Ann Thorac Surg 1996;61:1518-1520
© 1996 The Society of Thoracic Surgeons
Case Report
Development of Subneopulmonary Obstruction Early After Arterial Switch Operation in an Adult
Vladimir Alexi-Meskishvili, MD,
Frank Uhlemann, MD,
Felix Berger, MD,
Peter E. Lange, MD, PhD,
Roland Hetzer, MD, PhD
Departments of Cardiothoracic and Vascular Surgery and Pediatric Cardiology, German Heart Institute Berlin, Berlin, Germany
Accepted for publication November 2, 1995.
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Abstract
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In a 19-year-old woman who had previously undergone pulmonary artery banding at the age of 1.5 years, a muscular right ventricular outflow tract obstruction developed 3 days after an arterial switch operation. Although conservative therapy proved successful, prophylactic surgical intervention on the conal septum may be beneficial in preventing the postoperative development of right ventricular outflow tract obstruction.
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Introduction
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The arterial switch operation, a well-established procedure for treating a ventricular septal defect combined with D-transposition of the great arteries, is usually performed in infants [1]. Very limited experience has been made with this operation in adults [2], in whom it can be followed by unusual complications early after operation, as observed in the present case.
The female patient presented to the German Heart Institute Berlin for the first time when she was 18 years old and deeply cyanotic with arterial oxygen saturation at 76% and hematocrit at 0.70. When she was 1.5 years old pulmonary artery banding and a Blalock-Hanlon procedure were performed at another hospital.
Cardiac catheterization and angiography indicated a subpulmonary ventricular septal defect and transposition with anterior/posterior relation of the great arteries. The distal pulmonary artery/systemic pressure ratio was 0.46, with a 70-mm Hg pressure gradient across the pulmonary artery band. Neither a right ventricular aortic pressure gradient nor angiographic features of right ventricular outflow tract obstruction were observed (Fig 1A
; Table 1).
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Fig 1. . Right ventriculography before and after arterial switch operation (end-systolic phase). (A) Six months before arterial switch operation. No right ventricular outflow tract obstruction or systolic pressure gradient was observed. (B) Three days after arterial switch operation, right ventriculography revealed a significant subpulmonary dynamic muscular obstruction. The systolic pressure gradient between the right ventricles and pulmonary artery was 128 mm Hg.
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At the age of 19 years the patient underwent an arterial switch operation involving cardiopulmonary bypass, core cooling to 25°C rectal temperature, and myocardial protection with antegrade crystalloid cardioplegia, whereby ventricular and atrial septal defects were closed with Teflon patches. Afterward the patient was weaned from cardiopulmonary bypass without difficulty. Inotropic support was provided with epinephrine infusion (0.15 mg•kg-1•min-1).
Pressure measurement 30 minutes after bypass revealed a slight decrease in pulmonary arterial diastolic pressure and an 8-mm Hg systolic pressure gradient between the right ventricle and neopulmonary artery (see Table 1
). Cardiac index increased over the next 2 days from 1.6 L•min-1•m-2 on the first postoperative day to 3.1 L • min-1 • m-2 on the third. At the same time right ventricular systolic pressure increased significantly up to 180 mm Hg due to the development of dynamic subneopulmonary stenosis as documented by transesophageal echocardiography.
Cardiac catheterization and angiography on the third postoperative day revealed no residual defects except a 128-mm Hg pressure gradient across the right ventricular outflow tract as a result of dynamic subpulmonary muscular stenosis occurring at the end of systole (see Table 1; Fig 1B). Because the patient's cardiac output and ventricular function were adequate, and considering that the infusion of epinephrine (0.08 to 0.15 mg•kg-1•min-1) during the postoperative period might have caused subpulmonary obstruction, the patient was weaned from catecholamine support, which resulted in a decrease in right ventricular pressure (see Table 1). The patient was extubated 7 days after operation and discharged from the hospital on the 27th postoperative day. Transthoracic echocardiography indicated a 20-mm Hg systolic pressure gradient across the right ventricular outflow tract.
