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Ann Thorac Surg 2000;69:1880-1886
© 2000 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Anatomical risk factors for mortality and cardiac morbidity after arterial switch operation

^a Departments of Thoracic and Cardiovascular Surgery, University Hospital RWTH, Aachen, Germany
^b Department of Pediatric Cardiology, University Hospital RWTH, Aachen, Germany

Address reprint requests to Dr Daebritz, Department of Cardiac Surgery, LMU, University Hospital Grosshadern, Marchioninistr 15, D-81377 Munich, Germany
e-mail: sabine.daebritz{at}hch.med.uni-muenchen.de

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. The arterial switch operation (ASO) is the treatment of choice for transposition of the great arteries.

Methods. Anatomical risk factors on mortality and morbidity were analyzed retrospectively in 312 patients who underwent ASO between 1982 and 1997.

Results. Survival was 95%, 92%, and 92% after 30 days, 5, and 10 years, respectively. Operative survival improved after 1990 to 97% (p < 0.001). Risk factors for operative mortality were complex anatomy (p = 0.018), coronary anomalies (p = 0.008), and prolonged bypass time (p < 0.001). Determinants of late mortality were coronary distribution (p = 0.03), position of the great arteries (p = 0.0095), bypass time (p = 0.047), and aortic coarctation (p = 0.046). After a follow-up of 3.6 ± 2.7 years (0.1 to 14.9 years), 98% had good left ventricle function, 94% were in sinus rhythm, 2.4% had moderate to severe pulmonary stenosis, 0.3% had significant aortic regurgitation, and 1% had coronary stenosis. Freedom from reoperation was 100%, 96%, and 94% after 1, 5, and 10 years, respectively. No preoperative anatomic parameter correlated with long-term morbidity.

Conclusions. ASO can be performed with low operative mortality (< 5%) and long-term morbidity. Malformations associated with complex transposition of the great arteries influence early and late mortality.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Since the introduction of the arterial switch operation (ASO) by Jatene and associates in 1975 [1] and its modification by Lecompte and associates in 1981 [2], it has become the operative therapy of choice for newborns with transposition of the great arteries (TGA). In contrast to the atrial switch procedure (Mustard or Senning), this operation has the advantages of maintenance of sinus node function, preservation of the left ventricle as the systemic ventricle, and the mitral valve as the systemic atrioventricular valve. Therefore, the ASO is thought to have lower long-term morbidity. Midterm results have confirmed these assumptions [3]. However, in the ASO, the coronary arteries are translocated, the pulmonary valve becomes the systemic outflow valve, and the pulmonary arteries may be distorted because of the atypical relation of the great arteries. Therefore, concerns exist regarding the fate of the coronary arteries, the function of the neoaortic valve, and the development of pulmonary stenosis. Long-term results are rare to evaluate these issues.

In this report, our experience in a series of over 300 patients operated on in a time period of 15 years is analyzed. Special attention was given to the evaluation of preoperative anatomical features and their impact on short- and long-term mortality and morbidity.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Between 1982 and 1997, 312 patients underwent an arterial switch operation in our institution for TGA. Patients with single ventricles and TGA, who also underwent an ASO, were excluded from this study. An intact ventricular septum (IVS) was present in 245 cases. In 54 patients, a hemodynamically significant ventricular septal defect (VSD) was present, 3 of them had multiple VSDs, and 13 had a double-outlet right ventricle with subpulmonary VSD (Taussig Bing anomaly); these cases were categorized as complex TGA. The median age at operation was 7 days (mean 84 days, range 0 days to 7.8 years); 254 patients (82%) were neonates. Mean age at the ASO for patients with TGA and IVS was 15 ± 14 days (median 6 days), with TGA and significant VSD at 359 ± 771 days (median 33 days), and with Taussig Bing anomaly at 335 ± 484 days (median 102 days). Five patients with TGA and IVS were older than 28 days (4 to 13 weeks); they also underwent a one-stage ASO without prior training of the left ventricle. The management and the results of this subgroup have been previously reported [4]. Four patients had had previous Senning operation for ASO with VSD and developed right ventricular failure. These patients underwent banding of the pulmonary artery (PAB) before the ASO for training of the left ventricle. They were not included in the group of 10 patients (3.2%) with palliative PAB before the ASO. Twenty-two (7.1%) patients had concomitant coarctation of the aorta (CoA), which was repaired before the ASO in 9 and after in 11; 1 patient of this subgroup did not survive the ASO. Three patients underwent correction of interrupted aortic arch type A (IAA) before the ASO. Simultaneous operation of a CoA or IAA was not performed in this study group. Patients characteristics are summarized in Table 1. Coronary patterns were classified according to the Leiden convention [5]. A normal coronary pattern (A1, n = 226) and the most common variant with the circumflex arising from the right coronary (AB1, n = 40) were found in 266 (85.2%). A single right coronary, giving rise to the left coronary artery with just a conal branch coming off the left sinus, was present in 23 patients (7.4%) and was the most frequent variant. We summarized an intramural course, the presence of a large conal branch, or ostium stenosis independent of the coronary distribution as coronary anomalies.

