30 years' experience with the arterial switch operation: risk of pulmonary stenosis and its impact on post-operative prognosis.

Pulmonary stenosis is one of the most common complications in patients with transposition of the great arteries after the arterial switch operation. The reason for this is multifactorial and related to the anterior shift of the pulmonary trunk during the LeCompte manoeuvre, the complex suture line required to fill the gaps after harvesting the coronary arteries, and the need for patch implantation to maintain a tensionless anastomosis.We reviewed all patients with transposition of the great arteries operated on at our institute between 1991 and 2020 to establish the frequency of pulmonary stenosis during post-operative follow-up, reinterventions, and reoperations related to pulmonary stenosis and its potential risk factors.During the analysed period, we performed 848 arterial switch operations for simple and complex cases of transposition of the great arteries. The overall early mortality was 6.96%, and the late mortality was 2.53%. Among all study groups, 243 (28.66%) patients developed mild pulmonary stenosis, 43 patients (5.07%) developed moderate, and 45 patients (5.31%) developed severe pulmonary stenosis. During follow-up, 21 patients required interventions related to pulmonary stenosis. Pulmonary reconstruction with patches, aortic arch anomalies, and ventricular septal defects associated with transposition of the great arteries were significant risk factors. Nine patients required reoperation because of pulmonary artery stenosis with patch reconstruction of the pulmonary artery, aortic arch anomalies, and aortic cross-clamping time, increasing the risk of reoperation.Pulmonary stenosis in patients with transposition of the great arteries after the arterial switch operation is a common complication. If significant, it occurs early after surgery and is the most frequent reason for post-operative interventions and reoperations.

Intramural coronary pattern in patients with transposition: incidence and impact on follow-up.

OBJECTIVES: Coronary complications are still the main reason for early mortality after an arterial switch operation. The high incidence of coronary anomalies in patients with transposition of the great arteries may increase the difficulty of coronary transfer, and among them, an intramural pattern was shown to be an independent risk factor of early mortality. However, recently published studies have reported that this rare coronary variant has no impact on the survival rate. The aim of this study was to assess the frequency of intramural coronary patterns in patients with transposition and the impact on overall mortality after an arterial switch operation. Additionally, we presented all coronary arrangements associated with intramural patterns in our cohort and the surgical techniques used to manage them successfully. METHODS: All arterial switch operations were retrospectively reviewed. In each case, the surgical reports contained detailed graphical representations and coronary anatomy patterns. All operatively confirmed intramural patterns were included in the analysis. RESULTS: Among 806 patients, 271 patients had coronary anomalies (33.62%), and 28 patients had an intramural pattern (3.47%), which was frequently associated with other complex coronary anomalies (P < 0.001). Overall survival was significantly higher in patients with intramural coronary artery patterns than in those with other coronary variants (21.34% vs 8.74%, P = 0.024, log-rank test). CONCLUSIONS: Intramural patterns associated with transposition remain a surgical challenge and increase overall mortality in our cohort. To reliably confirm or reject the significance of the observed impact of this rare coronary variant, a multicentre data analysis is required.

Neoaortic Regurgitation in Patients with Transposition Long Term After an Arterial Switch Operation and Its Relation to the Root Diameters and Surgical Technique Used.

Neoaortic regurgitation and root dilatation are common findings in patients with transposition after an arterial switch operation. The aim of this study was to describe the relation between neoaortic regurgitation long term after an arterial switch procedure, aortic root diameters, and surgical technique used. We also assessed the agreement of the neoaortic regurgitation grade and root diameters in different imaging modalities. For this retrospective study, we qualified 56 consecutive patients who, according to our institutional protocol, had a routine postoperative evaluation of more than 16 years with multimodality imaging studies. Neoaortic regurgitation was assessed by both transthoracic echocardiography and magnetic resonance imaging, and the root diameters obtained by echocardiography and tomography were compared to the reference values and associated with the presence of neoaortic insufficiency. Neoaortic insufficiency was present in 75% of examined patients; the vast majority of them had trace or mild regurgitation, and its qualitative evaluation was significantly different between echocardiography and magnetic resonance imaging. In our study group, the neoaortic valve and aortic sinus were larger in relation to the normal values, and they were significantly correlated with the presence of neoaortic insufficiency, but not with the surgical technique used. Values obtained by echocardiography and tomography correlated well but were significantly different. Transthoracic echocardiography has a tendency to overestimate the severity of regurgitation compared to magnetic resonance imaging. Neoaortic valve and sinus dilatation are significantly correlated with valve insufficiency, but in most cases of root dilatation, the valve remains competent.

