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Ann Thorac Surg 2006;81:2259-2266
© 2006 The Society of Thoracic Surgeons

Original article: Cardiovascular

Late Results After Extended Pulmonary Artery Reconstruction in the Arterial Switch Operation

Michael V. Ullmann, MD a , * , Matthias Gorenflo, MD b , Christian Bolenz a , Christian Sebening, MD a , Michael Goetze, MD b , Raoul Arnold, MD b , Herbert E. Ulmer, MD b , Siegfried Hagl, MD a

a Department of Cardiac Surgery, University Medical Center, University of Heidelberg, Heidelberg, Germany
b Department of Pediatric Cardiology, University Medical Center, University of Heidelberg, Heidelberg, Germany

Accepted for publication January 5, 2006.

* Address correspondence to Dr Ullmann, Department of Cardiac Surgery, University Medical Center, University of Heidelberg, Im Neuenheimer Feld 110, D-69120 Heidelberg, Germany (Email: michael.ullmann{at}web.de).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: Pulmonary artery stenosis remains the most frequent late complication and cause of reintervention after the arterial switch operation for transposition of the great arteries. We investigated the influence of an extended pericardial patch augmentation of the neopulmonary root and pulmonary artery on late pulmonary artery stenosis development.

METHODS: Augmentation of the neopulmonary root and pulmonary artery was achieved by reconstructing the posterior wall using a large glutaraldehyde-treated autologous pericardial patch. Reviewed were regular follow-up echocardiograms from 58 out of 87 patients undergoing the arterial switch operation who presented a follow-up period of at least 5 years. An actual follow-up echocardiographic evaluation focusing on the maximal instantaneous transpulmonary continuous-wave (cw)-Doppler gradient was performed, followed by cardiac catheterization when indicated (peak cw-Doppler gradient > 40 mm Hg).

RESULTS: Follow-up was 8.9 [5 to 15] years. There was no reintervention due to residual pulmonary artery stenosis. Actual Doppler examination revealed a transpulmonary peak gradient of 19.5 [0 to 56] mm Hg, compared with 20 [0 to 60] mm Hg at discharge. Forty-three patients (74.1%) had no or only trivial pulmonary artery stenosis (pressure gradient < 25 mm Hg), 14 patients (24.2%) had mild stenosis (25 to 49 mm Hg), and 1 patient (1.7%) had moderate stenosis (50 to 79 mm Hg).

CONCLUSIONS: Compared with the majority of literature data, we could demonstrate a low incidence of late pulmonary artery stenosis after the arterial switch operation by employing an extended pericardial patch reconstruction technique with augmentation of the neopulmonary root and pulmonary artery.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Since its successful introduction by Jatene and colleagues in 1976 [1] the arterial switch operation (ASO) has become the surgical treatment of choice for correction of transposition of the great arteries (TGA) for about the last 15 years. A considerable number of series have been reported recently with excellent functional and clinical results [2–12]. The most common complication and cause of reintervention in survivors is supravalvular pulmonary artery stenosis (PAS), with a reported incidence varying from 1% to 42%, depending on PAS criteria and length of follow-up period [2–12]. Various factors have been attributed to cause PAS; for instance, growth failure of the valve annulus [13, 14] or distortion and stretching of the pulmonary arteries as a result of the anterior placement of the pulmonary bifurcation [15, 16], and the so-called Lecompte maneuver [17]. The type of neopulmonary root reconstruction using autologous pericardial patch material (single pantaloon technique or double-patch technique) is reported to be a major risk factor for the development of PAS; the incidence of postoperative PAS seems to be affected not only by number, but also by size and by pretreatment of the pericardial patches used for neopulmonary root reconstruction [9, 7, 18]. Despite various modifications of the PA reconstruction technique [19] there is still a high incidence of this postoperative complication leading to reoperation in 16% to 30% of long-term survivors [10, 12].

