Atrioventricular discordance: results of repair in 127 patients

Cardiac MR imaging reveals L-type transposition of the great vessels and failing right heart

L-type transposition of the great vessels is a rare congenital heart disease in which both the great arteries and the ventricular chambers are reversed. Because this condition preserves a physiologic circulatory pathway, it can be challenging to diagnose in infants with no concurrent cardiac abnormalities. Early detection is essential, however, because these patients will eventually experience severe complications, as the structural right ventricle is unable to function long-term in the systemic position. We report a rare case of L-type transposition of the great vessels in a 32-year-old male who presented in adulthood with tachycardia and palpitations. The initial echocardiogram was inconclusive. Further imaging (cardiac MRI & transesophageal echocardiogram) revealed the inverted anatomy due to the presence of key morphological features, such as the malposed great vessels along with the moderator band and prominent trabeculae within the right ventricle, which was functioning systemically.

Congenitally corrected transposition of the great arteries outcomes of different surgical techniques in a paediatric population: A single-centre report

BACKGROUND

Congenitally corrected transposition of the great arteries is a complex pathology characterised by atrioventricular and ventriculo-arterial discordance. Optimal surgical approaches are still a matter of debate.

OBJECTIVE

To evaluate the outcomes of different surgical treatments in a single centre.

METHODS

Between 1998 and 2020, 89 patients were studied. The cohort was divided into three groups: physiologic, anatomic, and univentricular repair.

RESULT

Physiologic correction (56.18%) was associated with significant tricuspid valve regurgitation progress (42%) and complete AV block (30%) compared to anatomic repair. Right ventricular systolic dysfunction was developed in 14%. Instead, anatomic correction (30.34%) (double switch 59% and Rastelli type 40.7%) presented moderate to severe aortic regurgitation (4%) and left ventricular systolic dysfunction (11%). Complete AV block was developed in 14.8%. Rate of reintervention was 34% for physiologic and 26% for anatomic. Univentricular palliation (13.8%) presented no complications or late mortality during the follow-up. The overall survival at 5 and 10 years, respectively, was 80% (95% CI 69, 87) and 75% (95% CI 62, 84). There was no statistically significant difference in mortality between the groups (p log-rank = 0.5752).

CONCLUSION

Management of congenitally corrected transposition of the great arteries remains a challenge. In this cohort, outcomes after physiologic repair were satisfactory in spite of the progression of tricuspid regurgitation and the high incidence of AV block. Anatomic repair improved tricuspid regurgitation but increased the risk of aortic regurgitation and left ventricular systolic dysfunction. The Fontan group showed the lowest incidence of complications.

Contemporary outcomes of the double switch operation for congenitally corrected transposition of the great arteries

OBJECTIVE

To determine the contemporary outcomes of the double switch operation (DSO) (ie, Mustard or Senning + arterial switch).

METHODS

A single-institution, retrospective review of all patients with congenitally corrected transposition of the great arteries undergoing a DSO.

RESULTS

Between 1999 and 2019, 103 patients underwent DSO with a Mustard (n = 93) or Senning (n = 10) procedure. Segmental anatomy was (S, L, L) in 93 patients and (I, D, D) in 6 patients. Eight patients had heterotaxy and 71 patients had a ventricular septal defect. Median age was 2.1 years (range, 1.8 months-40 years), including 34 patients younger than age 1 year (33%). Median weight was 10.9 kg (range, 3.4-64 kg). Sixty-one patients had prior pulmonary artery bands for a median of 1.1 years (range, 14 days-12.9 years; interquartile range, 0.7-3.1 years). Median intensive care unit and hospital lengths of stay were 5 and 10 days, respectively. Median follow-up was 3.4 years (interquartile range, 1-9.8 years) and 5.2 years (interquartile range, 2.3-10.7 years) in 79 patients with >1 year follow-up. At latest follow-up, aortic, mitral, tricuspid valve regurgitation, and left ventricle dysfunction was less than moderate in 96%, 98%, 96%, and 93%, respectively. Seventeen patients underwent reoperation: neoaortic valve intervention (n = 10), baffle revision (n = 5), and ventricular septal defect closure (n = 4). At latest follow-up, 17 patients (17%) had a pacemaker and 27 (26%) had cardiac resynchronization therapy devices. There were 2 deaths and 2 transplants. Transplant-free survival was 94.6% at 5 years. Risk factors for death or transplant included longer cardiopulmonary bypass time and older age at DSO.

CONCLUSIONS

The outcomes of the DSO are promising. Earlier age at operation might favor better outcomes. Progressive neoaortic regurgitation and reinterventions on the neo-aortic valve are anticipated problems.

Congenitally Corrected Transposition Presenting in the First Year of Life: Survival and Fate of the Systemic Right Ventricle

Introduction:

Knowledge gaps exist in the life expectancy and functional outcome of patients with congenitally corrected transposition (ccTGA) presenting early in life, which is relevant in the evaluation of early anatomic repair.

Methods:

In a single-center analysis, 91 patients with ccTGA were identified over 25 years, of which 31 presented with biventricular anatomy in the first year of life and formed the study cohort. End points for analysis included survival, moderate or worse tricuspid valve regurgitation, and systemic right ventricle (RV) dysfunction. Median follow-up was 4.9 years (range: 7 days to 20 years).

Results:

Among 31 patients presenting in the first year of life, 9 (29%) never received cardiac surgery, while 22 (71%) underwent 36 cardiac operations. Overall freedom from moderate or severe systemic RV dysfunction was 75% at 10 years. Overall survival was 82% at 10 years. Surgical mortality was 5.6% (2/36). Among survivors with a systemic RV, 23 (100%) of 23 were Ross or NYHA class I or II at last follow-up.

Conclusions:

Congenitally corrected transposition presenting in the first year of life and maintaining a systemic RV can expect (1) long-term survival of more than 80% at 10 years, (2) low expected surgical mortality (overall 6%), and (3) 75% late freedom from major RV dysfunction at 10 years. Pending multi-institutional analyses, this experience with a systemic RV in ccTGA provides an initial benchmark for comparison when considering early elective anatomic correction.

