Outcomes and re-interventions after one-stage repair of transposition of great arteries and aortic arch obstruction

• Published in: European journal of cardio-thoracic surgery Vol. 39; no. 2; pp. 213 - 220
• Main Authors: Huber, Christoph, Mimic, Branko, Oswal, Nilesh, Sullivan, Ian, Kostolny, Martin, Elliott, Martin, de Leval, Marc, Tsang, Victor
• Format: Journal Article
• Language: English
• Published: Oxford Elsevier Science B.V 01.02.2011; Oxford University Press
• Subjects: Aorta, Thoracic - abnormalities; Aorta, Thoracic - surgery; Aortic Coarctation - surgery; Aortic Diseases - surgery; Arterial Occlusive Diseases - surgery; Biological and medical sciences; Blood Vessel Prosthesis Implantation - methods; Cardiology. Vascular system; Congenital heart diseases. Malformations of the aorta, pulmonary vessels and vena cava; Double Outlet Right Ventricle - surgery; Follow-Up Studies; Heart; Humans; Infant; Infant, Newborn; Medical sciences; Pneumology; Postoperative Care - methods; Recurrence; Reoperation; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Transposition of Great Vessels - surgery; Treatment Outcome; Transposition of the great arteries; Aortic arch obstruction; Arterial switch; Taussig-Bing anomaly; Taussig— Bing anomaly; Corrective surgery; Prognosis; Cardiovascular disease; Congenital disease; Obstruction; Vascular disease; Treatment; Heart disease; Aortic arch; Anomaly; Circulatory system; Transposition of the great vessels; Cardiology; Repair; Pneumology
• ISSN: 1010-7940; 1873-734X
• DOI: 10.1016/j.ejcts.2010.05.009

Abstract Objectives: One-stage repair of transposition of great arteries (TGA) and aortic arch obstruction (AAO) is currently advocated, but carries formidable surgical challenges. This report presents our experience and re-interventions for residual lesions over the last 10 years. Methods: Twenty-two patients (19.5 ± 42.4 days; range 2-206; median 10 days, 3.5 ± 0.6 kg) diagnosed with TGA (nine patients) or double outlet right ventricle (DORV) (13 patients) and AAO underwent one-stage repair. Of the nine TGA patients (two with intact ventricular septum), AAO were: two patients hypoplastic arch, one patient discrete coarctation, four patients hypoplastic arch with coarctation and two patients interrupted aortic arch. The 13 DORV patients were all of Taussig-Bing type and one showed multiple ventricular septal defects (VSDs). The degree of AAO ranged from hypoplastic arch in five patients, coarctation two patients, combined four patients and interrupted aortic arch (IAA) two patients. Arterial switch with Lecomte ± VSD repair was performed during cooling, and aortic arch repair was performed under deep hypothermic circulatory arrest (DHCA) (35 ± 14 min at 16.9 ± 0.7 °C). Our preference was to use homograft patch-plasty for arch and direct end-to-side anastomosis for coarctation repair. Aortic-cross-clamp time was 124 ± 24 min and cardiopulmonary bypass (CPB) time 215 ± 84 min. Results: Early survival was 19/22 (86%) up to 30 days without mortality in the second half of our series. Three patients required extracorporeal membrane oxygenation (ECMO) support and renal support was needed in three and preferred permanent pace maker (PPM) implantation in two. Length of stay was 21.9 ± 22.1 days. There was one late death and overall survival was 18/22 (82%) for the follow-up period of 4.8 years (0.2-9.8 years). Eight patients (44%) required re-intervention for re-coarctation. Four patients required right ventricular outflow tract (RVOT)/pulmonary artery re-interventions. At follow-up, there was no requirement for aortic valve replacement, residual VSD closure and no evidence of ventricular dysfunction. Conclusions: One-stage repair of TGA/DORV and AAO can be performed safely with a good survival rate. Three important lessons that we have learnt are as follows: (1) the subpulmonary VSD may have a perimembraneous component, (2) late re-coarctation is not infrequent and (3) late residual right-sided cardiac lesions remain an issue in complex TGA repair.