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Ann Thorac Surg 2000;69:851-857
© 2000 The Society of Thoracic Surgeons

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Original Articles

Arterial switch after failed atrial baffle procedures for transposition of the great arteries

^a Division of Cardiovascular-Thoracic Surgery, Children’s Memorial Hospital and Department of Surgery, Northwestern University Medical School, Chicago, Illinois, USA

Address reprint requests to Dr Mavroudis, Division of Cardiovascular-Thoracic Surgery, Children’s Memorial Hospital, 2300 Children’s Plaza, M/C 22, Chicago, IL 60614-3394
e-mail: c-mavroudis{at}nwu.edu

Presented at the Forty-sixth Annual Meeting of the Southern Thoracic Surgical Association, San Juan, Puerto Rico, Nov 4–6, 1999.

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Late failure of the systemic right ventricle after atrial baffle procedures in patients with transposition of the great arteries poses significant management problems. We reviewed our experience with staged conversion to arterial switch operation (ASO) in these patients.

Methods. Between 1984 and 1999, 11 patients underwent pulmonary artery band (PAB) to prepare the left ventricle for ASO conversion. One additional patient had subpulmonic stenosis and was naturally prepared. Mean age at the initial PAB was 12.2 ± 7 years (range, 1.9 to 23 years). Four patients underwent reoperation to tighten the PAB before ASO. Mean interval from PAB to ASO was 1.3 ± 0.9 years.

Results. There was no mortality from PAB. Six patients had ASO conversion and 2 died. Recent surgical modifications at the time of ASO were used to prevent neoaortic valve insufficiency and to cryoablate atrial reentry tachycardia. Four patients developed biventricular failure after PAB and had orthotopic cardiac transplantation (OCT) 14 ± 10 months after PAB. The other 2 patients are still with PAB: 1 is awaiting ASO conversion and the other has insufficient left ventricular hypertrophy necessary for ASO conversion despite two preparatory PABs.

Conclusions. A select group of patients with right ventricular failure after atrial baffle operations can undergo staged conversion to ASO with the opportunity for excellent long-term outcome. Surgical modifications at the time of ASO can address the problems of neoaortic insufficiency and persistent atrial arrhythmias. PAB may be a therapeutic endpoint in some patients not responding with adequate left ventricular hypertrophy. Those patients who develop biventricular failure after PAB will require cardiac transplantation.

	Introduction

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Late complications of the atrial baffle operations for transposition of the great arteries (TGA) include right (systemic) ventricular (RV) failure and life-threatening atrial arrhythmias [1–3]. The idea that the low pressure and underloaded left ventricle (LV) in TGA patients with established atrial baffle operations could be retrained en route to baffle takedown and an arterial switch operation (ASO) was introduced by Mee [4]. This require a series of operations commencing with a preparatory pulmonary artery band(s) (PAB), and eventual ASO.

A few centers have documented the clinical results of such a program [5–8] and identified accompanying complications, which can include ineffective induction of LV hypertrophy, neoaortic insufficiency, persistent troubling atrial arrhythmias, and biventricular failure that can lead to cardiac transplantation. The purpose of this article is to report our results with TGA patients with failed atrial baffle procedures who underwent PAB with the intention to treat by ASO conversion after induction of LV hypertrophy.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Between November 1984 and June 1999, 11 patients with a failed atrial baffle operation for TGA underwent at least one preparatory PAB to induce LV hypertrophy en route to ASO conversion. An additional patient developed subpulmonic stenosis and experienced natural induction of LV hypertrophy. The pre-PAB clinical features of the 12 patients are listed in Table 1. There were 8 boys and 4 girls. The mean age at the atrial baffle operation was 6.5 ± 5 months. The mean age at the first preparatory PAB was 12.2 ± 7 years (range, 1.9 to 23 years). The relevant pre-PAB catheterization and echocardiographic data are listed in Table 2. The mean pre-PAB LV/RV pressure ratio was 0.46 ± 0.22.