Anatomical correction of atrioventricular discordance using three-dimensional replica

Surgical experience with {S,L,D} segmental anatomy of atrioventricular discordance with double-outlet right ventricle is extremely rare. In addition to ordinary cardiac examination, we reviewed electrophysiological studies and a three-dimensional cardiac replica (crossMedical, Inc., Kyoto, Japan). Consequently, we preoperatively confirmed the intracardiac rerouting line and the appropriate right ventricle incision line. A Senning procedure, intracardiac rerouting, and subaortic stenosis resection were performed in a 2.6-year-old patient (weight, 10.6 kg). The three-dimensional cardiac replica contributed definitively to the anatomical correction.

Echocardiography-Derived Left Ventricular Outflow Tract Gradient and Left Ventricular Posterior Wall Thickening Are Associated with Outcomes for Anatomic Repair in Congenitally Corrected Transposition of the Great Arteries

BACKGROUND

Congenitally corrected transposition of the great arteries is a rare form of congenital heart disease. Management is controversial; options include observation, physiologic repair, and anatomic repair. Assessment of morphologic left ventricle preparedness is key in timing anatomic repair. This study's purpose was to review the modalities used to assess the morphologic left ventricle preoperatively and to determine if any echocardiographic variables are associated with outcomes.

METHODS

A retrospective review of patients with congenitally corrected transposition of the great arteries eligible for anatomic repair at Lucile Packard Children's Hospital from 2000 to 2016 was conducted. Inclusion criteria were (1) presurgical echocardiography, magnetic resonance imaging, and cardiac catheterization and (2) clinical follow-up information. Echocardiographic measurements included left ventricular (LV) single-plane Simpson's ejection fraction, LV eccentricity index, LV posterior wall thickening, pulmonary artery band (PAB)/LV outflow tract (LVOT) pressure gradient, and LV and right ventricular strain. Magnetic resonance imaging measurements included LV mass, ejection fraction, eccentricity index, and LV thickening. LV pressure, PAB/LVOT gradient, right ventricular pressure, pulmonary vascular resistance, and Qp/Qs constituted catheterization data. Outcomes included achieving anatomic repair within 1 year of assessment in patients with LVOT obstruction or within 1 year of pulmonary artery banding and freedom from death, transplantation, or heart failure at last follow-up.

RESULTS

Forty-one patients met the inclusion criteria. PAB/LVOT gradients of 85.2 ± 23.4 versus 64.0 ± 32.1 mm Hg (P = .0282) by echocardiography and 60.1 ± 19.4 versus 35.9 ± 18.9 mm Hg (P = .0030) by catheterization were associated with achieving anatomic repair and freedom from death, transplantation, and heart failure. Echocardiographic LV posterior wall thickening of 35.4 ± 19.8% versus 20.6 ± 15.0% (P = .0017) and MRI LV septal wall thickening of 37.1 ± 18.8% versus 19.3 ± 18.8% (P = .0306) were associated with achieving anatomic repair. Inter- and intraobserver variability for echocardiographic measurements was very good.

CONCLUSIONS

PAB/LVOT gradient and LV posterior wall thickening are highly reproducible echocardiographic measurements that reflect morphologic LV performance and can be used in assessing patients with congenitally corrected transposition of the great arteries undergoing anatomic repair.

Left Ventricular Retraining and Double Switch in Patients With Congenitally Corrected Transposition of the Great Arteries

PURPOSE

Congenitally corrected transposition of the great arteries (CC-TGA) is a complex form of congenital heart defect with numerous anatomic subgroups. The majority of patients with CC-TGA are excellent candidates for a double-switch procedure. However, in the absence of an unrestrictive ventricular septal defect or subpulmonary stenosis, the left ventricle (LV) may undergo involution and require retraining prior to double switch. The purpose of this study was to review our experience with patients having CC-TGA who required LV retraining prior to a double-switch procedure.

METHODS

This was a retrospective review of 24 patients with CC-TGA who were enrolled in an LV retraining program in preparation for a double-switch procedure. The median age at the time of enrollment for retraining was 11 months (range 1 month-24 years). The average left ventricle to right ventricle pressure ratio was 0.39 ± 0.07 prior to intervention. All 24 patients underwent placement of an initial pulmonary artery band (PAB) for LV retraining.

RESULTS

Eighteen (75%) of the 24 patients underwent a double-switch procedure with no operative mortality. Of these 18 patients, 9 had a single PAB and 9 required a second band for retraining. Six patients have not undergone a double-switch procedure to date. Five patients are good candidates for a double switch and are 2 weeks, 3 weeks, 4 weeks, 8 months, and 35 months since their last PAB. One patient died from a noncardiac cause 26 months after PAB retightening. The 18 patients who underwent a double switch were followed for an average of 5 ± 1 years (range 0.1-10.3 years). There has been no late mortality, and only 2 patients required further reinterventions.

CONCLUSION

The data demonstrate that LV retraining has been highly effective in this select group of patients with CC-TGA. The data also demonstrate that the results of the double-switch procedure have been excellent at midterm follow-up. These results suggest that LV retraining and double switch offer a reliable strategy option for patients with CC-TGA.

Clinical Outcomes after Anatomic Repair Including Hemi-Mustard Operation in Patients with Congenitally Corrected Transposition of the Great Arteries

Background and Objectives

The aims of this study were to determine the early and late outcomes of anatomic repair of congenitally corrected transposition of the great arteries (ccTGA) and to evaluate effectiveness of the hemi-Mustard procedure.

Subjects and Methods

We conducted a retrospective, single-center study of patients who underwent anatomic repair for ccTGA between July 1996 and December 2013. Sixteen patients were included in the study. The median age at the time of the operation was 3.5 years (range: 0.5-29.7), and the median body weight was 13.3 kg (range: 5.8-54). The median follow-up duration was 7.7 years (range: 0.2-17.4).

Results

Atrial switch was achieved using the Mustard procedure in 12 patients (hemi-Mustard procedure in 11) or the Senning procedure in four patients. The ventriculoarterial procedure was performed using the Rastelli procedure in 11 patients and arterial switch in five patients. Six patients underwent tricuspid valvuloplasty. The survival rate was 93.8±6.1%. The rate of freedom from reoperation at 5 years was 92.3±7.4% in the Rastelli group. All patients except one were New York Heart Association class I. All patients except one had mild tricuspid regurgitation.

Conclusion

Anatomic repair can be performed with a low risk of in-hospital mortality. The hemi-Mustard strategy for selected patients is one solution for reducing early mortality and morbidity, and long-term complications such as venous pathway stenosis or sinus node dysfunction.