Preoperative assessment and management
All patients underwent echocardiography before surgery in our institution. Cardiac catheterization was performed in 74.4% and most commonly (55.1%) before referral to our institution. Two hundred-sixteen patients (69%) had undergone balloon atrioseptostomy, which recently was performed using bedside echocardiography. Cardiac catheterization was obligatory in all patients with complex transposition, except in those with a single VSD. Because abnormal coronary distributions were not considered, a contraindication for the ASO, cardiac catheterization was not performed to visualize the coronaries since 1991.

Prostaglandin (PGE1) infusion before surgery was administered to 242 patients (76%). Typically infusion was continued until the patient was in the operating room.

Surgical and anesthetic management
All patients were operated on by two surgeons with standard surgical techniques. Circulatory arrest was used during surgery with additional low flow perfusion if required. Myocardial protection included administration of 30 mL/kg cristalloid cardioplegia according to Bretschneider.

The following technical considerations were taken into account. The pulmonary arteries were dissected beyond the upper lobe branching. The coronaries were cut out with an aortic button and were mobilized at least 5 mm with a low threshold of dividing early emerging conal branches. Intramural course of a coronary required special techniques including takedown of the commissure and creation of a button of the aortic wall including the coronary. The coronary buttons were implanted after punching a 4-mm hole into the ascending aorta. In special cases, a trap-door incision was made to create a flap. The coronaries were typically implanted at the level of or above the commissures of the neoaortic valve. Resorbable monofilament sutures were used for all anastomoses. A Lecompte maneuver was performed in 99% of the patients, independent of the relation of the great arteries. The aorta was reconstructed by an end-to-end anastomosis; a size difference between the neoaortic root and the distal aorta was adjusted by the suture technique without use of patch material. No patient underwent simultaneous arch enlargement or coarctation repair. The pulmonary trunk was reconstructed with two fresh autologous pericardial patches. A single patch was used only in the presence of a single coronary without a conal branch arising of a second ostium.

Closure of a VSD was performed during circulatory arrest, either directly or with a Dacron patch using a continuous 5-0 polypropylene patched mattress suture line through a right atrial approach or a transarterial approach for Taussig-Bing VSDs. One patient had a right ventriculotomy.

Intracardiac lines were not placed routinely; occasionally, a left atrial pressure line was inserted. Since 1989, the pericardium was closed with a polytetrafluoroethylene patch and 97.1% (302 of 312) of the patients had primary closure of the sternum. A 10F retrocardial and a 12F retrosternal irrigating tube were placed for postoperative blood drainage. Operative data are listed in Table 2.

Follow-up and statistical methods
A cross-sectional follow-up was conducted for all patients by contacting the pediatric cardiologists. Three foreign patients, living outside Germany, were excluded from long-term follow-up. Routine follow-up consisted of assessment of clinical status, electrocardiography (ECG), and echocardiography including Doppler interrogation of the right and left ventricular outflow tract. Abnormal findings led to further investigations including Holter ECG, stress ECG, cardiac catheterization, and coronary angiography or myocardial scintigraphy. Until 1995, routine cardiac catheterization approximately 1 year postoperatively was performed. At the time of follow-up, 82% of the patients had had cardiac catheterization.

If a patient had died, the patient’s physician was contacted to evaluate the cause of death. No patient died outside a hospital.

