the great arteries (TGA) to analyze the accuracy of fetal echocardiography for achieving a precise diagnosis of the TGA type (simple vs. complex) and to examine the short-term outcome.

METHODS

A total of 94 cases of simple and complex TGA types (ventriculoarterial discordance with atrioventricular concordance) prenatally evaluated in our referral center between 1998 and 2014 were included. Fetuses with additional congenital anomalies and those with incomplete follow-up were excluded. Prenatal diagnostic accuracy and short-term survival were analyzed for the different types of TGA.

RESULTS

The TGA type was correctly ascertained prenatally in 93.3%. Most fetuses were diagnosed with simple TGA (62.7%). There were 6 discrepancies: 5 fetuses with simple TGA had postnatally TGA + ventricular septal defect (VSD; n = 3) or TGA + VSD + coarctation of the aorta (n = 2), and 1 fetus with TGA + VSD postnatally showed severe left ventricular outflow tract obstruction. The mortality rate was 6.6%; it was higher in complex versus simple forms (12.8 vs. 1.9%, p = 0.038), and in cases with intramural coronary artery versus those without (60 vs. 3.5%, p < 0.001). We found no relationship between the arrangement of the great arteries and coronary arterial abnormalities.

CONCLUSIONS

Simple TGA has a better outcome than the complex forms. A discrepancy rate of 7% with potential influence on the prognosis of survival between the prenatal diagnosis of the TGA type and the definitive diagnosis was found.

Transposition of the great arteries--outcomes and time interval of early neonatal repair

BACKGROUND

This study evaluates the relationship of morbidity and resource utilization with the timing of early neonatal repair of transposition of the great arteries and intact ventricular septum (d-TGA/IVS).

METHODS

All patients with d-TGA/IVS who underwent arterial switch in the first 14 days of life, between January 2000 and May 2011, were reviewed. Patients undergoing repair at ≤ 4 days of age were categorized as group I, 5 to 7 days as group II, and 8 to 14 days as group III. Outcomes included mortality, morbidity, and resource utilization.

RESULTS

Hospital survival was 69 (98.6%) of 70. The length of stay (LOS) and total charges were lowest in group I--15.5 days compared to group II--18.0 days and group III--23.5 days (P = .005); group I--US$128,219 compared to group II--US$141,729 and group III--US$217,427 (P = .0006). Using regression analysis to account for potentially confounding effects of multiple variables and treating time as a continuous variable demonstrated that age at surgery was significantly associated with total LOS (P = .029), hospital charges (P = .029) and intensive care unit charges (P = .002). Younger age at repair was not associated with worse outcomes for any measure of morbidity.

CONCLUSIONS

Earlier repair of d-TGA/IVS was associated with decreased resource utilization and no detriment to clinical outcomes. Further analysis based on a larger cohort of patients is needed to verify these results that have important implications for improving the value of care.

D-transposition of the great arteries: the current era of the arterial switch operation

This paper aims to update clinicians on "hot topics" in the management of patients with D-loop transposition of the great arteries (D-TGA) in the current surgical era. The arterial switch operation (ASO) has replaced atrial switch procedures for D-TGA, and 90% of patients now reach adulthood. The Adult Congenital and Pediatric Cardiology Council of the American College of Cardiology assembled a team of experts to summarize current knowledge on genetics, pre-natal diagnosis, surgical timing, balloon atrial septostomy, prostaglandin E1 therapy, intraoperative techniques, imaging, coronary obstruction, arrhythmias, sudden death, neoaortic regurgitation and dilation, neurodevelopmental (ND) issues, and lifelong care of D-TGA patients. In simple D-TGA: 1) familial recurrence risk is low; 2) children diagnosed pre-natally have improved cognitive skills compared with those diagnosed post-natally; 3) echocardiography helps to identify risk factors; 4) routine use of BAS and prostaglandin E1 may not be indicated in all cases; 5) early ASO improves outcomes and reduces costs with a low mortality; 6) single or intramural coronary arteries remain risk factors; 7) post-ASO arrhythmias and cardiac dysfunction should raise suspicion of coronary insufficiency; 8) coronary insufficiency and arrhythmias are rare but are associated with sudden death; 9) early- and late-onset ND abnormalities are common; 10) aortic regurgitation and aortic root dilation are well tolerated; and 11) the aging ASO patient may benefit from "exercise-prescription" rather than restriction. Significant strides have been made in understanding risk factors for cardiac, ND, and other important clinical outcomes after ASO.

