The Role of Cardiac Resynchronization Therapy for Arterial Switch Operations Complicated by Complete Heart Block

• Published in: The Annals of thoracic surgery Vol. 96; no. 3; pp. 904 - 909
• Main Authors: Mah, Douglas Y., MD, Alexander, Mark E., MD, Banka, Puja, MD, Abrams, Dominic J., MD, Triedman, John K., MD, Walsh, Edward P., MD, Fynn-Thompson, Francis, MD, Mayer, John E., MD, Cecchin, Frank, MD
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Inc 01.09.2013
• Subjects: Abnormalities, Multiple - diagnosis; Abnormalities, Multiple - surgery; Atrioventricular Block - diagnosis; Atrioventricular Block - etiology; Atrioventricular Block - mortality; Atrioventricular Block - therapy; Cardiac Resynchronization Therapy - methods; Cardiac Surgical Procedures - adverse effects; Cardiac Surgical Procedures - methods; Cardiothoracic Surgery; Cohort Studies; Female; Follow-Up Studies; Heart Septal Defects, Ventricular - diagnostic imaging; Heart Septal Defects, Ventricular - mortality; Heart Septal Defects, Ventricular - surgery; Hospital Mortality - trends; Humans; Infant, Newborn; Male; Pacemaker, Artificial; Postoperative Complications - physiopathology; Postoperative Complications - therapy; Retrospective Studies; Risk Assessment; Surgery; Survival Rate; Time Factors; Transposition of Great Vessels - diagnostic imaging; Transposition of Great Vessels - mortality; Transposition of Great Vessels - surgery; Treatment Outcome; Ultrasonography; Ventricular Dysfunction, Left - diagnosis; Ventricular Dysfunction, Left - etiology; Ventricular Dysfunction, Left - therapy; 24; CRT; RV; cardiac resynchronization therapy; VSD; LVEF; LV; D-loop transposition of the great arteries; left ventricular ejection fraction; left ventricular end-diastolic volume; right ventricle; D-TGA; arterial switch operation; LVEDV; left ventricular; ventricular septal defect; ASO; 21
• ISSN: 0003-4975; 1552-6259
• DOI: 10.1016/j.athoracsur.2013.05.082

Background As mortality in patients with D-loop transposition of the great arteries (D-TGA) has decreased after the arterial switch operation (ASO), the focus has shifted to higher risk groups and outcomes that impact long-term morbidity and mortality, such as left ventricular (LV) dysfunction. We sought to examine the perioperative factors associated with LV dysfunction in patients with D-TGA and ventricular septal defects (VSD) after ASO. Methods A retrospective study was made of all patients with D-TGA/VSD who underwent ASO/VSD closure from 2001 to 2011. Patients with prematurity, L-looped ventricles, and straddling atrioventricular valves were excluded. The primary endpoint was moderate or severe LV dysfunction measured by echocardiogram 2 months or more after surgery. Results A total of 112 patients underwent ASO/VSD closure at a median age of 5 days. Median time of follow-up was 6.5 months, with no mortality noted. Six patients (8%) were noted to have at least moderate LV dysfunction. Risk factors were heart block requiring pacemaker placement ( p < 0.001) and length of intensive care unit admission ( p  = 0.04). All 6 patients with heart block had an epicardial lead on the right ventricular free wall; 4 had moderate or severe LV dysfunction and underwent upgrade to cardiac resynchronization therapy (CRT); median time from initial pacemaker to CRT was 5 months. With a median follow-up of 5 months after CRT, LV function improved to normal (2 patients) or mild dysfunction (2 patients). Conclusions Left ventricular dysfunction after surgical repair for D-TGA/VSD is low, with heart block and pacemaker insertion playing a significant role. The LV function improved after patients were upgraded to a CRT device.