We modified the double-patch technique of PA reconstruction during ASO as reported by Quaegebeur and colleagues [20] by performing an extended pericardial patch reconstruction with augmentation of the posterior wall of the neopulmonary root, the main pulmonary artery (MPA), the pulmonary bifurcation, the left pulmonary artery (LPA), and the proximal part of the right pulmonary artery (RPA). Augmentation was achieved by means of an oversized glutaraldehyde-treated autologous pericardial patch, which was fashioned in a triangular shape. To investigate the influence of this reconstruction technique on late PAS development we reviewed the follow-up reports of all 87 patients undergoing ASO for TGA and excluded those patients with a follow-up period of less than 5 years from this prospective echocardiographic long-term study.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Acknowledgments
 References
 
This study was approved by the Ethics Committee, University of Heidelberg (approval No. 135/2005, 15/08/2005), and informed individual consent was obtained.

Study Patients
Between April 1989 and October 2004, 87 consecutive patients presenting with simple (n = 57) or complex TGA (n = 30) underwent an ASO with extended PA pericardial patch reconstruction at our institution. Twenty-nine of 87 patients presenting a follow-up period of less than 5 years were excluded from this prospective echocardiographic study. In the remaining 58 patients (simple TGA, n = 42; complex TGA, n = 16) an actual clinical examination was performed, including an echocardiographic evaluation focusing on the maximal instantaneous transpulmonary continuous-wave (cw)-Doppler gradient (Table 1), in order to investigate the incidence of late PAS after ASO [21–24]. Cardiac catheterization was performed in patients presenting a peak cw-Doppler gradient greater than 39 mm Hg (n = 4) and in patients presenting with a residual ventricular septal defect (VSD, n = 3; Table 2).


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  		Table 1. Mild (Maximal cw-Doppler gradient 25 to 49 mm Hg) and Moderate (50 to 79 mm Hg) Pulmonary Artery Stenosis [25] in Patients After the Arterial Switch Operation With Extended Reconstruction of the Neopulmonary Root, Pulmonary Trunk, and Left Pulmonary Artery (n = 15/58): Localization and Amount (mm Hg) of Maximal cw-Doppler Gradient at the Latest Follow-Up Echocardiographic Examination
 

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  		Table 2. Comparison of Transpulmonary Peak Gradient (mm Hg) Measured by cw-Doppler Examination (Doppler) and by Cardiac Catheterization (Catheter)
 
Surgical Procedures
After median sternotomy standard cardiopulmonary bypass was established by cannulation of the proximal aortic arch followed by single cannulation of the right atrium. After cross-clamping of the aorta antegrade single dose cold crystalloid cardioplegia was administered and the patient was cooled down. When a body temperature of 22°C to 24°C was reached, closure of an atrial septal defect (ASD) and (or) VSD was performed under circulatory arrest followed by closure and transection of the patent ductus arteriosus (PDA). Then, an extended dissection and mobilization of LPA and RPA was performed bilaterally to the hilus level followed by an extended dissection and mobilization of the aortic arch and the supra-aortic branches. After transection of the aorta and the pulmonary trunk at different levels (Fig 1) the coronary ostia were excised as buttons out of the aortic root in the form of an O for the right coronary artery and in the form of a U for the left coronary artery, starting from the transection level of the proximal aortic root (Fig 2). After proceeding with the Lecompte maneuver [17], the coronary arteries were reimplanted in the neoaortic root (Fig 2). Then, a large incision of the posterior wall of the pulmonary bifurcation and LPA was performed including the proximal RPA part (Fig 2). To fill the defects in the neopulmonary root we used two glutaraldehyde-treated autologous pericardial patches; a small one for the right-sided defect in the form of a circle and a large one for the left-sided defect, which was fashioned in a triangular shape (Fig 3). After closure of the left-sided defect the large triangular pericardial patch was used for an extended reconstruction with augmentation not only of the neopulmonary root, but also of the posterior aspect of the pulmonary trunk, of the bifurcation of the pulmonary artery and LPA, and the proximal RPA part (Figs 4, 5). Go Additional procedures performed at the time of ASO included closure of a patent foramen ovale or secundum atrial septal defect and ligature with transection of a patent ductus arteriosus in all patients (n = 58), closure of a ventricular septal defect (VSD) in 12 patients (VSD direct closure, n = 7; VSD patch closure, n = 5), pulmonary artery debanding (n = 3), explantation of a central prosthetic aortopulmonary shunt (n = 1), relief of left ventricular outflow tract obstruction by subvalvular myectomy (n = 1), and aortic arch reconstruction (n = 1). Closure of atrial and (or) ventricular septal defects was performed under hypothermic circulatory arrest.