To calculate the influence of parameters on operative and 1-year survival, univariate comparisons were carried out using the two-tailed ² test. Whenever necessary, the Fisher’s exact test was used.

The probability of long-term survival was estimated by the Kaplan-Meier method. Differences between groups were calculated by the log-rank test. The association of parameters to long-term survival was first tested in an univariate model. Every univariate parameter reaching or approaching significance (p < 0.1) was then tested in a Cox multivariate model and removed stepwise if no significant influence was proved. Statistical analyses were done with the help of SPSS statistical software (SPSS Inc, Chicago, IL).

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Overall survival
The mean duration of follow-up was 3.6 ± 2.7 years (median 3.0, maximum 14.7 years). Actuarial 30-day, and 1-, 5-, and 10-year survival in the 312 patients was 95%, 93%, 92%, and 92%, respectively. Long-term survival was excellent but still significantly lower than in matched pairs of the German normal population (p < 0.001). There was no mortality beyond the second postoperative year (see Fig 1). Altogether, 25 patients died. There were 18 operative and seven late deaths. Table 3 describes the causes of death and the time of their occurrence in detail.

View larger version (14K): [in this window] [in a new window]   Fig 1. Survival after ASO for TGA. Each step in the curve denotes an event, and at each event the standard error is indicated in vertical bars. Mortality is highest in the early postoperative period; after the first months, the curve flattens down and no patient died after 2 years.

Long-term survival
Univariate determinants of long-term mortality were presence of a CoA (p = 0.046) and side-to-side or oblique position of the great arteries (p = 0.0095), a single coronary ostium (p = 0.03), and prolonged bypass time (p = 0.047). No factor proved to be significant in multivariate analysis.

Survival according to previous palliative operations
Operative survival was significantly lower in patients with previous palliative surgery (p = 0.041). Looking at previous pulmonary artery banding, 2 of 10 patients died in the operative period, resulting also in an impaired survival (p = 0.05). The patients with prior Senning operation and preparatory pulmonary artery banding were not included in this subgroup.

Survival according to the date of the operation
To test the hypothesis that the experience of the surgeon affects mortality, we divided the patients according to the date of the operation into patients operated on during the first 8 years (1982 to 1989; n = 51) and those during the second eight years (1990 to 1997; n = 261). Operative techniques apparently did not change during the whole period, although minor changes cannot be ruled out. Anaesthetic and cardiopulmonary bypass management and postoperative care, however, had improved. Operative survival was significantly higher for patients operated on during the latter period (survival 97%, p < 0.001). There was no difference in long-term survival.

Follow-up data and reoperations
At the time of follow-up, echocardiography revealed a good left ventricular function in 98% of the patients, and ECG showed sinus rhythm in 94%. Eighty-four percent of the surviving patients had no pulmonary stenosis (no gradient or a maximal instantaneous gradient of 15 mm Hg or less), 39 (13.6%) had mild, and 7 patients (2.4%) had severe pulmonary stenosis with a gradient of more than 35 mm Hg; 1 patient had significant aortic regurgitation. Stenoses of the coronary arteries were found in 3 patients (1.0%), 2 of those had an intramural course of the left main (coronary pattern A1) or left anterior descending artery (coronary pattern AB1). Long-term medication was deemed necessary in 5%. Ten patients (3.4%) were administered digoxin and 4 (1.3%) were under antiarrhythmic medication.

Six patients had to be reoperated using cardiopulmonary bypass after 6, 25, 41, 51, 61, and 75 months because of pulmonary stenoses, (n = 3), residual VSD (n = 2), or coronary stenosis (n = 1). Freedom from reoperation was 99.6%, 96%, and 94%, at 1, 5, and 10 years, respectively. None of the preoperative anatomical factors correlated with morbidity or freedom from reoperation.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
The results of this study confirm the low operative mortality for the ASO in patients with TGA with or without VSD and for the Taussig-Bing anomaly over a period of 15 years, which has been reported by several other groups [6–8].

Preoperative assessment
The ASO is performed in all patients who are scheduled for this procedure in our center, independent of coronary anatomy. Therefore, angiographic visualization of the coronaries is not considered necessary. In most patients, the coronary artery pattern is determined by echocardiography. A coronary artery arising from an unusual sinus crossing a commissure is suspicious of an intramural course.

