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Ann Thorac Surg 1995;60:510
© 1995 The Society of Thoracic Surgeons
DR BRUNO MESSMER (Aachen, Germany): I am somewhat amazed that you did not find any rhythm disturbances in your cohort of arterial switch patients. We have studied the late postoperative rhythm behavior in 33 of 78 patients who had neonatal switch repair. Supraventricular and sporadic ventricular extrasystoles were quite common on Holter electrocardiograms. More dangerous rhythm disturbances such as persistent junctional rhythm or supraventricular tachycardia, however, were present in only 3 patients, which is roughly 10%. Rhythm problems are certainly less after an arterial switch than after the Senning or Mustard procedure, but they are not absent as one would assume after your presentation. Therefore I would like to ask you whether you checked your patients with long-term electrocardiograms or only by looking at casually recorded electrocardiograms.
DR TURLEY: This material was from the Congenital Heart Surgeons Society database. It did not include Holter data unless the individual cardiologists had chosen to perform that study. We have followed up 74 patients with arterial switches in our entire series and have noted 3 patients in whom rhythm disturbances have developed in that total group. The series presented today is a very unusual group of patients within an unusual time frame followed up by the database, and in that very small group, no rhythm disturbances were seen.
DR LUDWIG von SEGESSER (Zürich, Switzerland): Did you evaluate the patients studied with regard to aortic incompetence, and is there a difference between groups?
DR TURLEY: We have reviewed all of our arterial switch patients by echocardiography and have seen only mild incompetence in 3 of the patients in the current series.
DR CARL L. BACKER (Chicago, IL): I enjoyed your presentation. We reviewed our patients at Children's Memorial Hospital and did a similar comparison [1]. We looked at neonates with transposition of the great arteries and assessed 23 infants who underwent a Mustard operation and 37 an arterial switch procedure. Our findings were almost identical to yours; there was a significantly higher incidence of both early and late arrhythmias after the Mustard operation (atrial repair). The other factor that we reviewed and that I was curious as to whether you had any data on is related to the higher incidence of tricuspid regurgitation after the Senning procedure. We looked at ventricular function angiographically, comparing both systemic ventricular ejection fraction and systemic ventricular end-diastolic volume in both the arterial switch (left ventricle) and the Mustard groups (right ventricle). The right ventricular function was significantly lower after the Mustard operation as compared with the left ventricular function after the arterial switch. The systemic ventricular end-diastolic volume was significantly greater after the Mustard procedure as compared with the arterial switch. Would you comment on the significance of tricuspid regurgitation after the Senning procedure, and ventricular function, if that was examined?
DR TURLEY: Concerning the issues of tricuspid regurgitation and ventricular function after the atrial repairs, we have been disturbed by the findings in 3 patients of regurgitation noted in the past 2 years. Before that time, no regurgitation had developed in the series. Several years ago, we reported our follow-up on Mustard operations performed on infants less than 3 months of age. This patient series now extends to 18 years of follow-up, and when we have compared them with arterial switch patients in exactly the functional categories we are discussing, we found that right ventricular performance was significantly impaired, even though those patients have continued to experience excellent clinical courses. There were no early deaths in that group of 36 Mustard patients less than 3 months of age and only one late death, actually a drowning; however, major rhythm disturbances and the need for pacemakers were noted and those rhythm disturbance episodes increased over time. Now only 48% of those patients are without major rhythm disturbances, and we believe the findings in the current study using the Senning procedure for atrial repair in neonates and infants demonstrate these same findings in relation to both the need for pacemaker and rhythm disturbances. We project the same problems as seen in our much longer Mustard experience.
DR JOHN E. MAYER, JR (Boston, MA): Could I ask just one question. Are these all intact ventricular septums?
DR TURLEY: During the period of the Congenital Heart Surgeons Society study we enrolled 46 patients; in 2 with ventricular septal defects, Rastelli repair was performed. Two of the patients with arterial switches presented today, likewise, had simultaneous closure of the ventricular septal defect at the time of neonatal arterial switch. These are included as no difference in their outcomes from the remaining arterial switch patients was evident. No ventricular septal defect repairs were performed in the atrial groups.
Reference
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