Figure 1
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  		Fig 1. Schematic illustration of different transection levels (dashed circles) of the aorta and pulmonary artery in the arterial switch operation with extended pulmonary artery reconstruction.

 

Figure 2
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  		Fig 2. Schematic illustration of coronary ostia excision as buttons out of the aortic root in form of an "O" for the right coronary artery and in form of a "U" for the left coronary artery (dashed line, left side) followed by the anterior placement of the pulmonary artery (Lecompte maneuver [17]) after performing a large incision of the posterior wall of the pulmonary bifurcation and left pulmonary artery including the proximal part of the right pulmonary artery (thin dashed line, right side).

 

Figure 3
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  		Fig 3. Schematic illustration of defect closure of the neopulmonary root using two glutaraldehyde-treated autologous pericardial patches (grey), a small round one for the right-sided defect (left side) and a large triangular one for the left-sided defect (right side) after anterior placement of the pulmonary artery (Lecompte maneuver [17]).

 

Figure 4
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  		Fig 4. Schematic illustration of the neopulmonary root and pulmonary artery after extended pericardial patch reconstruction in the arterial switch operation with augmentation of the posterior wall of the neopulmonary root, the main pulmonary artery, the pulmonary bifurcation, the left pulmonary artery, and the proximal part of the right pulmonary artery (front view).

 

Figure 5
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  		Fig 5. Schematic illustration of the neopulmonary root and pulmonary artery after extended pericardial patch reconstruction in the arterial switch operation with augmentation of the posterior wall of the neopulmonary root, the main pulmonary artery, the pulmonary bifurcation, the left pulmonary artery, and the proximal part of the right pulmonary artery (back view).

 
Data Collection and Echocardiographic Evaluation
Patient data were analyzed retrospectively from hospital charts, including preoperative investigations, operative reports, postoperative course, and regular follow-up investigations including clinical and echocardiographic examinations. After obtaining informed consent of all 58 patients a prospective clinical evaluation was performed including an actual follow-up echocardiographic examination focusing on the maximal instantaneous transpulmonary cw-Doppler gradient [23]. A variety of echocardiographic machines were used with transducers of 5 or 7.5 MHz, and studies were recorded on a videotape recorder. Using a left parasternal short-axis and a right oblique subxiphoid view a cw-Doppler cursor was positioned in the reconstructed main pulmonary artery [21, 22]. The maximal Doppler velocity signal obtained from multiple plans was converted to pressure gradient, using the modified Bernoulli equation [24]. Depending on Doppler findings PAS was classified as trivial (transpulmonary peak gradient < 25 mm Hg), mild (25 to 49 mm Hg), moderate (50 to 79 mm Hg), or severe (>79 mm Hg) [25]. Indication for postoperative cardiac catheterization was a peak cw-Doppler gradient greater than 39 mm Hg or suspicion of important residual ventricular septal defect.

Statistical Analysis
Specific software (SPSS for Windows, Rel. 11.5.1, 2002; SPSS Inc, Chicago, IL) was used for statistical analysis. Comparisons of follow-up transpulmonary Doppler peak gradients in the same patient at different time points were made using nonparametric testing (Wilcoxon). Probability (p) of less than 0.05 was considered statistically significant. Data are given as median [range].