"Baby Heart Project": the Italian project for accreditation and quality management in pediatric cardiology and cardiac surgery

Optimization of the relationship between the supply and the demand for medical services should ideally be taken into consideration for the planning within each national Health System. Although government national health organizations embrace this policy specifically, the contribution of expert committees (under the scientific societies' guarantee in any specific medical field) should be advocated for their capability to collect and analyze the data reported by the various national institutions. In addition, these committees have the competence to analyze the need for the resources necessary to the operation of these centers. The field of pediatric cardiology and cardiac surgery may represent a model of clinical governance of particular interest with regard to programming and to a definition of the quality standards that may be extended to highly specialized institutions and ideally to the entire Health System. The "Baby Heart Project," which represents a model of governance and clinical quality in the field of pediatric cardiology and cardiac surgery, was born from the spontaneous aggregation of a committee of experts, supported by duly appointed Italian Scientific Societies and guided by a national agency for accreditation. The ultimate aim is to standardize both procedures and results for future planning within the national Health System.

Characteristics and outcomes of transposition of great arteries in the neonatal period

INTRODUCTION AND OBJECTIVES

Transposition of the great arteries is a prevalent congenital heart defect with a high survival rate and a good long-term outcome, especially if managed with early surgical intervention during the neonatal period. In this study, our main objective was to describe patient characteristics and outcomes and to identify possible predictors of early and long-term morbidity and mortality.

METHODS

Retrospective analysis through review of clinical and surgical charts of patients with transposition of the great arteries admitted to the service of neonatology during 2000-2011.

RESULTS

The study included 136 patients; 119 of them had undergone corrective surgery during the neonatal period. Patients were divided into 3 groups: group I, 81 cases of isolated transposition; group II, 24 cases with ventricular septal defect; and group III, 31 with "complex" transposition of the great arteries. The overall postoperative survival was 96.7% (115 of 119 patients); no patients from group I died after surgery. Duration of surgery, intubation, inotropic treatment, and length of stay were higher in patients in groups II and III. The overall survival rate after an average of 6 years of follow-up was 90.4% 123 of 136 patients, with no deaths after discharge in group I. The most frequent residual defect during cardiac follow-up was supravalvular pulmonary stenosis, in 33 of 113 patients that had follow-up data.

CONCLUSIONS

In our study, the survival rate was high in patients with transposition of great arteries and especially in those undergoing arterial switch. The number of subsequent residual heart defects was low.

Arterial switch for transposed great vessels with intact ventricular septum beyond one month of age

BACKGROUND

Late referral of patients with transposition of the great arteries (TGA) and intact ventricular septum (IVS) is common in China. This study investigates the impact of later age on the arterial switch operation (ASO) performed for TGA-IVS beyond 1 month of age.

METHODS

From 2000 to 2011, a total 109 patients with TGA-IVS were referred over 1 month of age. In group A, 78 patients with satisfactory left ventricular (LV) geometry underwent a one-stage ASO. In group B, 31 patients with LV regression underwent a two-stage ASO with prior LV retraining.

RESULTS

The median age at ASO was older in group B (6 months, versus group A 1.9 months; p = 0.01). Group A had more frequent patent ductus arteriosus (70.5%, versus group B 38.7%; p = 0.02). The in-hospital mortality was similar in both groups (group A 2.6%, group B 9.7%; p = 0.14). Late mortality was higher in group B (16%, versus group A 2.7%; p = 0.03), as well as aortic regurgitation rate (group A 9.8% versus group B 33.3%; p = 0.01). The median duration of retraining in group B was 18 days. There were no deaths at retraining, although 2 patients required revision of the pulmonary artery banding. The only significant risk factor for late mortality in group B was age at retraining, as continuous variable (p = 0.04). Age beyond 3 months at LV retraining was associated with late impaired LV ejection fraction (p = 0.01).

CONCLUSIONS

The overall outcomes of ASO for TGA-IVS performed beyond 1 month of age are satisfactory. Two-stage ASO has higher late mortality and more neoaortic regurgitation. Later age at retraining is associated with higher late mortality. Age beyond 3 months at retraining is associated with impaired LV function.

Coronary implantation using the autologous flap extension technique in complicated arterial switch operations

