Abstract： Objective To investigate the longterm complications and preventions of rapid twostage arterial switch operation through longterm follow-up. Methods We reviewed the clinical information of 21 patients of rapid twostage arterial switch operation from September 2002 to September 2007 in Shanghai Children’s Medical Center. Among them, there were 13 males and 8 females with an average age of 75 d (29-250 d) and an average weight of 5 kg (3.5-7.0 kg). The data of left ventricle training period and the data before and after the twostage arterial switch operation were analyzed, and the risk factors influencing the aortic valve regurgitation were analyzed by the logistic multivariable regression analysis. Results The late diameter of anastomosis of pulmonary and aortic artery were increased compared with those shortly after operation (0.96±0.30 cm vs. 0.81±0.28 cm, t=-1.183,P=0.262; 1.06±0.25 cm vs. 0.09±0.21 cm, t=-1.833,P=0.094), but there was no significant difference. The late velocity of blood flow across the anastomoses was not accelerated, which indicated no obstruction. The late heart function was better than that shortly after operation, while there was no significant difference between left ventricular ejection fraction(LVEF) during these two periods (62.88%±7.28% vs. 67.92%±7.83%,t=1.362,P=0.202). The late left ventricular end diastolic dimension(LVDd) was significantly different from that shortly after operation (2.16±0.30 cm vs.2.92±0.60 cm，t=-5.281，P=0.003). Compared with earlier period after operation, the thickness of left ventricular posterior wall thickness（LVPWT）was also increased (0.39±0.12 cm vs. 0.36±0.10 cm,t=0.700,P=0.500), but there was no significant difference. The postoperative aortic valve regurgitation was worsened in 4 patients (30.77%, 4/13), not changed in 7 patients and alleviated in 2 patients compared with that before operation. There was no severe regurgitations during the followup. The logistic regression analysis showed that the small preoperative diameter ratio of aortic valve to pulmonary valve and long follow-up time were two risk factors for the [CM(159mm]aggravation of aortic regurgitation. Conclusion There is a relatively high aortic regurgitation rate after rapid two stage arterial switch operation, but there is no later death or reoperation and the survival conditions are satisfactory. All patients must be followed up periodically to check the anastomosis of pulmonary and aortic arteries and the aortic valve.
Abstract: Objective To review the shortterm outcome of modified Nikaidoh operation, aortic translocation and biventricular outflow tract reconstruction as an alternative surgical procedure for the treatment of transposition of the great arteries with ventricular septal defect and pulmonary stenosis (TGA/VSD/PS). Methods Between January 2004 and December 2005, 8 consecutive patients had undergone Nikaidoh procedure for the treatment of TGA/VSD/PS at Shanghai Children’s Medical Center. All patients had ventriculoarterial discordance and atrioventricular concordance. Associated lesions included a straddling atrioventricular valve in one patient and hypoplastic left pulmonary artery. The median age at operation was 11.4±7.6months (4 to 29months). Weight of body was 8.0±1.9kg (5.2 to 11.0kg). No patient had previous palliative procedure. The surgical technique used was a modification of the Nikaidoh procedure. Results The median total cardiopulmonary bypass time was 176±50 minutes (range,112 to 250 minutes), and the median aortic crossclamp time was 101±27 minutes (range, 73 to 139minutes). The median length of stay in the intensive care unit was 12±9 days, with a median hospital stay of 19±12 days. There was 1 hospital death as a esult of severe left ventricle failure. There was no residual left ventricular outflow tract obstruction (LVOTO) and right ventricular outflow tract obstruction (RVOTO), but 3 patients with mild to moderate pulmonary regurgitation and 4 patients with moderate. At a median follow-up of 8.8 months (range, 3 to 18months), all patients were alive. All have the normal ventricular function. There were ejection fraction (EF) 0.64±0.02 and fractional shortening (FS) 0.33±0.02. None of the patients developed aortic insufficiency and progressed LVOTO or RVOTO. Conclusions Nikaidoh procedure is a valuable surgical option for TGA/VSD/PS in infant, especially in the presence of “inadequate anatomy” for a Rastelli repair. Big evidence and longer follow-up are required to fully assess the potential longterm benefits of this procedure compared with the Rastelli repair.