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Acknowledgments
 References
 
The study population included 58 infants (40 boys and 18 girls) presenting with TGA (Fig 6), who underwent ASO with extended reconstruction of the neopulmonary root and PA. Age at operation was 5.5 [2 to 241] days (median [range]), and weight was 3.37 [1.75 to 4.71] kg. Transposition of the great arteries (with intact ventricular septum [simple TGA]) was present in 43 patients (74.1%) and TGA with a ventricular septal defect (VSD, complex TGA) in 15 patients (25.9%) (single VSD, n = 13, 22.5%; multiple VSDs, n = 2, 3.4%). There was no Taussig-Bing anomaly observed among the study population. Associated cardiovascular anomalies included patent foramen ovale or secundum atrial septal defect in all patients (n = 58), right aortic arch (n = 2), hypoplastic aortic arch (n = 1), and left ventricular outflow tract obstruction (n = 1). Coronary artery distribution and relationship of the great arteries was determined at the operation and classified according to Gittenberger-de Groot and colleagues [26]: 1LCx-2R, n = 45 (77.6%); 1L2RCx, n = 7 (12.1%); not classifiable, n = 3 (5.2%); 1LCx-R, n = 1 (1.7%); 2R-LCx, n = 1 (1.7%); 1LR-2Cx, n = 1 (1.7%); oblique position of the great arteries, n = 35 (60.3%); anterior-posterior, n = 23 (39.7%); and side-by-side, n = 0. Cardiopulmonary bypass time was 144 [113 to 215] minutes, and aortic cross-clamp time was 79 [18 to 116] minutes. In all 58 patients, closure of atrial and (or) ventricular septal defects was performed under hypothermic circulatory arrest, which was 16 [5 to 65] minutes. Interventions prior to ASO included balloon atrial septostomy (n = 51, 87.9%) and pulmonary artery banding (PAB) in 3 patients with or without additional procedures (PAB alone, n = 1; PAB + creation of an aortopulmonary shunt, n = 1; PAB + aortic coarctation repair, n = 1).


Figure 6
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  		Fig 6. Preoperative angiogram showing the transposition of the great arteries with the main pulmonary artery originating from the left ventricle (front view, patient No. 39).

 
The follow-up period was 8.9 [5 to 15] years. There was no bronchial compression or coronary artery compression observed after extended pulmonary artery reconstruction. Regular postoperative echocardiographic examinations revealed the presence of a small residual VSD in 4 patients (6.9%). During the follow-up period, one out of these 4 patients developed an important residual VSD, which was closed at 3.9 years after ASO. Cardiac catheterization after ASO (Figs 7, 8) Go was performed in 7 patients (in 3 patients with residual VSD and in 4 patients presenting a peak cw-Doppler gradient greater than 39 mm Hg during follow-up echocardiographic examination), showing a good correlation with echocardiographic findings (Table 2). There was no reintervention (neither catheter intervention nor surgical procedure) due to pulmonary artery stenosis. Latest follow-up Doppler examination revealed a median transpulmonary peak gradient of 19.5 [0 to 56] mm Hg compared with 20 [0 to 60] mm Hg at discharge (p = 0.595; Fig 9). Forty-three patients (74.1%) had no or only trivial pulmonary artery stenosis (maximal cw-Doppler gradient <25 mm Hg), 14 patients (24.2%) had mild stenosis (25 to 49 mm Hg), 1 patient (1.7%) had moderate stenosis (50 to 79 mm Hg), and no patient had severe pulmonary artery stenosis (>79 mm Hg) (Fig 10). There was no significant difference of maximal instantaneous transpulmonary cw-Doppler gradient at discharge (median, 20 mm Hg) compared with postoperative transpulmonary gradient at 1 year (15 mm Hg, p = 0.061), at 5 years (18 mm Hg, p = 0.464), and at 10 years (20 mm Hg, p = 0.698). All patients were in good health and had resumed normal physical activity. According to the functional classification of the New York Heart Association (NYHA), 56 patients (96.6%) were in NYHA class I and 2 patients (3.4%) in NYHA class II.


