The Arterial Switch Operation in the Developing World: Risk Factors and Current Outcomes

BACKGROUND

Published data on the outcomes of the arterial switch operation in the developing world are limited. We sought to identify the midterm outcomes of and risk factors for mortality and morbidity in patients undergoing the arterial switch operation at a high-volume center in Vietnam.

METHODS

A retrospective review was conducted of 608 patients who underwent an arterial switch operation for the treatment of transposition of the great arteries (TGA; n = 509) or double-outlet right ventricle TGA (DORV-TGA; n = 99) at a single center from 2010 to 2021.

RESULTS

Overall early mortality was 5.9%, and late mortality was 1%. Multivariate Cox regression showed weight at operation of <3 kg (P < .001), prolonged aortic cross-clamp time (P < .001), and need for secondary aortic cross-clamp (P = .011) as risk factors for overall mortality. The actuarial 10-year survival rate was 93%. The overall cardiac reoperation rate was significantly higher in patients with DORV-TGA (hazard ratio [HR], 16.43; 95% CI, 4.70-57.43; P < .001). The rate of freedom from cardiac reoperation at 10 years was 94%. Risk factors for outflow tract reoperation were patients with DORV-TGA (HR, 23.28; 95% CI, 2.86-189.66; P = .003), single coronary artery (HR, 4.1; 95% CI, 1.16-14.46; P = .028), and mild aortic valve regurgitation observed in 3.7% of patients.

CONCLUSIONS

The outcomes of the arterial switch operation in a low- and middle-income country were satisfactory. Nevertheless, the complexity of the procedure and lower weight of patients are still challenges. Patients with DORV-TGA and single coronary artery need to be closely followed up.

Alternative pulmonary artery reconstruction technique in the arterial switch operation

OBJECTIVES

Late complications of arterial switch operations (ASO) for transposition of the great arteries, such as neo-pulmonary artery (PA) stenosis and/or neoaortic regurgitation, have been reported. We developed an alternative reconstruction method called the longitudinal extension (LE) method to prevent PA bifurcation stenosis (PABS).

METHODS

We identified 48 patients diagnosed with transposition of the great arteries and performed ASO using the Lecompte manoeuvre for neo-PA reconstruction. In 9 consecutive patients (from 2014), the LE method was performed (LE). Before 2014, conventional techniques were performed in 39 patients (C). The median body weight and age in the LE and C groups were 3.0 and 3.1 kg and 12 and 26 days, respectively. In the LE group, 1 patient underwent bilateral PA banding before ASO. In C, PA banding and arch repair were performed in 1 patient each. Patients who received concomitant procedures were included.

RESULTS

The median follow-up in LE and C groups was 1.9 and 10.1 years, respectively. Early mortality/late death was not found in group LE and in 1 patient in group C. Only 1 case required ascending aorta sliding plasty in LE, and 8 patients needed PA augmentation for PABS in C. The median velocity of right/left PA was measured as 1.6/1.9 m/s in LE and 2.1/2.3 m/s in C, so it showed a lower value in LE.

CONCLUSIONS

Excellent mid-term results were obtained with the LE method. It was considered a useful procedure in preventing PABS, which is a primary late complication of ASO. Further follow-up and investigations are needed.

Grown-up Congenital Heart Surgery in 1093 Consecutive Cases: A "Hidden" Burden of Early Outcome

BACKGROUND

Surgery in grown-ups with congenital heart disease (GUCH) is characterized by complex anatomy, comorbidities, reoperations, and technical challenges. Although 30-day postoperative mortality is low, this measure might be insufficient to reflect adverse outcome monitoring. Our study aimed to establish whether prolonged intensive care unit (ICU) stay (≥7 days) and 6-month mortality were more clinically meaningful measures than 30-day mortality and to identify predictors of adverse outcome.

METHODS

All consecutive GUCH patients from 1998 to 2015 were identified. Perioperative characteristics, diagnoses, and postoperative data were collected retrospectively. Predictors of 30-day and 6-month mortality and prolonged ICU stay were determined with logistic regression. Era effect was tested for quality assurances by dividing the cohort into 4 time intervals.

RESULTS

Within 17 years, 1093 consecutive cardiac surgical procedures were identified in 1026 GUCH patients. During the study period, 30-day mortality improved significantly, with an overall 30-day mortality of 1.5%; 6-month mortality and prolonged ICU stay were 2.4% and 6.7%, respectively. Despite a decreased number of preoperative patients in New York Heart Association Functional Classification III or higher, prolonged ICU stay increased over the eras. Predictors of adverse outcome were New York Heart Association class III or higher, preoperative renal failure, disease of great complexity, preoperative ventilator support, cardiopulmonary bypass time, and concomitant procedures.

CONCLUSIONS

In the current era of low 30-day mortality, extended 6-month mortality and prolonged ICU stay reporting may be more realistic measures of adverse outcomes for counseling GUCH patients at risk.

Technical challenges of lung transplantation in children after arterial switch operation

Pulmonary arterial hypertension after arterial switch operation for transposition of the great arteries is rare. Lung transplantation can be the last option in cases of failed medical therapy. We report 2 paediatric patients who underwent lung transplantation for this indication. Altered hilar anatomy, mediastinal adhesions and haemostatic control represent the main technical challenges. Volume-reduction surgery is sometimes necessary to address altered cardiopulmonary relationships while expanding the donor pool.