View larger version (24K): [in this window] [in a new window]   Fig 1. Representation of instrumentation and interventricular septal geometry before (A) and after (B) preparatory pulmonary artery band (PAB) in a patient with transposition of the great arteries after a failed atrial baffle procedure. The proximal pulmonary artery pressure is measured simultaneously with the systemic pressure. As the band is tightened, a rise in left ventricular (LV) pressure is noted, which is accompanied by an interventricular septal shift toward the right ventricle (RV; monitored by transesophageal echocardiography). This oftentimes results in improved tricuspid valve function and less tricuspid regurgitation (TR). Bold arrow represents severe TR, small arrow after PAB represents mild TR.

View larger version (64K): [in this window] [in a new window]   Fig 2. Right atrial view in a patient with an established Mustard baffle operation for transposition of the great arteries undergoing baffle excision en route to arterial switch operation conversion. Care is taken to remove the entire atrial baffle (outlined by dashed line) without injuring the superior vena cava, the inferior vena cava, and the sinoatrial node. A coronary sinus catheter is placed for retrograde cardioplegia delivery.

View larger version (45K): [in this window] [in a new window]   Fig 3. Right atrial view in a patient with an established Senning baffle operation for transposition of the great arteries undergoing baffle takedown. Care is taken to preserve the sinoatrial node and the original baffle connections for eventual reconnection to the posterior right atrial wall.

View larger version (48K): [in this window] [in a new window]   Fig 4. Right atrial view in a patient who had Senning baffle takedown and is now undergoing baffle reconnection to the right posterolateral atrial wall en route to Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ) atrial septum reconstruction and arterial switch operation conversion.

View larger version (43K): [in this window] [in a new window]   Fig 5. Right atrial view in a patient who had Mustard baffle excision and is now undergoing a right-sided Maze cryoablation procedure and Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ) reconstruction of the atrial septum. Lines of block are created to connect the inferoposterior os of the coronary sinus with the inferior vena cava, the edge of the atrial septal defect with the posterior atrial wall across the crista terminalis, and the atrial septal defect with the edge of the right atrial appendage. The Gore-Tex patch is placed to divide the anatomic left and right atria.

View larger version (39K): [in this window] [in a new window]   Fig 6. Hemashield (Meadox Medicals Inc, Oakland, NJ) neoaortic valve-sparing reconstruction used to prevent proximal neoaortic dilatation and resultant neoaortic insufficiency. The pulmonary artery wall is removed and the contoured Hemashield graft is sewn into the resected sinuses of Valsalva. Appropriately sized holes are made in the corresponding facing sinuses for coronary reimplantation. The distal Hemashield graft is sutured end to end into the ascending aorta, thereby reconstructing the neoaorta.

View larger version (38K): [in this window] [in a new window]   Fig 7. Aortic homograft implantation in a patient who had a Senning operation for transposition of the great arteries and moderate pulmonary stenosis. The patient underwent a preparatory PAB en route to arterial switch operation conversion by neoaortic reconstruction using an aortic homograft because of the poor quality of the existing pulmonary valve (neoaortic valve).

Two recent patients had preparatory PAB and are presently being evaluated for ASO conversion based on LV posterior wall thickness, LV pressure, and LV function.

LV evaluation before ASO
Assessment of an adequately prepared LV after PAB was made by echocardiography and cardiac catheterization. Measurements included assessment of biventricular function, LV posterior wall thickness, and LV systolic pressure. In general, patients were referred for ASO conversion when the LV diastolic posterior wall measurement was more than 8 mm thick and when the LV systolic pressure was more than 80% of the RV (systemic) pressure with a well-functioning LV.