In our study group, 74% of the patients had undergone cardiac catheterization, but in 56%, this was performed in the referring hospitals often in connection with a Rashkind balloon atrioseptostomy. Currently, in our institution, indication for catheterization is restricted to complex TGA, excluding patients with a single VSD and to patients with TGA and IVS beyond the neonatal period to assess intracardiac pressures. This is in agreement with other centers [6].

Operative survival
Significant risk factors for early death in this study group were coronary anomalies, certain coronary distributions, prolonged cardiopulmonary bypass (CPB) time, and earlier date of operation. Prior surgery and palliative pulmonary artery banding (PAB) were also risk factors for operative mortality. Therefore, corrective surgery is advisable early in life and palliative procedures should generally be avoided. Exceptions are prior Senning procedure or late referral of patients with TGA and IVS. These patients might need a training of the left ventricle. In our series, 4 patients with prior Senning palliation underwent one to three PAB procedures, each with no operative death. Five patients with TGA and IVS were referred beyond the neonatal period at the age of 4 to 13 weeks. They survived primary ASO after testing the left ventricle intraoperatively with temporary PAB. Thus, our study does not contain patients with a rapid two-stage ASO.

A coronary artery distribution with a single left or right ostium was a significant risk factor for early mortality in our study group. Coronary anomalies, which occur independent of the coronary pattern, also added to the operative mortality. However, the surgeon might not always have mentioned coronary anomalies in the operative report in uncomplicated cases or might have paid more attention to them if there were operative complications.

Some authors described a coronary pattern, in which the entire blood supply of the left coronary originates from an ostium on the right side as a risk factor [9]. In the experience of other groups, an intramural course was associated with a higher mortality; it is even considered to be a contraindication for the ASO by some [6, 7]. In our group, only 4 of the patients had an intramural course and none of these died. This rare incidence is in accordance with Sim and associates [10], who described an intramural course of a coronary in 0.8% of 255 autopsy specimens. Other groups reported an incidence of 5% in large series [6, 9]. These variations in incidence might result from a different definition of an intramural course. We defined an intramural course if the coronary was crossing a commissure and the orifice of the coronary did not have a cone. In our center as in others, the ASO is performed independent of the coronary distribution, as techniques have been developed for transfer of any coronary abnormality [8, 11].

Earlier date of operation has been a risk factor in most studies. This might result from a learning curve of the operative team [9]. Additional factors are improvement in CPB management and equipment as well as changes in anesthesia and intensive care. With respect to operative management, our study group is quite homogenous since 1990, with only two surgeons being involved in the ASO and with a standardized CPB and anaesthetic management. Operative mortality since then is 3% for all anatomical subgroups and is in the range of other experienced institutions [6, 8, 9].

CoA was not a risk factor for early death in our series. Management consisted of a two-step correction in this study group. A one-step repair has become treatment of choice in many centers. In the study of Planche and associates [6], 116 of 1032 patients had simultaneous CoA repair without an increase in mortality. Contrary to this, in the study of Wernovsky and associates [7], CoA repair with arch augmentation was a risk factor. The study, however, is limited by the small number of patients with CoA (6 of 470 patients). According to our results, a two-step management is acceptable for treatment of TGA with CoA.

Three patients in our study had an interrupted aortic arch type A. All three had a two-step repair with one operative death. Whether a one-step repair is advantageous has to be assessed in a larger series.

Late survival
The midterm results of this study group are encouraging, because no patient died after the second postoperative year. The most common cause of late death was related to pulmonary vascular disease. CoA, probably contributing to pulmonary volume overload before surgery, was a risk factor for late death in our series. Di Donato and associates [12] found pulmonary obstructive disease as cause of late death in two of three cases in a series of 62 patients with TGA and VSD. Both patients underwent surgery after the neonatal period. Rivenes and associates [13] reported a case of late death because of obstructive pulmonary vascular disease after neonatal ASO in a patient with simple TGA. In our study, three late deaths because of pulmonary vascular obstructive disease occured in patients with simple TGA who underwent the ASO in the neonatal period, so that a primary form of pulmonary hypertension must be suspected.

Late morbidity
Late coronary obstruction was a rare finding in our series. A varying incidence of up to 18.2% [14] has been reported by different centers. We believe that this complication is related to the surgical technique. As both surgeons in our series were using the same technique, differences cannot be analyzed.

