Transposition of the great vessels corrective surgery

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Dextro-transposition of the great arteries
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3]; Keri Shafer, M.D. [4]; Kristin Feeney, B.S. [5]

Overview

Surgical approach is the mainstay of treatment for transposition of great vessels. Type of surgery mainly depends on the age of the patient at presentation, the presence of associated congenital cardiac lesions, and the experience of the cardiothoracic surgeon with a given surgical technique. Most full-term neonates with uncomplicated transposition of the great arteries can undergo an arterial switch procedure in one operation, with minimal mortality. Recent advances in surgical correction of transposition of the great arteries have reduced the mortality drastically from 95% in uncorrected patients to 5% in corrected patients.

Surgery

Surgical approach is the mainstay of treatment for transposition of great vessels. Type of surgery mainly depends on the age of the patient at presentation, the presence of associated congenital cardiac lesions, and the experience of the cardiothoracic surgeon with a given surgical technique. Most full-term neonates with uncomplicated transposition of the great arteries can undergo an arterial switch procedure in one operation, with minimal mortality. Recent advances in surgical correction of transposition of the great arteries have reduced the mortality drastically from 95% in uncorrected patients to 5% in corrected patients[1].

Arterial switch or Jatene Operation

  • The arterial switch operation is the standard procedure for patients with D-TGA without major pulmonic stenosis.[2]
  • During the ASO, the surgeon will transect both the pulmonary trunk and aorta then translocate them to their anatomically correct positions.
  • The coronary arteries are mobilized and reimplanted into the aortic trunk. If a VSD is present., it is also repaired during this time.
Immediate post-operative (Jatene procedure) d-TGA + VSD neonate.


Below are the images depicting different arterial switch procedures for TGA



Rastelli operation

  • The Rastelli procedure is indicated in patients presenting with D-TGA, a large VSD, and pulmonary stenosis.[3]
  • During this procedure, the VSD is closed using a baffle. By doing so, oxygenated blood from the left ventricle is directed into the aorta.
  • A conduit is then placed from the right ventricle to the pulmonary artery thus shunting deoxygenated blood into the pulmonary arteryBelow is an image depicting the procedure of Rasteli operation for TGA:


ACC/AHA Guideline:Recommendations for Surgical Interventions After Atrial Baffle Procedure (Mustard, Senning)(DO NOT EDIT)[4]

Class I
"1.Surgeons with training and expertise in congenital heart disease (CHD) should perform operations in patients with d-TGA and the following indications:
    • Moderate to severe systemic (morphological tricuspid) AV valve regurgitation without significant ventricular dysfunction. (Carrel & Pfammatter, 2000)(Level of Evidence: B) "
    • Baffle leak with left-to-right shunt greater than 1.5:1, right to-left shunt with arterial desaturation at rest or with exercise, symptoms, and progressive ventricular enlargement that is not amenable to device intervention.(Level of Evidence: B)
    • Superior vena cava or inferior vena cava obstruction not amenable to percutaneous treatment.(Level of Evidence: B)
    • Pulmonary venous pathway obstruction not amenable to percutaneous intervention.(Level of Evidence: B)
    • Symptomatic severe subpulmonary stenosis.(Level of Evidence: B)"

ACC/AHA Guideline:Recommendations for Surgical Interventions After Arterial Switch Operation(DO NOT EDIT)[4]

Class I
"1.It is recommended that surgery be performed in patients after the ASO with the following indications:
    • RVOT obstruction peak-to-peak gradient greater than 50 mm Hg or right ventricle/left ventricle pressure ratio greater than 0.7, not amenable or responsive to percutaneous treatment; lesser degrees of obstruction if pregnancy is planned, greater degrees of exercise are desired, or concomitant severe pulmonary regurgitation is present.(Level of Evidence: C)
    • Coronary artery abnormality with myocardial ischemia not amenable to percutaneous intervention.(Level of Evidence: C)
    • Severe neoaortic valve regurgitation.(Level of Evidence: C)
    • Severe neoaortic root dilatation (greater than 55 mm) after ASO. (Coady et al., 1999) (This recommendation is based on data for other forms of degenerative aortic root aneurysms).(Level of Evidence: C)"

ACC/AHA Guideline:Recommendations for Surgical Interventions After Rastelli Procedure(DO NOT EDIT)[4]