Can we predict potentially dangerous coronary patterns in patients with transposition of the great arteries after an arterial switch operation?

INTRODUCTION: Coronary artery complications are the main reason for early mortality after an arterial switch operation. Late complications are relatively rare, and there is no consensus regarding the need or indications for routine follow-up coronary artery evaluations or the best first-line assessment modality. The aim of this study was to present the long-term post-operative frequency of coronary abnormalities in asymptomatic patients with transposition of the great arteries discovered by coronary CT angiography and potential "red flags" revealed by other examinations. PATIENTS AND METHODS: A group of 50 consecutive asymptomatic patients who underwent routine long-term coronary artery evaluation after an arterial switch operation according to our institutional protocol were qualified for this study. This routine in-hospital visit included a detailed medical interview, electrocardiography, echocardiography, Holter electrocardiography examinations, and laboratory and cardiopulmonary exercise tests. Patients who showed significant abnormalities were qualified for perfusion scintigraphy. RESULTS: Unfavourable coronary abnormalities were detected in 30 patients (60%) and included ostial stenosis, muscular bridge, coronary fistula, interarterial course, proximal kinking, high ellipticity index, proximal acute angulation (<30 degree) of the left coronary artery, and proximal acute angulation of the right coronary artery. These features could not be predicted based on the medical interviews, surgical reports, or non-invasive screening test results. CONCLUSION: Complex coronary configurations with potentially dangerous coronary features are common in patients with transposition after an arterial switch operation. Such high-risk patients cannot be identified indirectly, and coronary CT angiography provides accurate information that is useful for post-operative management.

Successful Late Recruitment of the Occluded Left Main Coronary Artery After Initial Arterial Switch Operation.

We describe a surgical technique for late recruitment of the proximally occluded left main coronary artery (LMCA) after initial arterial switch operation, which had been complicated by severe left ventricular dysfunction. This technique allowed for LMCA recanalization, using the patent conal artery branching off the LMCA close to the ostium. It is particularly useful in small children, where surgical options for coronary arteries are limited and associated with a high risk of restenosis. It was successfully used in a two-month-old boy with successful revascularization confirmed by angiography.

Usefulness of Routine Coronary CT Angiography in Patients with Transposition of the Great Arteries After an Arterial Switch Operation.

Coronary complications in patients with transposition of the great arteries (TGA) after an arterial switch operation (ASO) are relatively rare, but of all the possible postoperative adverse events, they are potentially the most dangerous. The fate of the coronary arteries, which are transplanted during the neonatal ASO, remains uncertain. There is also no consensus regarding their postoperative evaluation, especially in asymptomatic patients. The aim of this study was to present the early results of routinely performed coronary computed tomography angiography (CCTA) in asymptomatic adolescents and young adults with TGA after an ASO. An initial series of 50 CCTAs performed in asymptomatic patients with TGA after an ASO were evaluated. In each case, a detailed examination of the coronary anatomy, its relationship to the surrounding structures, its exact position in the neoaortic sinus, and the presence of significant coronary abnormalities was performed. The CT scans revealed significant coronary abnormalities in 12 asymptomatic patients: three had acute proximal angulation and stenosis, four had an intra-arterial course, seven had a muscular bridge, one had a left anterior descending artery with an intramuscular course, and one had coronary fistulas to the pulmonary arteries. Additionally, in 25 patients, proximal acute angulation of at least one coronary artery was detected, and four of them had a high ellipticity index. Most of the potentially severe anatomical features were related to the left coronary artery or the left anterior descending artery. CCTA routinely performed on asymptomatic patients with TGA after an ASO provides accurate and useful information for postoperative management. The frequency of coronary anomalies and potentially dangerous anatomical features in this group of patients is high, and their impact on postoperative follow-up remains unknown.

Coronary Artery Anomalies in Patients With Transposition of the Great Arteries and Their Impact on Postoperative Outcomes.