We are confident to detect coronary obstructions with our follow-up strategy. Most patients have had cardiac catheterization. Additionally, patients who were older than 3 years of age at the time of this study underwent Bruce treadmill test. Routine echocardiography in 6-month intervals includes assessment of regional wall motion. In suspicious findings, myocardial scintigraphy and cardiac catheterization followed by selective coronary angiography are performed. We aim at revascularization with internal thoracic artery in cases with coronary obstructions.

With the current surgical technique, the need for reinterventions for right ventricular outflow tract obstruction (RVOTO) at any level is rare. Mild RVOTO, however, is common. Pulmonary stenosis with a gradient greater than 35 mm Hg was present in 7 patients (2.3%) in our study group. Kado and associates [15] found gradients of more than 30 mm Hg in the RVOT in 22% of 162 patients postoperatively. In a multiinstitutional study in 512 patients reported by Williams and associates [16] 83% of the patients were free from reintervention for RVOTO after 10 years. The study did not include Taussig-Bing patients. Risk factors were side-to-side position of the great arteries, CoA, single pulmonary sinus patch, lower birth weight, and certain surgical techniques. This is in contrast to the findings in our study, as no higher incidence of RVOTO was found in any anatomical subgroup. Particularly, patients with VSD or double-outlet right ventricle, who have a small aortic valve and root, which become pulmonary valve and root and who might have anterior malalignment of the conal septum, were not at higher risk of RVOTO. Possibly, the larger pulmonary arteries in these patients may be less prone to obstruction by the Lecompte maneuver. Further observation of the RVOT and the pulmonary arteries with assessment of the site of stenosis will be interesting, particularly under fast somatic growth in the adolescent period.

Most of the patients (94%) in this study had preserved sinus node function. This has been confirmed by other authors [6, 7, 17]; in their studies 96% to 97% of patients were in sinus rhythm after a follow-up of 12 to 51 months. The most common finding in ECG was an incomplete right bundle branch block. A subgroup of our study patients underwent Holter ECG at our institution [18]. Sinus rhythm was present in 93.5%, and 6.5% had ectopic atrial or junctional rhythm.