Anesthetic Considerations for Adult Cardiac Surgery Patients with Congenital Heart Disease

The number of adults with congenital heart disease surviving into adulthood is increasing. The proportion of adults undergoing revision of a previous repair is increasing in comparison to those that present for a palliative or curative operation. At the Toronto Congenital Cardiac Centre for Adults, 528 patients underwent cardiac surgery between January 1, 1992 and December 31, 2001. The anesthetic management of the surgical correction of simple and complex congenital heart lesions includes general physiologic considerations such as dysrhythmias, hypoxemia, polycythemia, and pulmonary hypertension. Palliative shunts from early childhood have anatomical and physiologic implications for the adult. Preparation for the operating room and postoperative care are natural extensions of the anesthetic management of the surgical correction of the congenital heart lesions. Anesthetic management of septal lesions in the interventional suite and operating room is discussed. Complex lesions such as tetralogy of Fallot, transposition of the great arteries, Glenn anastomosis, and the Fontan operation are reviewed. The anesthetic management of these patients is rewarding but impossible without an integrated team approach involving cardiologists, surgeons, perfusionists, and nursing staff.

Late left ventricular dysfunction after anatomic repair of congenitally corrected transposition of the great arteries

OBJECTIVE

Early results for anatomic repair of congenitally corrected transposition of the great arteries (ccTGA) are excellent. However, the development of left ventricular dysfunction late after repair remains a concern. In this study we sought to determine factors leading to late left ventricular dysfunction and the impact of cardiac resynchronization as a primary and secondary (upgrade) mode of pacing.

METHODS

From 1992 to 2012, 106 patients (median age at surgery, 1.2 years; range, 2 months to 43 years) with ccTGA had anatomic repair. A retrospective review of preoperative variables, surgical procedures, and postoperative outcomes was performed.

RESULTS

In-hospital deaths occurred in 5.7% (n = 6), and there were 3 postdischarge deaths during a mean follow-up period of 5.2 years (range, 7 days to 18.2 years). Twelve patients (12%) developed moderate or severe left ventricular dysfunction. Thirty-eight patients (38%) were being paced at latest follow-up evaluation. Seventeen patients had resynchronization therapy, 9 as an upgrade from a prior dual-chamber system (8.5%) and 8 as a primary pacemaker (7.5%). Factors associated with left ventricular dysfunction were age at repair older than 10 years, weight greater than 20 kg, pacemaker implantation, and severe neo-aortic regurgitation. Eight of 9 patients undergoing secondary cardiac resynchronization therapy (upgrade) improved left ventricular function. None of the 8 patients undergoing primary resynchronization developed left ventricular dysfunction.

CONCLUSIONS

Late left ventricular dysfunction after anatomic repair of ccTGA is not uncommon, occurring most often in older patients and in those requiring pacing. Early anatomic repair and cardiac resynchronization therapy in patients requiring a pacemaker could preclude the development of left ventricular dysfunction.

Morphology, Surgical Techniques, and Outcomes in Patients Above 15 Years Undergoing Surgery for Congenitally Corrected Transposition of Great Arteries

Background:

There is a paucity of data about morphology, surgical procedure, and results in older patients with congenitally corrected transposition of great arteries (ccTGAs).

Patients and Methods:

Between January 2002 and August 2012, 15 patients (7 males), median age 25 years, range 16 to 41 years underwent surgery for ccTGA. Associated lesions were tricuspid regurgitation (TR; n = 5) and ventricular septal defect (VSD) with pulmonary stenosis (PS; n = 10). Surgical procedures included tricuspid valve replacement (n = 4), tricuspid valve repair (n = 1), lateral tunnel Fontan (n = 2), extracardiac Fontan (n = 2), Kawashima procedure (n = 1), bidirectional (BD) Glenn (n = 2), Senning + Rastelli procedure (n = 1), and VSD closure + left ventricle to pulmonary artery conduit (n = 1). The details of these procedures and outcomes were analyzed.

Results:

There were no early or late deaths. Mean follow-up period was 49.9 ± 26 months. All patients who underwent tricuspid valve replacement are in New York Heart Association (NYHA) class I, with no progression of right ventricular (RV) dysfunction. One patient who underwent tricuspid valve repair is in NYHA class III and has progressed to severe RV dysfunction. None of the patients undergoing single ventricle palliation had any complications related to the surgery. Both patients who underwent anatomical and physiological biventricular (BV) repair had no complications.

Conclusions:

Older patients with ccTGA present a challenge. Fontan/BD Glenn remains a good option for patients who presented with VSD PS. Both anatomic and physiological BV repairs provide acceptable results. Tricuspid valve replacement is safe for patients presenting with TR who have improvement in functional class, though the right ventricular function may not improve.

Congenital Heart Defects in Adults : A Field Guide for Cardiologists

Advances in cardiology and cardiac surgery allow a large proportion of patients with congenital heart defects to survive into adulthood. These patients frequently develop complications characteristic of the defect or its treatment. Consequently, adult cardiologists participating in the care of these patients need a working knowledge of the more common defects. Occasionally, patients with congenital heart defects such as atrial septal defect, Ebstein anomaly or physiologically corrected transposition of the great arteries present for the first time in adulthood. More often patients previously treated in pediatric cardiology centers have transitioned to adult congenital heart disease centers for ongoing care. Some of the more important defects in this category are tetralogy of Fallot, transposition of the great arteries, functionally single ventricle defects, and coarctation. Through this field guide, we provide an overview of the anatomy of selected defects commonly seen in an adult congenital practice using pathology specimens and clinical imaging studies. In addition, we describe the physiology, clinical presentation to the adult cardiologist, possible complications, treatment options, and outcomes.

Long term follow up after surgery in congenitally corrected transposition of the great arteries with a right ventricle in the systemic circulation

Aim of the study

To investigate the long-term outcome of surgical treatment for congenitally corrected transposition of the great arteries (CCTGA), in patients with biventricular repair with the right ventricle as systemic ventricle.

Methods

A total of 32 patients with CCTGA were operated between January 1972 and October 2008. These operations comprised 18 patients with a repair with a normal left ventricular outflow tract, 11 patients with a Rastelli repair of the left ventricle to the pulmonary artery and 3 patients with a cardiac transplantation.