Class I
"1. Reoperation for conduit and/or valve replacement after Rastelli repair of d-TGA is recommended in patients with the following indications:
    • Conduit obstruction peak-to-peak gradient greater than 50 mm Hg.(Level of Evidence: C)
    • RV/LV pressure ratio greater than 0.7. (Level of Evidence: C)
    • Lesser degrees of conduit obstruction if pregnancy is being planned or greater degrees of exercise are desired.(Level of Evidence: C)
    • Subaortic (baffle) obstruction (mean gradient greater than 50 mm Hg).(Level of Evidence: C)
    • Lesser degrees of subaortic (baffle) obstruction if LV hypertrophy is present, pregnancy is being planned, or greater degrees of exercise are desired.(Level of Evidence: C)
    • Presence of concomitant severe aortic regurgitation (AR).(Level of Evidence: C) "
"2. Reoperation for conduit regurgitation after Rastelli repair of d-TGA is recommended in patients with severe conduit regurgitation and the following indicators:
    • Symptoms or declining exercise tolerance.(Level of Evidence: C)
    • Severely depressed RV function. (Level of Evidence: C)
    • Severe RV enlargement.(Level of Evidence: C)
    • Development/progression of atrial or ventricular arrhythmias.(Level of Evidence: C)
    • More than moderate tricuspid regurgitation (TR).(Level of Evidence: C)
    • Collaboration between surgeons and interventional cardiologists, which may include preoperative stenting, intraoperative stenting, or intraoperative patch angioplasty with or without conduit replacements, is recommended to determine the most feasible treatment for pulmonary artery stenosis.(Level of Evidence: C) "
"3.Surgical closure of residual VSD in adults after Rastelli repair of d-TGA is recommended with the following indicators:
    • Pulmonary blood flow/systemic blood flow (Qp/Qs) greater than 1.5:1.(Level of Evidence: B)
    • Systolic pulmonary artery pressure greater than 50 mm Hg.(Level of Evidence: B)
    • Increasing LV size from volume overload.(Level of Evidence: C)
    • Decreasing RV function from pressure overload. (Level of Evidence: C)
    • RVOT obstruction (peak instantaneous gradient greater than 50 mm Hg).(Level of Evidence: B)
    • Pulmonary artery pressure less than two thirds of systemic pressure, or PVR less than two thirds of systemic vascular resistance, with a net left-to-right shunt of 1.5:1, or a decrease in pulmonary artery pressure with pulmonary vasodilators (oxygen, nitric oxide, or prostaglandins).(Level of Evidence: C)
    • Surgery is recommended after Rastelli repair of d-TGA in adults with branch pulmonary artery stenosis not amenable to percutaneous treatment.(Level of Evidence: C)
    • In the presence of a residual intracardiac shunt or significant systemic venous obstruction, permanent pacing, if indicated, should be performed with epicardial leads. (Carrel & Pfammatter, 2000)(Level of Evidence: B)'' "
Class IIb
"1.A concomitant Maze procedure can be effective for the treatment of intermittent or chronic atrial tachyarrhythmias in adults with d-TGA requiring reoperation for any reason. (Level of Evidence: B) "

2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)[4]

Coronary Anomalies Associated With Dextro-Transposition of the Great Arteries After Arterial Switch Operation (DO NOT EDIT)[4]

Class I
"1. Adult survivors with dextro-TGA (d-TGA) after arterial switch operation (ASO) should have noninvasive ischemia testing every 3 to 5 years. (Level of Evidence: C)"

References

  1. ↑ Hutter PA, Kreb DL, Mantel SF, Hitchcock JF, Meijboom EJ, Bennink GB (2002). "Twenty-five years' experience with the arterial switch operation". J Thorac Cardiovasc Surg. 124 (4): 790–7. PMID 12324738.
  2. ↑ Jatene AD, Fontes VF, Paulista PP, Souza LC, Neger F, Galantier M, Sousa JE (September 1976). "Anatomic correction of transposition of the great vessels". J. Thorac. Cardiovasc. Surg. 72 (3): 364–70. PMID 957754.
  3. ↑ Rastelli GC, Wallace RB, Ongley PA (January 1969). "Complete repair of transposition of the great arteries with pulmonary stenosis. A review and report of a case corrected by using a new surgical technique". Circulation. 39 (1): 83–95. doi:10.1161/01.cir.39.1.83. PMID 5782810.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA; et al. (2008). "ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (23): e1–121. doi:10.1016/j.jacc.2008.10.001. PMID 19038677.

Acknowledgements and Initial Contributors to Page

Leida Perez, M.D.


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