BACKGROUND: Coronary anomalies are frequently present in children with transposition of the great arteries (TGA). Such anomalies significantly increase the complexity of arterial switch operations and may have an effect on postoperative outcomes. In this study, we aimed to assess the frequency of coronary anomalies in children with TGA and describe their effect on postoperative outcomes. METHODS: All patients with TGA who underwent an arterial switch operation between 1991 and 2015 were consecutively enrolled in this study. Patient coronary patterns were obtained from corresponding operative reports and analyzed to determine their associations with adverse postoperative outcomes. RESULTS: The study included 715 patients with isolated and complex TGA. Coronary anomalies were present in 33.7% of patients and were significantly correlated with the side-by-side configuration of the great arteries. Coronary sinuses with more than 1 ostium were associated with a significantly increased risk of postoperative death (hazard ratio [HR], 2.58), and coronary arteries with a single ostium were associated with an increased risk of postoperative reinterventions (HR, 2.49). In contrast, the trap-door technique of coronary artery transplantation was associated with a reduced risk of reinterventions during postoperative follow-up (HR, 0.40). Complex coronary anomalies were significantly associated with postoperative coronary events (HR, 2.12). CONCLUSIONS: With the exception of patients whose circumflex artery branches off of the right coronary artery, an anomaly that clearly has no effect on postoperative follow-up, patients with unusual coronary patterns are at higher risk for adverse postoperative outcomes than patients with normal coronary anatomy and must be monitored carefully.

Reoperations and catheter interventions in patients with transposition of the great arteries after the arterial switch operation.

OBJECTIVES: Reoperations and catheter interventions after the arterial switch operation (ASO) are relatively rare, but their frequency varies among different centres. They significantly impact the postoperative course of children with transposition of the great arteries (TGA). The aim of this study was to assess the frequency of reoperations and catheter interventions in patients with TGA after the ASO and to identify the potential risk factors. METHODS: For this retrospective case review study we included all consecutive 715 patients with TGA who underwent the ASO in the Department of Cardiac Surgery between the years 1991 and 2015. All of the surgical procedures were performed by one cardiac surgery team led by J.J.M., using the same surgical technique with his own specific modifications. RESULTS: The overall early mortality after the ASO was 7.4%; late mortality occurred in 15 cases (2.3%) and the mean clinical follow-up of our cohort was 10.5 years. Early reoperations (<30 days after surgery) were performed in 37 patients (5.1%). Reoperations were performed in 31 patients (4.7% of survivors), and their risk factors were previous early reoperation and left ventricle outflow tract obstruction, while isolated TGA reduced the risk of reoperations. Catheter interventions were performed in 25 patients (3.8% of survivors). In the majority of the cases, the indications for percutaneous procedures were pulmonary stenosis and recoarctation of the aorta. The statistically significant risk factors were aortic arch anomalies associated with TGA and neopulmonary artery anastomosis with a patch, while isolated TGA decreased the risk of reintervention. Freedom from cumulative reinterventions after the ASO was 90.4% at 5 years; 88.0% at 10 years; 86.5% at 15 years and 86.5% from 20 to 25 years. CONCLUSION: The frequency of reoperations and percutaneous interventions in patients with TGA after the ASO remains low. The majority of the procedures are performed because of pulmonary stenosis and recoarctation of aorta. Cardiac anomalies associated with TGA have a significant impact on the incidence of reoperation and reintervention.

Stenting of the right ventricular outflow tract in a symptomatic newborn with tetralogy of Fallot.

This case describes a successful percutaneous stent implantation to critical stenosis of the right ventricle outflow tract in a female neonate with tetralogy of Fallot. At the time of the procedure she had poor development of the pulmonary arteries (McGoon and Nakata index 1.45 and 120, respectively). Stent implantation ensured an immediate increase in oxygen saturation level, and the physiological pulsating blood inflow caused good development of the pulmonary arteries during 12 months of follow up (McGoon 2.5; Nacata Index 436). After this time she was qualified for surgery and underwent surgical correction without using a patch or conduit implantation.

Successful percutaneous removal of a fractured stent fragment using a novel stretching method.

We present the case of percutaneous removal of a fractured stent fragment during cardiac catheterisation using a novel stretching method. The procedure was performed in a 9-month-old infant. The small distal fragment of a fractured stent in the aorta was stretched using a two-sided approach - that is, from the carotid and femoral artery. This manoeuvre allowed for the removal of the stretched, linear-shaped stent part through a 6 Fr sheath without any local and general complications.