Clinical evaluation before cardiac transplantation
Patients became candidates for cardiac transplantation if they did not respond favorably to the preparatory PAB. They were deemed to have end-stage congenital heart disease based on poor systemic ventricular function, deteriorating functional class, and an estimated life expectancy of less than 6 months. None of these patients developed an increase in their LV posterior wall thickness. All of these patients were hospitalized for inotropic support before cardiac transplantation. Follow-up was complete in all patients. Results are expressed as mean ± standard deviation (SD).

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Mortality in this series of operations is categorized by procedure: PAB, ASO, and orthotopic cardiac transplantation (OCT). Eleven patients had 15 preparatory PAB procedures without operative mortality. There were 2 early deaths (33%) and no late deaths in the 6 patients in the ASO group. There were no early deaths in the OCT group and 1 late death 7 years after OCT from chronic rejection. The 2 deaths in the ASO group were related to an error in judgment in 1 patient and unanticipated postoperative LV dysfunction in the other. The error in judgment occurred intraoperatively when a presumed single coronary artery was transferred. Postmortem examination revealed the presence of another (untransferred) paracommissural coronary artery and myocardial infarction. The other death occurred in a 17-year-old boy who had two previous preparatory PABs. Before ASO his LV/RV pressure ratio was 0.9, with an LV pressure of 80 mm Hg. He had baffle takedown, a right-sided Maze operation for atrial arrhythmias, and ASO combined with Hemashield neoaortic valve-sparing reconstruction. He required placement of a LV assist device (Thoratec Laboratories Corp, Berkeley, CA) 12 hours after repair for low cardiac output and ventricular arrhythmias and eventually died 2 weeks postoperatively from a cerebral infarct and intracranial bleed. Postmortem examination revealed that the LV posterior wall had 7 mm of muscle and 3 mm of fibrous tissue (not 10 mm of muscle). His postoperative LV failure was probably because of inadequate LV hypertrophy. The intraoperative and postoperative pressure measurements in those patients who had preparatory PAB are listed in Table 3.

	Comment

Top Abstract Introduction Material and methods Results Comment References

Preparatory PAB was successful in inducing the necessary LV hypertrophy and LV pressure for ASO conversion in some but not all of our patients. There seems to be an age-dependent time when preparatory PAB has a smaller chance of resulting in successful anatomic correction. Although all of our successful ASO patients were less than 16 years of age, 2 of our PAB patients who required OCT were 6 and 9 years of age. Our 1 patient who died because of an inadequately prepared LV was 17 years old. There seems to be little trouble in inducing LV hypertrophy in infants with unoperated TGA who have aged beyond the neonatal period by PAB and systemic-to-pulmonary artery shunt [13, 14]. Why this is not true in older children may be related to two factors. First, the neonatal heart, unlike the older child’s heart, has the ability to undergo myocyte hyperplasia for several months, which favors myocardial mass development [15]. Second, the child’s heart with a failed atrial baffle operation often has some degree of biventricular failure, which may respond unfavorably to PAB and LV retraining. In our series the mean age at PAB was 12.2 years, the mean age at ASO was 11.5 years, and the mean age at OCT was 13.5 years. In the review by Prieto and colleagues [8], older age was a significant risk factor for mortality: mean ages for survivors and nonsurvivors were 11.0 ± 4.8 vs 15.8 ± 5.1 years, respectively. However, Cetta and associates [16] reported successful ASO conversion in a 36-year-old patient. In general, we would conclude from our data and clinical review that the older the patient, especially older than 16 years of age, the less likely ASO conversion will be.

A small subgroup of patients may be able to have successful ASO conversion without a preparatory PAB. We had 1 such patient in our series, a 12-year-old patient who had progressive subpulmonic obstruction and natural occurrence of LV hypertrophy. Several centers have reported successful "one-stage" arterial switch, often in the setting of pulmonary venous obstruction, which creates pulmonary hypertension and in effect prepares the LV serendipitously [16–18].