Results

Excluding the cardiac transplantation patients, mean age at operation was 16 years (sd 15 years, range 1 week - 49 years). Median follow-up was 12 years (sd 10 years, range 7 days - 32 years). Survival obtained from Kaplan-Meier analysis at 20 years after surgery was 63% (CI 53-73%). For the non-Rastelli group these data at 20 years were 62% (CI 48-76%) and for the Rastelli group 67% (CI 51-83%). Freedom of reoperation at 20 years was 32% (CI 19-45%) in the overall group. In the non-Rastelli group the data at 20 years were 47% (CI 11-83%) and for the Rastelli group 21% (CI 0-54%) after almost 19 years.

Conclusions

Long term follow up confirms that surgery in CCTGA with the right ventricle as systemic ventricle has a suboptimal survival and limited freedom of reoperation. Death occurred mostly as a result of cardiac failure.

Congenitally corrected transposition of the great arteries: an update

Congenitally corrected transposition of the great arteries is a rare condition in which systemic venous blood returns to normally positioned atria. However, the atria are connected to the opposite ventricle, right atrium to left ventricle, left atrium to right ventricle; so-called atrioventricular discordance. In addition, the ventricles are inverted (right to left change in position) and are connected to the opposite great artery, left ventricle to pulmonary artery, right ventricle to aorta; thus, forming ventricular-arterial discordance. The aorta is anterior and to the left of the pulmonary artery, L-transposed. Atrioventricular discordance plus ventricular-arterial discordance results in normal blood flow (ie, congenitally corrected). The right ventricle with the tricuspid valve is the systemic ventricle. Common associated conditions are ventricular septal defects (VSDs), pulmonary stenosis, and congenital heart block. Major issues related to management revolve around the status of the systemic right ventricle, which can develop dysfunction with increasing age and tricuspid regurgitation, which can increase in severity with age and contribute to ventricular dysfunction. One emerging treatment is the double switch operation. In patients with no pulmonary obstruction, it is possible to switch the systemic and pulmonary venous return using an atrial baffle procedure followed by an arterial switch procedure. This results in the anatomical left ventricle now functioning as the systemic ventricle. In those patients with associated pulmonary obstruction and a VSD, another type of double switch can be performed in which the left ventricle is tunneled through the VSD to the aorta, the right ventricle is connected to the pulmonary artery with a homograft or other conduit, and the atrial baffle procedure is performed. The most difficult challenge is choosing the patient who is a candidate for the double-switch operation and the timing of that operation, or the timing of a more classical operation for associated defects.

Outcomes of biventricular repair for congenitally corrected transposition of the great arteries

BACKGROUND

This study was undertaken to evaluate long-term results of biventricular repairs for congenitally corrected transposition of the great arteries, and to analyze the risk factors that affect mortality and morbidity.

METHODS

Between 1983 and 2009, 167 patients with congenitally corrected transposition of the great arteries underwent biventricular repairs. The physiologic repairs were performed in 123 patients, and anatomic repairs in 44. Average follow-up was 9.3 +/- 6.6 years.

RESULTS

Kaplan-Meier estimated survival was 83.3% +/- 0.5% at 25 years in biventricular repair. In anatomic repair, left ventricular training and right ventricular dysfunction had negative impact on survival, but bidirectional cavopulmonary shunt had positive impact on survival. The reoperation-free ratio was 10.1% +/- 7.8% at 22 years after physiologic repair, and 46.2% +/- 12.4% at 15 years after anatomic repair (p = 0.885). Freedom from any arrhythmia was 49.6% +/- 7.5% at 22 years after physiologic repair, and 60.8% +/- 14.8% at 18 years after anatomic repair (p = 0.458). Freedom from systemic atrioventricular valve and ventricular dysfunction as well as tricuspid valve and right ventricular dysfunction was significantly higher in anatomic repair than in physiologic repair.

CONCLUSIONS

Long-term results of biventricular repair were satisfactory. Patients presenting with right ventricular dysfunction or need for left ventricular training represent a high-risk group of anatomic repair for which selection criteria are particularly important. Late functional outcomes of anatomic repair were excellent compared with physiologic repair. Anatomic repair is the procedure of choice for those patients if both ventricles are adequate or if surgical technique is modified with the help of additional a bidirectional cavopulmonary shunt.

Outcomes of definitive surgical repair for congenitally corrected transposition of the great arteries or double outlet right ventricle with discordant atrioventricular connections: Risk analyses in 189 patients

OBJECTIVE

This study was undertaken to compare long-term results of various types of surgical repairs for either congenitally corrected transposition of the great arteries or double outlet right ventricle with discordant atrioventricular connections, and to analyze the risk factors that affect early and late mortality and reintervention.

METHODS

Between January 1972 and September 2005, a total of 189 patients (median age 8.3 years, range 2 months to 47 years old) with congenitally corrected transposition of the great arteries or double outlet right ventricle with discordant atrioventricular connections underwent definitive repairs. The definitive repairs comprised a conventional repair (atrial septal defect, or ventricular septal defect closure with or without pulmonary stenosis release, or isolated tricuspid valve surgery) in 36 patients (group I), conventional Rastelli in 31 patients (group II), double-switch operation (atrial switch plus arterial switch) in 15 patients (group III), atrial switch plus intraventricular rerouting (with or without extracardiac conduits) in 69 patients (group IV), and a Fontan-type repair in 38 patients (group V). The mean follow-up period was 10.1 years. Hospitalization and late mortality and reoperation were indicated as events. Risk factors for these events were analyzed by logistic regression for hospital death and a Cox proportional hazards model for late events.

RESULTS

The Kaplan-Meier survival including hospital and late mortality was 62.4% at 32 years in group I, 78.5% at 27 years in group II, 74.5% at 15 years in group III, 80% at 16 years in group IV, and 79.3% at 22 years in group V. The reoperation-free ratio was 64.2% in group I, 76.6% in group II, 84.4% in group III, 89.6% in group IV, and 91.3% in group V. Risk analyses showed that the risk for hospital death was preoperative in patients with more than moderate tricuspid regurgitation and a cardiopulmonary bypass time of more than 240 minutes. A risk for late mortality was the presence of tricuspid regurgitation. Risks for reoperation were preoperative cardiomegaly, preoperative tricuspid regurgitation of more than grade II, ventricular septal defect enlargement, and body weight less than 10 kg. Risks for pacemaker implantation, as indicated by multivariate analysis, were ventricular septal defect enlargement during operation and age less than 3 years.