The neoaortic root in children with transposition of the great arteries after an arterial switch operation.

OBJECTIVES: Neoaortic root changes in children with transposition of the great arteries (TGA) are reportedly risk factors for the development of neoaortic regurgitation (NeoAR). The aims of this study were to assess the neoaortic root diameter and relative proportion in children with TGA after surgical correction and to identify possible correlations with the development of neoaortic insufficiency. METHODS: Of the 611 children who had the arterial switch operation performed in the Cardiology Department of the Polish Mother's Memorial Hospital, 172 consecutive patients were qualified for this study. The inclusion criteria were: anatomical correction performed during the neonatal period, more than 10 years of postoperative observation and at least two full echocardiographic examinations. RESULTS: NeoAR increased during postoperative follow-up and at the end of the observation period, 76% of the patients had NeoAR (27%-trace, 42%-mild, 7%-moderate and 0.6%-severe). Among the analysed risk factors for NeoAR development, the significant ones were arterial valve discrepancy (OR = 2.05; 95% CI: 1.04-4.02; P = 0.031) and the non-facing commissures (OR = 4.05; 95% CI: 1.34-11.9; P = 0.01). The neoaortic root diameter was not statistically significantly correlated with the presence of NeoAR or with the heart defects associated with transposition. The neoaortic root was initially, on average, 37% (z-score = 1.58) bigger than the aortic root in healthy children. This disproportion increased during the follow-up evaluations to 57% (z-score = 2.09). CONCLUSIONS: The neoaortic root in children after the arterial switch procedure develops differently from that in healthy children, but this is not evidently related to NeoAR development or associated heart defects.

Long-term outcome of direct neopulmonary artery reconstruction during the arterial switch procedure.

BACKGROUND: Neopulmonary stenosis at anastomosis site is one of the most frequent complications after the arterial switch procedure for transposition of the great arteries. The surgical technique is a crucial factor associated with the frequency of stenotic complications. We present the outcomes of direct neopulmonary anastomosis during the arterial switch procedure in patients with simple transposition. This research was to assess the efficacy of this surgical technique based on the incidence of postprocedural supravalvular neopulmonary stenosis (SVPS). METHODS: Among 545 patients operated on in our department between 1992 and 2009, the 346 consecutive survivors who had undergone simple transposition in the first month of life were included in this analysis. Switch procedures were performed with direct neopulmonary artery anastomosis in 318 patients (92%); in the remaining 28 (8%), the risk of coronary artery compression required the use of a pericardial patch for pulmonary reconstruction. RESULTS: Neopulmonary stenosis occurred in 9 patients (2.6%): 5 had undergone direct neopulmonary reconstruction, and 4 had been treated with a patch. Balloon angioplasty of SVPS was performed twice in 1 patient. No patients required reoperation to treat neopulmonary stenosis. In multivariate analysis (logistic regression), patch reconstruction (odds ratio, 27.5; p=0.001) and nonfacing commissures (odds ratio, 11.1; p=0.004) were correlated significantly with the incidence of SVPS. CONCLUSIONS: Direct neopulmonary artery anastomosis during arterial switch is an interesting alternative to patch reconstructions and ensures a good postoperative result with low rates of complications and SVPS.

Right coronary artery dissection during intraoperative ostium cannulation. Presentation of successful treatment.

Right coronary artery dissection related to medical procedures is a very rare life-threatening complication caused by a combination of vessel occlusion and myocardial ischaemia. This paper presents a case of dissection which occurred during a Ross cardiac surgery procedure. The complication was observed after proximal right coronary constriction on the cannula used to administer cardioplegia. The damaged part of the internal membrane was resected during the operation. We present a five-year follow-up of this patient.

One center experience in pulmonary artery stenting without long vascular sheath.