The arterial switch operation (ASO) remains a challenging procedure, especially in cases with a complicated coronary anatomy. In recent years, the autologous flap extension technique has been used for coronary implantation in complicated ASOs. Operative techniques and indications are discussed in this report. From January 2006 to June 2011, ASO with the autologous flap extension technique for coronary implantation was used for 21 patients, including five cases involving transposition of the great arteries (TGA) with an intact ventricular septum, eight cases involving TGA with a ventriculoseptal defect, five cases of Taussig-Bing anomaly, and three cases involving corrected TGA. Age at operation varied between 3 and 314 days (median, 110 days). Body weight varied between 3.1 and 14 kg (median, 5.4 kg). Three patients underwent a two-stage operation. In all the patients, the main trunk of the right coronary artery or the dilated right ventricular conus branch originated from the left- or right-facing sinus and followed an abnormal course of anterior looping to the aorta. The operative techniques included a long coronary button excised from the aorta and a pedicle flap on the pulmonary artery (neoaorta) cut as a cuff extended to the button of the coronary artery with equal distance. The side edges of the flap and the button were sutured to each other, thus forming an extension tube that lengthened the coronary artery. No in-hospital operative mortality occurred. Delayed sternum closure occurred in five cases. The average mechanical ventilator time was 101.6 h. The average intensive care unit stay was 9.5 days. Follow-up evaluation after discharge was complete in 17 cases. Growth and development were improved in all patients. No ischemic electrocardiographic changes occurred. One patient underwent reoperation for supravalvular pulmonary stenosis 2 years later. The autologous flap extension technique for coronary implantation in complicated ASOs can decrease hospital mortality due to abnormal coronary arteries, especially for patients undergoing two-stage ASOs or patients whose main trunk of the right coronary artery or dilated right ventricular conus branch originates from the left- or right-facing sinus and follows an abnormal course of anterior looping to the aorta.

Complexity stratification of the arterial switch operation: a second learning curve

The arterial switch operation has become a safe operation in many centres. The complexity of the procedure has evolved over the last two decades. Several anatomical features can hardly be considered complex today, namely, normal coronary anatomy, circumflex coming off the right coronary artery, eccentric ostium, and early take-off of an infundibular artery. In addition, as peri-operative mortality becomes very low, the outcomes need to be evaluated on the peri-operative morbidity, late reoperations, and late deaths. The arterial switch operation remains complex in around 20% of the cases, where one or several complexity factors are associated. The complexity of the coronary arteries is a major factor. According to a classification essentially based on the course of the coronary arteries, complex coronaries include: double-looping coronaries, anterior-looping coronaries, intramural coronaries, and single coronary ostium. The most challenging coronary pattern remains the association of a single ostium with intramural course. Other features are equally complex: severe malalignment of the commissures, aortic arch obstruction, multiple ventricular septal defect, Taussig-Bing with subaortic obstruction, double-outlet right ventricle non-committed ventricular septal defect, transposition of the great arteries-intact ventricular septum >3 weeks, transposition of the great arteries-ventricular septal defect with high lung resistances and weight <2.5 kg. Owing to the fact that the risks of arterial switch operation vary according to the experience of the centres, we defined the arterial switch operation complexity based on a subjective approach as proposed by the Aristotle comprehensive score. The recent introduction of a morbidity score will allow to stratify more accurately the outcomes when the peri-operative mortality is very low or nil. The complexity of the coronary patterns tends to be well controlled today. It remains that rare coronary failures and aortic root dilation will occur in the long term, requiring a close follow-up of the most complex patients. Successfully achieving complex arterial switch operation implies a second learning curve.

Clinical features and surgical outcomes of complete transposition of the great arteries

Purpose

This single-center study aimed to assess the clinical features and surgical approaches and outcomes of complete transposition of the great arteries (TGA).

Methods

TGA patients who had undergone surgical correction at the Kyungpook National University Hospital from January 2000 to December 2010, were retrospectively evaluated for patient characteristics, clinical manifestation, preoperative management, intraoperative findings, postoperative progress, and follow-up status.

Results

Twenty-eight patients (17 boys and 11 girls, mean age=10.6±21.5 days) were included and were categorized as follows: group I, TGA with intact ventricular septum (n=13); group II, TGA with ventricular septal defect (VSD, n=12); and group III, TGA/VSD with pulmonary stenosis (n=3). Group I underwent the most intensive preoperative management (balloon atrial septostomy and prostaglandin E1 medication). Group II showed the highest incidence of heart failure (P<0.05). Usual and unusual coronary anatomy patterns were observed in 20 (71%) and 8 patients, respectively. Arterial and half-turned truncal switch operations were performed in 25 and 3 patients (Group III), respectively. Postoperative complications included cardiac arrhythmias (8 patients), central nervous system complications (3 patients), acute renal failure (1 patient), infections (3 patients), and cardiac tamponade (1 patient), and no statistically significant difference was observed between the groups. Group II showed the mildest aortic regurgitation on follow-up echocardiograms (P<0.05). One patient underwent reoperation, and 1 died. The overall mortality rate was 4%.

Conclusion

Our study showed favorable results in all the groups and no significant difference in postoperative complication, reoperation, and mortality among the groups. However, our results were inadequate to evaluate the risk factors for reoperation and mortality owing to the small number of patients and short follow-up duration.