CONCLUSIONS

There were no statistical differences between long-term survival rates of patients who underwent conventional surgical repair versus those of patients who underwent anatomic surgical repair. Results of conventional repair were satisfactory except in patients with significant tricuspid regurgitation. Results of anatomic repair were also satisfactory even for patients with significant tricuspid regurgitation, and therefore, anatomic repair should be the procedure of choice for those patients.

Intermediate-term results of the Senning or Mustard procedures combined with the Rastelli operation for patients with discordant atrioventricular connections associated with discordant ventriculoarterial connections or double outlet right ventricle

BACKGROUND

In patients with discordant atrioventricular and ventriculoarterial connections, anatomic repair restores the morphologically left ventricle to its role in supporting the systemic circulation. In this study, we have evaluated the outcomes in the intermediate term for this complex surgical procedure.

METHODS

Between December 1984 and October 2003, 4 patients underwent an atrial switch operation concomitantly with a Rastelli operation, and 2 patients underwent an atrial switch operation and a patch-plasty of the pulmonary outflow tract for anatomic repair at a mean age of 3.3 plus or minus 2.1 years. All patients had intracardiac rerouting, connecting the morphologically left ventricle to the aorta.

RESULTS

There were no hospital deaths. In 5 patients, reoperation was needed, either for baffle complications, exchange of the conduit, repair of a residual ventricular septal defect, or relief of obstruction within the left ventricular outflow tract. Death occurred in 1 patient, from cardiac failure 6 months after correction. Mean follow-up time was 6.5 plus or minus 6.4 years, with a range from 6 months to 17 years. At follow-up, 1 patient presented with moderate tricuspid insufficiency, and 1 patient with mild obstruction of the pulmonary venous pathway. The remaining 3 patients showed good left and right ventricular function, and no, or mild tricuspid and mitral insufficiency.

CONCLUSIONS

Anatomic repair can be performed with low hospital mortality. Restoration of the morphologically left ventricle into the systemic circulation in patients with discordant atrioventricular and ventriculoarterial connections is a demanding approach, associated with various reoperations over time. Despite this, the approach seems to be an appropriate solution for selected patients, since the majority of the patients show good left and right ventricular function, and no, or mild tricuspid and mitral insufficiency up to 17 years after correction.

State of the art of cardiac surgery in patients with congenital heart disease

During the last 20 years, pediatric cardiac surgery has been characterized by important changes, with reductions in surgical mortality and the achievement of complete repair at an earlier age, thus avoiding multiple procedures and strongly ameliorating the global outcome of these patients. In this review, we describe the actual trends in the surgical treatment of cardiac malformations. We analyze two groups of patients: in the first group (septal defects, tetralogy of Fallot, transposition of the great arteries, aortic stenosis and coarctation) the indications are well established and the goal is represented by a lessening of the surgical trauma and post-operative morbidity, with stable results in the follow-up. In the second group (univentricular heart, pulmonary atresia and intact ventricular septum, double discordance, conduit, hypoplastic left heart syndrome), the lesions are still considered complex and submitted to ongoing experimental and clinical research, in order to improve the post-surgical history of these diseases.

Cardiorespiratory responses to exercise after anatomic repair of atrioventricular discordance with abnormal ventriculoarterial connection

We evaluated exercise tolerance and cardiorespiratory responses to exercise in patients with atrioventricular discordance (AVD) and abnormal ventriculoarterial connection after anatomic repair. Cardiopulmonary treadmill exercise testing with gas measurement was done 62 times in 19 patients with AVD who had undergone anatomic repair at the National Cardiovascular Center. Exercise duration, oxygen uptake (V(O2)) and heart rate at anaerobic threshold and peak, and oxygen pulse during exercise were significantly lower in patients with AVD after anatomic repair than in controls. Carbon dioxide ventilatory equivalent during exercise was worse in patients with AVD after anatomic repair than in controls. Percentage peak V(O2) significantly correlated positively with percentage peak oxygen pulse and tended to correlate positively with the heart rate increments. Patients with AVD after anatomic repair exhibit impaired responses of heart rate and oxygen pulse with lower exercise capacity. Careful attention should be paid to patients with AVD after anatomic repair in terms of their functional capacity as well as other postoperative complications.

Determinants of Left Ventricular Dysfunction After Anatomic Repair of Congenitally Corrected Transposition of the Great Arteries

BACKGROUND

Early results for anatomic repair of congenitally corrected transposition of the great arteries are excellent with respect to right ventricular and tricuspid valve function. However, development of left ventricular (systemic ventricle) dysfunction late after repair remains a concern. In this study we sought to determine factors leading to late impairment in left ventricular performance.

METHODS

From August 1992 to July 2005, 44 patients (median age at surgery, 1.6 years; range, 0.6 to 39.6 years) with congenitally corrected transposition of the great arteries had anatomic repair. Left ventricular function and mitral regurgitation were evaluated by echocardiography at follow-up. Twenty-three patients had a Rastelli procedure, and 21 underwent an arterial switch. Twelve patients (27%) were pacemaker dependent at latest follow-up.

RESULTS

Early mortality was 4.5% (n = 2) with 1 late death as a result of leukemia. Median follow-up was 3.0 years (range, 7 days to 12.4 years). Left ventricular function remained unchanged (normal) in 35 patients, improved in 1 patient, and deteriorated in 8 patients (18%). Mitral regurgitation was unchanged in 30 patients, improved in 6 patients, and worsened in 8 patients (18%). Development of left ventricular dysfunction was significantly associated with pacemaker implantation (p = 0.005) and a widened QRS (>20% > 98% percentile of normal; p = 0.03).

CONCLUSIONS

Anatomic repair of congenitally corrected transposition can be performed with low operative mortality. However, late left ventricular dysfunction is not uncommon, with higher incidence in those requiring pacing and with a prolonged QRS. Resynchronization may be of value in patients requiring a pacemaker.