Figure 7
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  		Fig 7. Late postoperative angiogram of the neopulmonary root, the main pulmonary artery, the pulmonary bifurcation, and the left and right pulmonary artery after extended pulmonary artery reconstruction in the arterial switch operation (front view, patient No. 39).

 

Figure 8
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  		Fig 8. Late postoperative angiogram of the neopulmonary root, the main pulmonary artery, the pulmonary bifurcation, and the left and right pulmonary artery after extended pulmonary artery reconstruction in the arterial switch operation (lateral view, patient No. 39).

 

Figure 9
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  		Fig 9. Comparison of maximal transpulmonary continuous-wave (cw)-Doppler gradient at discharge and at the latest follow-up (FU) echocardiographic examination in patients with a follow-up of 5 years or more after the arterial switch operation with extended reconstruction of the neopulmonary root, pulmonary trunk, and left pulmonary artery (n = 58). The box represents the median and the 25th and 75th percentiles. The error bars (–) represent the 10th and the 90th percentiles. The circles represent the outliers (ns = not significant).

 

Figure 10
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  		Fig 10. Distribution of maximal transpulmonary continuous-wave (cw)-Doppler gradient (mm Hg) at the latest follow-up (FU) echocardiographic examination in patients with a follow-up of 5 years or more after the arterial switch operation with extended reconstruction of the neopulmonary root, pulmonary trunk, and left pulmonary artery (n = 58).

 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Acknowledgments
 References
 
Despite various techniques of reconstruction of the neopulmonary root, late development of supravalvular pulmonary artery stenosis (PAS) remains the most frequent complication and cause of reintervention after the arterial switch operation (ASO) for transposition of the great arteries [13–16, 27–35]. Depending on PAS criteria and length of follow-up, the incidence of PAS reported in the literature differs considerably from 1% to 42%, necessitating reintervention with operative relief of PAS in 1% to 30% [2–12]. There are a great number of midterm follow-up studies (4 to 6 years) reporting an incidence of reoperation due to PAS of about 1% to 8% [2–9], whereas the few long-term studies with a follow-up period of 9 to 10 years or more showed a marked time-dependent increase of PAS-related reoperation rate ranging from 8% to 30% [10–12].

Different mechanisms have been implicated, most notably inadequate somatic growth of PA localized at the suture line, probably secondary to the development of fibrous tissue, causing a circumferential narrowing. Inadequate distal PA mobilization may result in an increased tension at the anastomotic site, which is a possible adjunctive factor to inadequate somatic growth at the suture line causing PAS [9, 20]. The data of Yamaguchi and colleagues [34] suggest that supravalvular PAS is progressive with age. These findings are supported by Williams and colleagues [12, 31], who reported a doubling of the reoperation rate for relief of PAS after ASO from 8% after 7.6 years to 16% after 13.8 years in the same study group.