BACKGROUND: Pulmonary artery stenting without a long vascular sheath has a special significance, particularly for children with low body weight. Using only a short sheath often permits the implantion of a stent of the correct size; moreover, it improves access to peripherally located stenoses. The aim of this paper is to present the results of a balloon expandable stent implantation into pulmonary arteries without using a long vascular sheath. METHODS: The subjects were divided into two groups. The first group (28 patients, mean age 3.2 years) comprised patients with a single-ventricle heart after bi-directional Glenn procedure (Fontan procedure). The second group (22 patients, mean age 8.3 years) consisted of patients with a two-ventricle heart. Patients were retrospectively analyzed with regard to stenosis size widening and change in trans-stenotic pressure gradient after stenting. RESULTS: In our data, no statistically significant differences between the two groups in terms of the number of complications and incorrect stent position following implantation were noted (3% and 4%). Good treatment results, with a decrease in trans-stenotic pressure gradient in the first group of 3.2 mm and in the second group of 13.4 mm of mercury, and a widening of the stenosis, were obtained in most cases in both groups (97% and 96%). The average change of the vessel's diameter was in the first group 4.2 mm and in the second 5.4 mm. CONCLUSIONS: The obtained results suggest that pulmonary artery stenting with a short vascular sheath has numerous advantages and can be successfully performed in children. In the case of single-ventricle hearts after a Glenn procedure, it may indeed be the method of choice.

Acute and late obstruction of a modified Blalock-Taussig shunt: a two-center experience in different catheter-based methods of treatment.

Modified Blalock-Taussig (B-T) shunt occlusion results in a sudden reduction of pulmonary vascular perfusion, causing dramatic saturation drop and cyanosis which pose a direct hazard to a child's life. The results of percutaneous local r-tpa infusion, balloon angioplasty and additionally stent implantation in obstructed modified B-T shunts were studied to assess their role as an alternative to a re-do surgery. We outline two pediatric centers' experience (period 2004-2008) regarding the effectiveness of various emergency treatment methods for occlusion or critical stenosis of systemic-to-pulmonary arterial shunts in 23 children. Local r-tpa infusion via catheter was performed in 12/23 patients, balloon angioplasty in 22/23 and additionally stent implantation in 3/23 children. Procedures were successful in 22/23 patients (96%), with an increase in arterial saturation [average: 30%; standard deviation (S.D.) 15%; Shapiro-Wilk test; dependent t-test-P<0.01]. Unrestricted contrast flow was achieved in 18 patients, reduced central flow in three and minimal flow in one child. Neither local nor systemic complications occurred. Our experience demonstrates the possibility of successful early shunt recanalization with the use of local thrombolytic therapy combined with the balloon angioplasty. The presence of old fixed thrombus with neointimal hypertrophy in the shunt constitutes an indication for endovascular stent implantation.

Neoaortic valve function 10 to 18 years after arterial switch operation.

Anatomical correction is a procedure of choice for transposition of the great arteries (TGA) in neonates. During surgery, the aorta and pulmonary artery are switched-the native pulmonary valve becomes the neoaortic valve. The fate of this valve remains uncertain. Many reports suggest that its ability to function worsens with time after surgery. Of 519 patients with TGA operated on between 1991 and 2008, 161 met inclusion criteria for this retrospective study and were followed 10 years or more to assess neoaortic valve regurgitation (NeoAR) occurrence and development and to estimate potential risk factors. The subjects were divided into 2 groups: group 1 (simple TGA) and group 2 (TGA + ventricle septal defect). Within the analyzed group, the frequency of significant regurgitation increased from 9% 1 year after the operation to 47% at the most recent follow-up. No severe regurgitation necessitating reoperation was observed. Analysis of potential risk factors revealed that pulmonary/aortic valve diameter discrepancy and nonfacing commissures were associated with increased risk of development of neoaortic insufficiency. NeoAR arises and develops over time after correction of the defect. No hemodynamic repercussions necessitating cardiac surgical interventions were observed. The majority of insufficiencies are detected between 2 and 6 years after surgery. The degree of incompetence is usually mild and increases during follow-up by about 0.5 or 1 degree. The risk factors for NeoAR appearance are pulmonary artery/aortic annulus discrepancy and nonfacing commissures.

Fracture and dislocation of a pulmonary stent after cardiac massage.

Following a Glenn procedure, a stent was implanted into the pulmonary artery to relieve stenosis. After the procedure, the patient developed bradycardia and became asystolic. Resuscitation was successful following cardiac massage, but subsequent catheterization revealed the stent to be broken in two, with shift of the distal fragment. The two parts were stabilized and connected by implantation of an additional CP stent.