The classical and the one-and-a-half ventricular options for surgical repair in patients with discordant atrioventricular connections

The classical option for surgical repair in patients with congenitally corrected transposition takes advantage of the physiologic correction provided by nature. At the end of the surgical procedures, however, the morphologically right ventricle remains as the systemic ventricle. Surgical intervention is essentially the correction of associated lesions, including closure of ventricular septal defects, pulmonary valvotomy, placement of a conduit from the morphologically left ventricle to the pulmonary arteries, replacement of the morphologically tricuspid valve, and placement of pacemakers for third degree atrioventricular block. For many years, the classical approach was the “standard” surgical approach.1–4More recently, newer alternatives have become available, including forms of anatomic repair, the “one-and-a half” ventricular option, and conversion to the Fontan circulation. The goal of anatomic repair is to craft connections such that the morphologically left ventricle becomes the systemic ventricle. Surgical techniques that accomplish this are a Rastelli procedure combined with an atrial baffle,5and the combination of an arterial switch with an atrial baffle, be it a Mustard or Senning procedure.6

Physiologic versus anatomic repair of congenitally corrected transposition of the great arteries: meta-analysis of individual patient data

The objective of this meta-analysis of individual patients' data was to compare the immediate outcomes of anatomic and physiologic repair of congenitally corrected transposition of the great arteries. Eleven nonrandomized studies, involving 124 patients, met the inclusion criteria for this review. The Rastelli type anatomic repair and the era of surgery were significantly related to the outcome in different tested models. Entering all variables into the logistic regression model showed a significant protective effect of the Rastelli type anatomic repair (odds ratio = 0.05, 95% confidence interval: 0.01, 0.50, p = 0.02).

Intermediate Results of the Double-Switch Operations for Atrioventricular Discordance

BACKGROUND

Since 1987, anatomic biventricular repair using the double-switch operations has been our principal choice for patients with atrioventricular discordance. These alternative procedures have the theoretical advantage of using the anatomic left ventricle to support the systemic circulation.

METHODS

A total of 45 patients underwent the double-switch operation. Their ages ranged from 6 months to 21 years. Associated malformations included pulmonary atresia in 27, pulmonary stenosis in 11, and Ebstein's malformation in 5. An atrial switch plus an arterial switch procedure was performed in 7, and an atrial switch plus a Rastelli-type ventriculoarterial switch procedure in 38. Follow-up ranged from 6 months to 15 years.

RESULTS

Early mortality was 8.9% (n = 4). In the latter half of the series (n = 23, since 1994), there was no early death. Six patients died late. Actuarial survival at 5 and 10 years was 83.6% and 77.6%, respectively. Six patients required conduit replacement, and 2 required revision of an intraatrial baffle for pulmonary venous channel obstruction and infection, respectively. Freedom from reoperation was 95.3% at 5 years and 76.2% at 10 years. Freedom from arrhythmia was 88.8% at 5 years and 78.4% at 10 years. The systemic ventricular ejection fraction was 0.568 +/- 0.103 at 1 year (n = 39), 0.555 +/- 0.105 at 5 years (n = 17), and 0.539 +/- 0.098 at 10 years (n = 12).

CONCLUSIONS

The surgical results of the double-switch operations have been improving. Intermediate follow-up suggests that these alternative procedures are a reasonable option for patients with atrioventricular discordance.

The double switch for atrioventricular discordance

Conventional surgery for atrioventricular discordance usually associated with ventricular arterial discordance leaves the morphologic right ventricle in the systemic circulation. Long-term follow-up results with this approach reveal a high incidence of right ventricular failure. The double switch procedure was introduced to restore the morphologic left ventricle to the systemic circulation. This operation is performed in two main ways: the atrial-arterial switch and the atrial switch plus Rastelli procedure. This double switch approach has been successful at least in the medium term in abolishing morphologic right ventricular failure and its associated tricuspid valve regurgitation. In the atrial-arterial switch group, there is an incidence of morphologic left ventricular dysfunction, sometimes associated with neoaortic valve regurgitation, and the minority of cases need aortic valve replacement. The long-term function of the morphologic left ventricle and the aortic valve need careful surveillance in the future. The atrial-Rastelli group of patients has not in the medium term shown evidence of ventricular dysfunction but will require change on a regular basis of their ventricular to pulmonary artery valved conduits.

Congenital heart disease never goes away, even when it has been 'treated': the adult with congenital heart disease

PURPOSE OF REVIEW

As the specialties of pediatrics and pediatric cardiology continue to forge ahead with better diagnoses, medical care, and surgical results, an expanding population of patients with congenital heart disease (CHD) outgrows the pediatric age group, yet does not quite graduate to routine adult cardiology or general medicine. The adult with congenital heart disease (ACHD) faces medical, surgical, and psychosocial issues that are unique to this population and must be addressed as such. This review attempts to discuss and highlight some of the important advances and controversies brought up in the past year, in the care and management of these patients.

RECENT FINDINGS

The past five to 10 years have seen dynamic interest in understanding sequelae of corrected, uncorrected, or palliated congenital heart disease. The search for the ideal surgery, optimal prosthesis, and a smooth transition to adult care continues and is reflected in the vast amount of academic work and publications in this field. Of particular interest, conduit reoperations and single ventricle pathway modifications are still an art and a science in evolution.

SUMMARY

While all are agreed that there is a pressing need to focus on the delivery of care to the adult with congenital heart disease, this essentially requires a clearer understanding of late sequelae of CHD. The sheer heterogeneity of anatomy, age, surgery, and institutional management protocols can make it difficult to develop clear guidelines. This review attempts to give an up-to-date perspective on some of the new findings related to the more common lesions and problems faced in this group.

The hemi-Mustard, bi-directional Glenn, and Rastelli operations used for correction of congenitally corrected transposition, achieving a "ventricle and a half " repair

Based on experience in several centers, the double switch operation has reportedly become the standard surgical therapy for congenitally corrected transposition. We report and discuss here the use of a "ventricle and a half" double switch operation performed due to the concerns raised intraoperatively because of the size of the morphologically right ventricle. Although the long-term course of such a procedure in this setting remains unknown, we submit that the proposed benefits of the double switch operation, even when used in the "ventricle and a half" configuration, may be superior to the alternatives.

Congenitally Corrected Transposition of the Great Arteries: Current Treatment Options

Congenitally corrected transposition of the great arteries is a relatively rare cardiac malformation characterized by atrioventricular and ventriculoarterial discordance. This double discordance results in a physiologically corrected circulation with the morphologic right ventricle (RV) serving as the systemic pump. Associated anomalies are present in approximately 98% of cases and include most commonly ventricular septal defect, pulmonary stenosis, and anomalies of the systemic atrioventricular valve (SAVV). Conduction abnormalities are common as well, predisposing these patients to the development of complete heart block. The management of these patients is primarily determined by the presence and severity of the associated anomalies. Conventional repair, which leaves the morphologic RV as the systemic ventricle, has resulted in high incidence of tricuspid regurgitation (TR) and progressive dysfunction of the RV. In the majority of patients, congestive heart failure secondary to RV dysfunction occurs by the fifth or sixth decade. The cause and effect relationship between TR and RV dysfunction remains to be determined. The advent of the Double Switch operation, which restores the morphologic left ventricle (LV) as the systemic ventricle, has yielded favorable outcomes at early follow-up. This procedure should be applied in young patients to achieve optimal results. Retraining the LV by pulmonary artery banding is associated with high morbidity and mortality when attempted after infancy or early childhood. Long-term follow-up is needed to evaluate the potential superiority of this procedure and the incidence of rhythm, baffle, and conduit complications for this management option.