Morbidity of the arterial switch operation

BACKGROUND

The arterial switch operation (ASO) has become a safe, reproducible surgical procedure with low mortality in experienced centers. We examined morbidity, which remains significant, particularly for complex ASO.

METHODS

From 2003 to 2011, 101 consecutive patients underwent ASO, arbitrarily classified as "simple" (n=52) or "complex" (n=49). Morbidity was measured in selected complications and postoperative hospitalization. Three outcomes were analyzed: ventilation time, postextubation hospital length of stay, and a composite morbidity index, defined as ventilation time+postextubation hospital length of stay+occurrence of selected major complications. Complexity was measured with the comprehensive Aristotle score.

RESULTS

The operative mortality was zero. Twenty-five major complications occurred in 23 patients: 6 of 25 (12%) in simple ASO and 19 of 49 (39%) in complex ASO (p=0.002). The most frequent complication was unplanned reoperation (15 vs 6, p=0.03). No patients required permanent pacing. The complex group had a significantly higher morbidity index and longer ventilation time and postextubation hospital length of stay. In multivariate analysis, factors independently predicting higher morbidity were the comprehensive Aristotle score, arch repair, bypass time, and malaligned commissures. Myocardial infarction caused one sudden late death at 3 months. Late coronary failure was 2%. Overall survival was 99% at a mean follow-up of 49±27 months.

CONCLUSIONS

In this consecutive series without operative mortality, morbidity was significantly higher in complex ASO. The only anatomic incremental risk factors for morbidity were aortic arch repair and malaligned commissures, but not primary diagnosis, weight less than 2.5 kg, or coronary patterns.

[Prognostic evaluation of arterial switch in the transposition of great arteries]

INTRODUCTION AND OBJECTIVES

The arterial switch is the procedure of choice for transposition of great arteries, with or without ventricular septal defect. The aim of this study was to identify risk factors for hospital mortality.

METHODS

The study included 121 children between January 1994 and June 2008. Of these, 80 (66%) were diagnosed with intact ventricular septum, and 41 (34%) with ventricular septal defect. Variables were collected pre-operatively, during surgery, and postoperatively.

RESULTS

The mean age was 11 [8 to 16] days and a mean weight of 3.5 [3.0 to 3.7] kg. A ventricular septal defect was closed in 11 children (9.1%). A total of 81.8% had a normal coronary pattern. There was delayed closure of the chest in 38 patients (31.4%). The hospital mortality was 11.6%, decreasing over the past 5 years to 2.1%. The weight, abnormal coronary pattern, time of cardiopulmonary bypass, mean arterial pressure at admission, pulmonary dead space, and delayed closure of the chest, were risk factors of mortality. The model that best predicts death, consists of the mean arterial pressure at admission, and delayed closure of the chest.

CONCLUSIONS

The reduction in extracorporeal circulation time and the use of delayed closure of the chest, have helped to reduce mortality. The abnormal coronary pattern remains a risk factor for mortality. In children with delayed closure of the chest, a mean arterial pressure at admission ≥ 47.5 mmHg is a goal to achieve.

Analysis of 8681 neonates with transposition of the great arteries: outcomes with and without Rashkind balloon atrial septostomy

BACKGROUND

Rashkind balloon atrial septostomy is a common cardiac procedure aimed at improving systemic oxygenation in newborns with cyanotic congenital cardiac defects, such as transposition of the great arteries. Recent reports on the safety of this procedure were from limited series at single institutions. We analysed two complementary national databases to evaluate clinically relevant outcomes of this procedure.

METHODS AND RESULTS

We performed an analysis of transposition of the great artery patients nationwide using 15 years of the Nationwide In-patient Sample and three complementary years of the Kids' Inpatient Database. Variables included gender, race, age, and co-existing diagnoses. Outcomes included mortality, length of stay, and hospital charges. Comparison between patients undergoing Rashkind procedure or not was performed using Pearson's chi-square and Kruskal-Wallis tests. We identified 8681 patients with transposition of the great arteries, of whom 1742 (20%) underwent Rashkind procedure. Patients undergoing Rashkind procedure had lower mortality (10% versus 12%, p = 0.021), despite higher median co-morbidities and longer median length of stay. Rashkind procedure was not associated with increased risk of necrotising enterocolitis (1% versus 1%, p = 0.630), but was associated with nearly twice the risk of clinically recognised stroke (1% versus 0%, p = 0.046).

CONCLUSIONS

This study represents the largest national analysis of transposition of the great artery patients to date, with a subset treated with Rashkind procedure. Patients not undergoing Rashkind procedure had higher mortality. Rashkind procedure was not associated with increased risk of necrotising enterocolitis, but was associated with twice the risk of stroke.