Dextro-transposition of the great arteries corrective surgery

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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]; Assistant Editor(s)-In-Chief: Kristin Feeney, B.S. [5]

Overview

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.

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Immediate post-operative (Jatene procedure) d-TGA + VSD neonate.

Rastelli operation

ACC/ AHA Guidelines 2008- Recommendation for evaluation of the Operated Patient with Dextro- Transposition of the Great arteries (DO NOT EDIT)

Class I

"1.Patients with repaired d-TGA should have annual follow-up with a cardiologist who has expertise in the management of ACHD patients.(Level of Evidence: C)

ACC/ AHA Guidelines 2008- Recommendations for Surgical Interventions - After Atrial Baffle Procedure (Mustard, Senning) - Dextro- Transposition of the Great arteries (DO NOT EDIT)

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 Guidelines 2008- Recommendations for Surgical Interventions -After Arterial Switch Operation- Dextro- Transposition of the Great arteries (DO NOT EDIT)

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 Guidelines 2008- Recommendations for Surgical Interventions -After Rastelli Procedure- Dextro- Transposition of the Great arteries (DO NOT EDIT)

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)

"'3.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)

"'4.*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: B) RVOT obstruction (peak instantaneous gradient greater than 50 mm Hg). 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: B) 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 IIa

"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: C) "

Acknowledgements and Initial Contributors to Page

Leida Perez, M.D.