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Comment
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Arterial switch operations in adults in whom pulmonary artery banding was performed in infancy are rare [2]. Although no right ventricular subaortic obstruction was found preoperatively or intraoperatively, significant right ventricular (subneopulmonary) dynamic outflow tract muscular stenosis developed during the early postoperative period with suprasystemic pressure in the right ventricle. Right ventricular (subaortic) outflow obstruction in patients with transposition of the great arteries and subpulmonary ventricular septal defect, or Taussig-Bing anomaly, observed in 40% to 50% of the cases, is the result of anterior displacement of the conal septum and hypertrophy of the ventricular infundibulum fold, which can be aggravated by pulmonary artery banding [3–8]. Vogel and associates [8] established the correlation between preoperative subaortic obstruction in cases in which the subaortic region was tubular and smaller than the aortic valve during the systolic and diastolic phases, even in the absence of a pressure gradient. If not recognized and treated properly, this complication can be lethal in the early postoperative period. Kanter and colleagues [7] intraoperatively observed the development of subvalvular right ventricular outflow tract obstructions in 5 patients with complex transposition, which manifested themselves as suprasystemic pressure in the right ventricle as well as the inability to be weaned from cardiopulmonary bypass. None of these patients had a right ventricular outflow tract gradient preoperatively. Despite a second period of cardiopulmonary bypass and transventricular infundibular resection, only 2 of the 5 patients survived. In the present case neither echocardiographic, angiographic, nor pressure parameters preoperatively indicated a subaortic obstruction (see Fig 1A; Table 1). Postbypass pressure measurements were not predictive.
An improvement in cardiac index and contractility during the first 3 postoperative days resulted in the development of a subneopulmonary right ventricular muscular obstruction presumably aggravated by circulatory support with epinephrine infusion. Weaning the patient from vasopressor support resulted in a significant decrease in right ventricular systolic pressure.
This case illustrates that arterial switch operations can be successfully performed in adult patients after a long period of pulmonary artery banding (17 years in the present case). Because the anatomy of the conal septum plays an important role in determining the surgical procedure, even during arterial switch operations [3, 5, 7, 8], the development of a right ventricular outflow muscular obstruction must be considered, even despite the absence of preoperative indications for this. Prophylactic transatrial partial resection of the conal septum in patients after a long period of pulmonary artery banding may be beneficial in preventing right ventricular outflow tract obstruction during the early postoperative period.
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Acknowledgments
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We thank Jonathan Davis for proofreading the manuscript.
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Footnotes
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Address reprint requests to Dr Alexi-Meskishvili, Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany.
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References
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- Brawn WJ, Mee RBB. Early results for anatomic correction of transposition of the great arteries and for double-outlet right ventricle with subpulmonary ventricular septal defect. J Thorac Cardiovasc Surg 1988;95:230–8.[Abstract]
- Trehen H, Ott DA. Arterial switch procedure in an adult. Ann Thorac Surg 1991;51:122–4.
- Kurosawa H, van Mierop LHS. Surgical anatomy of the infundibular septum in transposition of the great arteries with ventricular septal defect. J Thorac Cardiovasc Surg 1986;91:123–32.[Abstract]
- Waldman JD, Schneeweiss A, Edwards WD, Lamberti JF, Shem-Tov A, Neufeld HN. The obstructive subaortic conus. Circulation 1984;70:339–94.[Abstract/Free Full Text]
- Quaegebeur JM, Bartelings M, Gittenberger-de Groot AC. Double outlet right ventricle with sub-pulmonary ventricular septal defect: an anatomical basis for surgical repair [Abstract]. Presented at the XXI Annual Meeting of the Association of European Pediatric Cardiologists, Vienna, Austria, May 1–4, 1984:60.
- Yacoub MH, Radley-Smith R. Anatomic correction of the Taussig-Bing anomaly. J Thorac Cardiovasc Surg 1984;88:380–8.[Abstract]
- Kanter KR, Anderson RH, Lincoln C, Rigby ML, Shinebourne EA. Anatomic correction for complete transposition and double outlet right ventricle. J Thorac Cardiovasc Surg 1985;90:690–9.[Abstract]
- Vogel M, Freedom RM, Smallhorn JF, Burrows P, Williams WG, Trusler GA. Morphologische Variationen bei 37 Patienten mit Taussig-Bing Herzen und deren Bedeutung für die chirurgische Behandlung. Z Herz Thorax Gefäßchir 1991;5:110–4.
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