The technical aspects of our series are interesting because we have addressed the problems of resultant neoaortic insufficiency and troubling atrial arrhythmias at the time of ASO. Five of our 6 patients who eventually had ASO had some kind of neoaortic valve reconstruction at the initial operation (n = 4) or aortic valve replacement later because of neoaortic regurgitation (n = 1). So far, neoaortic insufficiency has not occurred in the patients who had neoaortic reconstruction at the initial operation. Whether this will be maintained over time and whether this approach will compare favorably with those patients who did not have modified neoaortic reconstruction remain to be evaluated. Cochrane and colleagues [6] reported 2 of 16 patients having ASO conversion requiring aortic valve replacement (12%) and 5 other patients (31%) having mild aortic insufficiency under observation. Chang and coworkers [7] reported a high incidence of neoaortic insufficiency after anatomic correction, and 1 of their 5 patients required an aortic valve replacement 4 months after ASO.

There was hope during the initial evaluation of this strategy that once the ASO was performed, the atrial pressures would decrease and this would be accompanied by a resolution of atrial arrhythmias. This has proved not to be the case. As a result, we instituted a strategy to evaluate for atrial arrhythmias and to perform arrhythmia operations when appropriate. This strategy, which we have applied in other patients [11], has been successful in our 2 patients with nodal reentry tachycardia and atrial reentry tachycardia, respectively.

Four patients in this series required OCT after PAB because of biventricular failure. The mean age of these patients at OCT was 13.5 ± 7 years. One of those patients died 7 years posttransplant from chronic rejection. OCT has been reported in many patients with end-stage congenital heart disease, including those with failed atrial baffle procedures [7, 12]. In our series these patients tended to have had other prior procedures—tricuspid valve replacement (2), pacemaker (2), superior vena cava obstruction (1)—and were not as easy to obtain a reasonable LV pressure at the time of PAB.

There is a subset of failed atrial baffle procedure patients that undergoes preparatory PAB resulting in improved functional class without sufficient LV hypertrophy induction or LV pressure for ASO conversion. The patients in this subset may improve their hemodynamic status because of induction of LV hypertrophy and septal deviation toward the midline resulting in more favorable geometric conditions for tricuspid valve function and improved ventricular contractility. These findings have been reported previously [5, 6] and are consistent with our results. We have 1 patient who had two PABs over a 2.5-year period who did not develop sufficient LV pressure or hypertrophy to undergo ASO. She has, however, experienced increased functional class because of improved RV function and decreased tricuspid valve regurgitation. One has to consider whether PAB in a subset of these patients will represent a therapeutic endpoint. Unfortunately, the needed and resolving prospective trial is unlikely to be performed. In many ways this is a diminishing problem as the current standard of care for patients with TGA is neonatal arterial switch. However, the large number of patients with extant atrial baffle operations will require some attention in the future. This makes small series like this and others like it all the more important to document the results and discuss the options that are likely to present themselves.

A select group of patients with RV failure after atrial baffle operations can undergo staged conversion to ASO with the opportunity for excellent long-term cardiac function. Surgical modifications can address the problems of neoaortic insufficiency and persistent atrial arrhythmias. Some PAB patients will improve symptomatically but will not develop sufficient LV hypertrophy for ASO conversion. Whether PAB will represent a therapeutic endpoint in these patients remains to be seen. Those patients who develop biventricular failure after PAB will require cardiac transplantation.