Midterm results after restoration of the morphologically left ventricle to the systemic circulation in patients with congenitally corrected transposition of the great arteries

OBJECTIVE

This study was undertaken to determine the outcomes of patients with congenitally corrected transposition of the great arteries after restoration of the morphologically left ventricle to the systemic circulation.

METHODS

Between November 1991 and June 2001, a total of 54 patients (median age 3.2 years, range 7 weeks-40 years) with either congenitally corrected transposition of the great arteries (n = 51) or atrioventricular discordance with double-outlet right ventricle (n = 3) underwent anatomic repair. This comprised a Senning procedure in all cases plus arterial switch (double-switch group) in 29 cases (53.7%), plus a Rastelli procedure (Rastelli-Senning group) in 22 cases (40.7%), and plus intraventricular rerouting (Senning-tunnel group) in 3 cases (5.6%). Left ventricular training by PA banding was performed before the double-switch operation in 9 of 29 cases (31%). Follow-up is complete (median 4.4 years).

RESULTS

Early mortality was 5.6% (n = 3), with 2 late deaths. Kaplan-Meier survivals (+/- SEM) were 94.4% +/- 3.1% at 1 year and 89.7% +/- 4.4% at 9 years. Survivals at 7 years were 84.9% +/- 7.1% in the double-switch group and 95.5% +/- 4.4% in the Rastelli-Senning group (P =.32). Of the 49 survivors, 46 (94%) were in New York Heart Association functional class I. Six have acquired new left ventricular dilatation or impaired systolic ventricular function. Four patients in the double-switch group had moderate aortic valve regurgitation develop, and 2 of them required valve replacement. Overall freedoms from reoperation at 1 and 9 years were 94.2% +/- 3.3% and 77.5% +/- 9.0%, with no significant difference between the groups (P =.60).

CONCLUSIONS

Anatomic repair of congenitally corrected transposition of the great arteries can be carried out with low early mortality. Excellent functional status can be achieved, with good midterm survival. Continued surveillance is necessary for patents with valved conduits and to determine the longer-term function of the aortic valve and the morphologically left ventricle in the systemic circulation.

Extended somatic support for pregnant women after brain death

OBJECTIVE

To review case reports of pregnant women who have been supported after brain death until successful delivery of their infants. From these reports and other literature about brain death, normal physiologic changes of pregnancy, and specific needs for fetal development, recommendations were made to assist in supporting pregnant women after brain death until delivery of a mature fetus who is likely to survive.

DATA SOURCES

Personal files and experiences, MEDLINE review of case reports and publications about physiologic changes present during normal pregnancy and after brain death, and the critical needs for fetal development were included.

DATA EXTRACTION

Eleven reports of ten patients comprise the accumulated clinical experience. Hypotension, requiring fluid administration and inotropic/vasopressor therapy, occurred in all the mothers, and in six cases, was the reason for urgent delivery. The longest period of support was 107 days, from 15 to 32 wks of gestation. Two mothers also became organ donors. Recurrent infections, thermolability, and other complications common to prolonged ICU care were encountered. All infants survived. One had congenital abnormalities caused by phenytoin use by the mother. When followed, all others developed within normal growth and mental variables. These cases plus literature citations noted above were used to develop recommendations for maternal/fetal care.

CONCLUSION

Preservation of uterine/placental blood flow is the most important priority during somatic support. Imprecise autoregulation of the uterine vasculature during maternal hypoxemia or hypotension makes this goal a significant challenge. Special considerations for nutrition; medication use; cardiovascular, respiratory, or endocrine therapy; fetal monitoring; hormone replacement; and ethical concerns are discussed.

Outcome of the unoperated adult who presents with congenitally corrected transposition of the great arteries

OBJECTIVES

The goal of this study was to determine the presentation and outcome of the unoperated adult with congenitally corrected transposition of the great arteries.

BACKGROUND

The presentation of this disorder and the outcome in unoperated adults have not been well defined.

METHODS

All unoperated patients > or =18 years old were evaluated for spectrum of disease, hemodynamic severity, timeliness of diagnosis and referral, and outcome.

RESULTS

Forty-four patients aged 20 to 79 years (mean, 44) were followed up to 144 months. In 29 (66%), the correct diagnosis was first made at age > or =18 years; the diagnosis was missed in seven of these patients in a prior cardiology consultation, despite cardiac imaging. Systemic atrioventricular valve (SAVV) regurgitation (grade > or =3/4) was noted in 26 patients (59%). Thirty (68%) had surgical intervention, including SAVV replacement in all, with no early mortality. Preoperatively, this subset had significant dysfunction of the systemic ventricle (SV) (ejection fraction [EF], 40 +/- 10%), and most had advanced symptoms (25 with ability index > or =2/4). In 16 (53%), SAVV regurgitation > or =3/4 and ventricular dysfunction had been documented for >6 months. The mean EF of the SV decreased significantly postoperatively (34 +/- 11%, p = 0.006). Four patients (13%) eventually required cardiac transplantation. Poor preoperative EF of the SV predicted eventual need for transplantation (p = 0.001).

CONCLUSIONS

Patients with unoperated congenitally corrected transposition of the great arteries are often misdiagnosed in adulthood and are referred late despite symptomatic SAVV regurgitation and significant SV dysfunction. Although excellent early surgical results can be achieved, significant residual dysfunction of the SV is common.

Comparable systemic ventricular function in healthy adults and patients with unoperated congenitally corrected transposition using MRI dobutamine stress testing

BACKGROUND

Failure of the systemic right ventricle (RV) often complicates adult survival in unoperated or physiologically repaired congenitally corrected transposition of the great arteries (CCTGA). Healthy controls schematically represent an optimal outcome of anatomic repair, which is increasingly performed to treat CCTGA. Magnetic resonance imaging dobutamine stress testing measures cardiac reserve, and sets to compare the left ventricle of controls with the systemic RV of unoperated and physiologically repaired patients with CCTGA.