Various surgical techniques were proposed for PA reconstruction such as direct anastomosis without any patch material [36], PA reconstruction using two pericardial patches to fill the defects of the neopulmonary root followed by direct PA anastomosis, the commonly named double-patch technique [1] and its modification [20], or the pantaloon patch technique [27] using a single pantaloon-shaped pericardial patch for PA reconstruction comprising partial or total PA circumference. Regarding direct PA anastomosis, Carrel and colleagues [36] recently reported excellent hemodynamic midterm results employing this technique without any patch material with a low incidence of PAS. These findings are in contrast to those of Prifti and colleagues [9], who observed significant progression of mean transpulmonary gradient after direct PA anastomosis compared with patch reconstruction techniques, whereas the single pantaloon technique seemed to be superior to the double-patch technique in this study. These results were supported by other studies, which showed a low incidence of postoperative PAS when using a single oversized pantaloon-shaped patch [2, 7, 9, 10, 18, 30, 37]. In contrast, some authors achieved excellent results after PA reconstruction employing the double-patch technique [4, 5, 11]. However, there is still a considerably high incidence of PAS after ASO despite various modifications regarding number and size of the pericardial patches [19, 20, 37]. In almost all midterm and long-term studies pulmonary artery reconstruction techniques changed with investigation time course, which makes it difficult to compare the different techniques in terms of late results. In only one long-term follow-up study, of Hövels-Gürich and colleagues [11], the same reconstructive technique (double-patch technique) was employed in all patients (n = 60) resulting in a reoperation rate of 1.7% due to late PAS.

We modified the double-patch technique as reported by Quaegebeur and colleagues [20] by performing an extended pericardial patch reconstruction not only of the neopulmonary root but also of the pulmonary trunk and the left pulmonary artery using a large pericardial patch, which was fashioned in a triangular shape. This procedure was employed in all of our patients without any modifications. To investigate the influence of this reconstructive technique on late PAS development we performed a prospective clinical evaluation including an echocardiographic examination only in patients with a postoperative course of at least 5 years. During long-term follow-up only one patient (1.7%) developed moderate PAS (peak cw-Doppler gradient 50 mm Hg) without any clinical symptoms at the latest follow-up examination. Cardiac catheterization was performed revealing a maximal transpulmonary gradient of 31 mm Hg. At our institution a peak cw-Doppler gradient of 40 mm Hg or more and (or) an increase in right ventricular systolic pressure above 50 mm Hg in rest clearly represents an indication for catheterization and, if so confirmed, an indication for reintervention (balloon angioplasty or surgical reintervention).

During follow-up there was no reintervention (neither catheter intervention nor surgical procedure) for PAS. Our results are in accordance with those of other series, in which PA reconstruction was performed by means of the double patch technique [4, 5, 11], and which reported a reoperation rate for PAS ranging from 1% to 2.4%. The low incidence of PAS in our series was also seen in patients presenting with known risk factors for development of PAS after ASO; for instance, low weight or young age at operation or complex coronary artery anatomy [4, 7–10, 12].

Our results may be explained by an effective reduction of anastomotic tension performing an extensive mobilization of distal PA combined with an extended PA reconstruction, which comprised not only the pulmonary trunk but also the left pulmonary artery and the proximal part of the right pulmonary artery. Regular postoperative echocardiographic studies showed no progression of transpulmonary peak cw-Doppler gradient during midterm and long-term postoperative course compared with discharge findings.

We are conscious of the technical limitation of correct flow velocity assessment by Doppler examination in the pulmonary arteries after the Lecompte maneuver in some patients. A valid peak flow often comprises the overall increase in the flow velocity across the right ventricular outflow tract, the pulmonary valve, and the supravalvular pulmonary artery (and arteries, respectively). This is a methodic limitation of our study, but comparison of hemodynamic data obtained by echocardiography versus cardiac catheterization revealed a good correlation between these two methods with a slight tendency for overestimation of the transpulmonary gradient estimated by cw-Doppler compared with catheterization in nearly all our patients.

To summarize, we conclude that the presented modified double-patch technique of extended PA reconstruction during ASO presented by our group resulted in a very low incidence of important PAS regarding midterm and long-term follow-up with no PAS-related reintervention. Augmentation of the neopulmonary root, the pulmonary trunk, the left pulmonary artery, and proximal part of the right pulmonary artery was done by means of an oversized triangular autologous pericardial patch, which seemed to reduce, effectively, the tension at the anastomotic site and provided excellent functional and clinical results.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
References
 
We cordially thank Jutta von Bergmann, Graphics, Department of Surgery, University of Heidelberg, Heidelberg, Germany, for the illustrations.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 

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