	Footnotes

 
This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/section/atsdiscussion/

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Turina M.I., Siebenmann R., von Segesser L., Schönbeck M., Senning A. Late functional deterioration after atrial correction for transposition of the great arteries. Circulation 1989;80(3 Pt 1):I162-I167.
2. Gelatt M., Hamilton R.M., McCrindle B.W., et al. Arrhythmia and mortality after the Mustard procedure. J Am Coll Cardiol 1997;29:194-201.[Abstract]
3. Kirjavainen M., Happonen J.M., Louhimo I. Late results of Senning operation. J Thorac Cardiovasc Surg 1999;117:488-495.[Abstract/Free Full Text]
4. Mee R.B.B. Severe right ventricular failure after Mustard or Senning operation. Two-stage repair. J Thorac Cardiovasc Surg 1986;92:385-390.[Abstract]
5. Van Son J.A.M., Reddy V.M., Silverman N.H., Hanley F.L. Regression of tricuspid regurgitation after two-stage arterial switch operation for failing systemic ventricle after atrial inversion operation. J Thorac Cardiovasc Surg 1996;111:342-347.[Abstract/Free Full Text]
6. Cochrane A.D., Karl T.R., Mee R.B.B. Staged conversion to arterial switch for late failure of the systemic right ventricle. Ann Thorac Surg 1993;56:854-862.[Abstract]
7. Chang A.C., Wernovsky G., Wessel D.L., et al. Surgical management of late right ventricular failure after Mustard or Senning repair. Circulation Suppl 1992;86(Suppl 2):140-149.
8. Prieto L.R., Latson L.A., Flamm S.D., Drummond-Webb J., Mee R.B.B. Conversion from atrial to arterial switch in patients with D-transposition of the great arteries. Circulation 1998;17:I61.
9. Wernovsky G., Giglia T.M., Jonas R.A., Mone S.M., Colan S.D., Wessel D.L. Course in the intensive care unit after "preparatory" pulmonary artery band and aortopulmonary shunt placement for transposition of the great arteries with low left ventricular pressure. Circulation Suppl 1992;86(Suppl II):133-139.
10. David T.E., Feindel C.M. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992;103:617-622.[Abstract]
11. Mavroudis C., Backer C.L., Deal B.J., Johnsrude C.L. Fontan conversion to cavopulmonary connection and arrhythmia circuit cryoablation. J Thorac Cardiovasc Surg 1998;115:547-556.[Abstract/Free Full Text]
12. Backer CL, Zales VR, Mavroudis C. Heart transplantation in the infant and child. In: Mavroudis C, Backer CL, eds. Pediatric cardiac surgery, 2nd ed. St. Louis: Mosby Yearbook, Inc, 1994:571–83.
13. Boutin C., Wernovsky G., Sanders S.P., Jonas R.A., Castañeda A.R., Colan S.D. Rapid two-stage arterial switch operation—evaluation of left ventricular systolic mechanics late after an acute pressure overload stimulus in infancy. Circulation 1994;90:1294-1303.[Abstract/Free Full Text]
14. Boutin C., Jonas R.A., Sanders S.P., Wernovsky G., Mone S.M., Colan S.D. Rapid two-stage arterial switch operation—acquisition of left ventricular mass after pulmonary artery banding in infants with transposition of the great arteries. Circulation 1994;90:1304-1309.[Abstract/Free Full Text]
15. Sonnenblick E.H., Anversa P. Models and remodeling. Cardiologia 1999;44:609-619.[Medline]
16. Cetta F., Bonilla J.J., Lichtenberg R.C., Stasior C., Troman J.E., DeLeon S.Y. Anatomic correction of dextrotransposition of the great arteries in a 36-year-old patient. Mayo Clin Proc 1997;72:245-247.[Abstract]
17. Shinebourne E.A., Jahangiri M., Carvalho J.S., Lincoln C. Anatomic correction for post-Mustard pulmonary venous obstruction. Ann Thorac Surg 1994;57:1655-1656.[Abstract]
18. Reisman M., Rosengart R.M., Degner T.L., Sintek C., Khonsari S. Post-Mustard procedure pulmonary venous obstruction. Pediatr Cardiol 1999;20:301-303.[Medline]

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This Article Abstract Full Text (PDF) Online Discussion Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Constantine Mavroudis Carl L. Backer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mavroudis, C. Articles by Backer, C. L. Search for Related Content PubMed PubMed Citation Articles by Mavroudis, C. Articles by Backer, C. L. Related Collections Related Article