METHODS

Baseline and stress magnetic resonance imaging (maximum dobutamine dose, 15 microg/kg/min) assessed systemic RV function in 13 minimally or asymptomatic adult patients with CCTGA (unoperated, n = 7; physiologically repaired, n = 6). The left ventricles of 11 healthy age-matched adults served as controls.

RESULTS

Baseline and stress end-diastolic volumes similar between the systemic RV of unoperated patients and the left ventricle of controls, as well as base end-systolic volumes. Stress ejection fraction was lower in unoperated and physiologically repaired patients (70 +/- 6% and 60 +/- 5%, respectively, vs healthy controls (84 +/- 8%). However, comparable with healthy controls, both subsets of CCTGA patients responded appropriately to dobutamine stress, as illustrated by similar RV stroke volume, heart rate, mean blood pressure, and cardiac index.

CONCLUSIONS

Compared with the left ventricles of healthy controls, both patient groups had larger systemic RV volumes, diminished ejection fraction, but an appropriate response to dobutamine stress. Values of unoperated patients are closer to normal than physiologically repaired patients. Magnetic resonance imaging dobutamine may help to define the subgroups of CCTGA patients with favorable anatomy, whereby asymptomatic adult survival could be anticipated without the need for an operation.

Left ventricular reconditioning and anatomical correction for systemic right ventricular dysfunction

The morphologically right ventricle (mRV) fails after managing systemic workload for a variable period of time in some patients with transposition of the great arteries (TGA) who have undergone an atrial switch operation and in patients with congenitally corrected transposition of the great arteries (cc-TGA). Conventional therapy for progressive mRV failure, including tricuspid valve replacement and cardiac transplantation, has been disappointing. Anatomical correction, reincorporating the morphologically left ventricle (mLV) into systemic circulation, was performed in a total of 84 patients (39 TGA, 45 cc-TGA) in 2 institutions (Royal Children Hospital 1981-1993; Cleveland Clinic Foundation 1993-1999). The mVL was retrained to generate systemic pressure by means of pulmonary artery band in 43 patients. The overall mortality for patients entering this program is 15.4% (8 early and 5 late operative deaths). All of the operative deaths were patients with TGA and a prior atrial switch operation. Four patients (5%) have been transplanted or are on a transplantation waiting list. In patients with TGA and previous atrial switch operation, older age and abnormal coronary anatomy was associated with a higher operative mortality. None of the measured parameters of the mLV and mRV were predictors of failure of mLV reconditioning. Follow-up echocardiographic evaluations of the 46 survivors of anatomical correction showed normal mRV function in 41 (89%) and normal mLV function in 42 patients (91%). mLV retraining and anatomical correction produces good results in prepubescent patients. The response of older patients is less predictable and associated with a higher early and late mortality. Copyright 2000 by W.B. Saunders Company

The emerging adult population with congenital heart disease

The successes in managing infants and children with congenital heart disease have led to an emerging population of adult patients. As we enter this new century, the majority of patients with congenital heart disease will be adults, not children. It is important to maintain our commitment for continuing care to the emerging adult population. Psycho-social issues, including employment and pregnancy counseling, are required as well as the ongoing need for medical and occasionally surgical intervention. The health care system needs to develop supra-regional tertiary referral centers for care of these patients and provide information sharing and support for community-based physicians interested in the welfare of the adult with congenital heart disease. Copyright 2000 by W.B. Saunders Company

A case for anatomic correction in atrioventricular discordance? Effects of surgery on tricuspid valve function

OBJECTIVE

To assess tricuspid valve function in atrioventricular discordance after palliative procedures (pulmonary artery banding and Blalock-Taussig shunt) and corrective procedures (anatomic and physiologic repair).

METHODS

Tricuspid valve dysfunction was assessed by transthoracic echocardiography and graded as no regurgitation (0), mild (1), moderate (2), and severe (3) before and after palliative and corrective procedures performed in 97 patients with atrioventricular discordance between 1988 and 1999. Thirty-two percent had an isolated ventricular septal defect, 43% had a ventricular septal defect and pulmonary stenosis, and 16% had pulmonary stenosis. Twenty-six patients underwent pulmonary artery banding and 28 had a Blalock-Taussig shunt. Seventy patients underwent physiologic and 19 underwent anatomic repair. Six patients underwent one-ventricle repair.

RESULTS

After pulmonary artery banding, the tricuspid regurgitation score decreased from 1.7 +/- 0.8 to 0.9 +/- 0.6 (P <.001). In patients who underwent a Blalock-Taussig shunt, the tricuspid regurgitation score increased from 0.7 +/- 0.5 preoperatively to 1.4 +/- 0.6 postoperatively (P <.001). After physiologic repair, there was no significant change in the tricuspid regurgitation score; however, 7 patients required additional repair or replacement. The regurgitation score was significantly reduced from 1.5 +/- 0.8 to 0.4 +/- 0.5 (P <.001) after anatomic repair. The operative mortality in patients who underwent physiologic repair was 7% as compared with 0% in the anatomic repair group (P =.59). The median follow-up was 3.2 years.

CONCLUSIONS

Right ventricular volume loading (shunt) worsens tricuspid regurgitation, whereas volume reduction (banding) or left-to-right septal shift (anatomic repair) has beneficial effects. We have not observed a significant change in the tricuspid regurgitation score after physiologic repair. Anatomic repair can be performed in selected patients with atrioventricular discordance and provides superior functional results.

Surgery for congenital heart disease

General agreement has been reached on the indications for treating most congenital cardiac malformations. Strong disagreement exists, however, about timing and methods of treatment, either for congenital heart defects, for which the approach should be standardized after years of use, and even more when a new technique or a new approach is introduced to replace the existing ones. The ideal solution should be to perform prospective, randomized studies, with long-term follow-up, possibly with preliminary experimental studies to support the hypothesis. Unfortunately this is rarely possible, either because of the nonreproducibility of the malformation in an experimental environment, or because prospective, randomized studies with adequate follow-up are rarely feasible, due to the relatively small number of children with the same congenital heart defect. An updated review of the current trends in congenital heart surgery, based on the papers published in the past year, is presented here.