In conclusion, the results of this study confirm low operative and long-term mortality and morbidity for the ASO over a 15-year time period. Although anatomical risk factors can be identified, the ASO is the treatment of choice in all anatomical subgroups. Increasing experience and early corrective surgery have improved the results.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Jatene A.D., Fontes V.F., Souza L.C.B., et al. Successful anatomic correction of transposition of the great arteries. A preliminary report. Arg Bros Cardiol 1975;28:461-464.
2. Lecompte Y., Zannini L., Hazan E., et al. Anatomic correction of transposition of the great arteries. J Thorac Cardiovasc Surg 1981;82:629-631.[Abstract]
3. Martin R.P., Queshri S.A., Ettedgui J.A., et al. An evaluation of right and left ventricular function after anatomical correction and intra-atrial repair operations for complete transposition of the great arteries. Circulation 1990;82:808-816.[Abstract/Free Full Text]
4. Daebritz S., Engelhardt W., von Bernuth G., Messmer B.J. Trial of pulmonary artery banding. Eur J Cardiothorac Surg 1997;11:112-116.[Abstract]
5. Gittenberger de Groot A.C., Sauer U., Oppenheimer-Dekker A., Quaegebeur J.M. Coronary artery anatomy in transposition of the great arteries. Ped Cardiol 1983;4(Suppl I):15-24.
6. Planche C., Lacour-Gayet F., Serraf A. Arterial switch. Pediatr Cardiol 1998;19:297-307.[Medline]
7. Wernovsky G., Mayer J.E., Jonas R.A., et al. Factors influencing early and late outcome of the arterial switch operation for transposition of the great arteries. J Thorac Cardiovasc Surg 1995;109:289-302.[Abstract/Free Full Text]
8. Quaegebeur J.M., Rohmer J., Ottenkamp J., et al. The arterial switch operation. J Thorac Cardiovasc Surg 1986;92:361-384.[Abstract]
9. Mayer J.E., Sanders S.P., Jonas R.A., Castañeda A.R., Wernovsky G. Coronary artery pattern and outcome of arterial switch operation for transposition of the great arteries. Circulation 1990;82(suppl IV):139-145.
10. Sim E.K., van Son J.A.M., Edwards W.D., Julsrud P.R., Puga F.J. Coronary artery anatomy in complete transposition of the great arteries. Ann Thorac Surg 1994;57:890-894.[Abstract]
11. Asou T., Karl T.R., Pawade A., Mee R.B.B. Arterial switch. Ann Thorac Surg 1994;57:461-465.[Abstract]
12. Di Donato R.M., Wernovsky G., Walsh E.P., et al. Result of the arterial switch operation for transposition of the great arteries with ventricular septal defect. Circulation 1989;80:1689-1705.[Abstract/Free Full Text]
13. Rivenes S.M., Grifka R.G., Feltes T.F. Development of obstructive pulmonary vascular disease in D-transposition of the great arteries after neonatal arterial switch operation. Tex Heart Inst J 1998;25:201-205.[Medline]
14. Bonhoeffer P., Bonnet D., Piechaud J.F., et al. Coronary artery obstruction after arterial switch operation for transposition of the great arteries in newborns. J Am Coll Cardiol 1997;29:202-206.[Abstract]
15. Kado H., Asoh T., Imoto Y., Shiokawa Y., Yamasaki M., Yasui H. Reoperation for transposition of the great arteries. Rinsho Kyebu Geka 1994;14:192-197.
16. Williams W.G., Quaegebeur J.M., Kirklin J.W., Blackstone E.H. Outflow obstruction after the arterial switch operation. J Thorac Cardiovasc Surg 1997;114:975-990.[Abstract/Free Full Text]
17. Rhodes L.A., Wernovsky G., Keane J.F., et al. Arrhythmias and intracardiac conduction after the arterial switch operation. J Thorac Cardiovasc Surg 1995;109:303-310.[Abstract/Free Full Text]
18. Hovels-Gurich H.H., Seghaye M.C., Daebritz S., Messmer B.J., von Bernuth G. Cardiological and general health status in preschool- and school-age children after neonatal arterial switch operation. Eur J Cardiothorac Surg 1997;12:593-601.[Abstract]

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				H. Imura, P. Modi, A. Pawade, A. J. Parry, M.-S. Suleiman, G. D. Angelini, and M. Caputo Cardiac troponin I in neonates undergoing the arterial switch operation Ann. Thorac. Surg., December 1, 2002; 74(6): 1998 - 2002. [Abstract] [Full Text] [PDF]

				A. M. Scheule, D. Zurakowski, E. D. Blume, C. Stamm, P. J. del Nido, J. E. Mayer Jr, and R. A. Jonas Arterial switch operation with a single coronary artery J. Thorac. Cardiovasc. Surg., June 1, 2002; 123(6): 1164 - 1172. [Abstract] [Full Text] [PDF]

				S. K. Gandhi, F. A. Pigula, and R. D. Siewers Successful late reintervention after the arterial switch procedure Ann. Thorac. Surg., January 1, 2002; 73(1): 88 - 95. [Abstract] [Full Text] [PDF]

				J. Wetter, E. Belli, N. Sinzobahamvya, H. C. Blaschzok, A. M. Brecher, and A. E. Urban Transposition of the great arteries associated with ventricular septal defect: surgical results and long-term outcome Eur. J. Cardiothorac. Surg., October 1, 2001; 20(4): 816 - 823. [Abstract] [Full Text] [PDF]

				J. Losay, A. Touchot, A. Serraf, A. Litvinova, V. Lambert, J. D. Piot, F. Lacour-Gayet, A. Capderou, and C. Planche Late Outcome After Arterial Switch Operation for Transposition of the Great Arteries Circulation, September 18, 2001; 104 (2009): I-121 - I-126. [Abstract] [Full Text] [PDF]

				C. Dunbar-Masterson, D. Wypij, D. C. Bellinger, L. A. Rappaport, A. L. Baker, R. A. Jonas, and J. W. Newburger General Health Status of Children With D-Transposition of the Great Arteries After the Arterial Switch Operation Circulation, September 18, 2001; 104 (2009): I-138 - I-142. [Abstract] [Full Text] [PDF]

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