Objective To introduce a modified REV procedure of complicated transposition of the great arteries （TGA） or double outlet right ventricle （DORV） which was combined with ventrieular septal defect （VSD） and pulmonary valve stenosis（PS）. Methods From Sep. 2005 to Feb. 2006, 3 children with complicated transposition of the great arteries underwent a modified REV operation. This modified REV operation was designed on the basis of classical REV procedure to preserve the native pulmonary artery valve and its function. Results Two patients recovered uneventfully but one died after extraeorporeal membrane oxygenator （ECMO） treatment. After 4 and 1 months follow-up respectively, the discharged 2 patients were asymptomatie and the eehoeardiography revealed that the pressure gradient between left ventrieular-main pulmonary were estimated to be 15 and 5mmHg. Conclusion This modified REV operation for preservation of pulmonary artery valve is an ideal procedure to complicated transposition of the great arteries. Advantages and disadvantages of this modified REV procedure were discussed.
ObjectiveTo summarize clinical experience of staged left ventricular retraining for infants with transposition of the great arteries (TGA). MethodsFrom January 2001 to December 2011, 38 TGA infants with intact ventricular septum or a small ventricular septal defect underwent left ventricular retraining in Fu Wai Hospital. There were 26 male and 12 female patients with their age of 19.1±7.7 months and body weight of 7.6±4.7 kg. Preoperative arterial oxygen saturation (SaO2)was 72.6%±9.1%. Left ventricular retraining included aortopulmonary shunt and pulmonary artery banding. Three patients received concomitant excision of the atrial septum. All survival patients were followed up after discharge. ResultsPostoperatively, SaO2 increased to 83.9%±8.1% from preoperative 72.6%±9.1%, and left ventricle-to-right ventricle pressure ratio increased to 0.75±0.09 from preoperative 0.36±0.04. Three patients (7.89%)died postoperatively. Thirty-five patients were followed up for 2 to 11 years. During follow-up, 23 patients successfully received second stage arterial switch operation (ASO). ConclusionFor TGA infants with decreased left ventricular mass who have missed the neonate period, left ventricular retraining is a safe and efficacious procedure to provide necessary preparation for second stage ASO.
ObjectiveTo assess the function of left ventricular outlet tract and aortic valve after arterial switch operation (ASO) for patients with transposition of the great arteries (TGA) and left ventricular outlet tract obstruction (LVOTO). MethodsFrom 2002 to 2013, 549 pediatric TGA patients received ASO in Fu Wai Hospital. Among them, 42 patients had LVOTO, including 31 males and 11 females with their median age of 12 months (range, 7 days to 96 months), median body weight of 6.5(3.5-26.0) kg and percutaneous oxygen saturation of 52%-85%. LVOTO anomalies included pulmonary valve stenosis, subaortic membrane, tunnel-like subaortic stenosis, muscular subaortic stenosis, subvalvular apparatus and combined anomalies. Different surgical procedures were performed according to respective anomalies. Echocardiographic characteristics, intraoperative findings, surgical methods, early and follow-up results were summarized. ResultsCardiopulmonary bypass time was 147-344 (193.5±73.1) minutes, mean aortic cross-clamping time was 139(109-305) minutes, mean mechanical ventilation time was 36(3-960) hours, and mean length of ICU stay was 5(1-48) days. Three patients received and later successfully weaned from extracorporeal membrane oxygenation. Two patients died postoperatively including 1 patient with multiple organ dysfunction syndrome and another patient with severe infection. One patient died during follow-up for unknown reason, and 3 patients were lost during followup. Thirty-six patients were followed up for 24 (3-116) months. During follow-up, there were 1 patient with LVOTO recurrence, 1 patient with new-onset mild aortic valve stenosis, 11 patients with new-onset mild aortic regurgitation (AR), and 2 patients with new-onset moderate AR. Median systolic left ventricular-aortic pressure gradient[4 (2-49) mm Hg] was significantly lower than preoperative value[37.2 (12.1-70.6) mm Hg] (Z=-5.153). Cardiac event-free rate was 91%±5% at 1 year and 78%±8% at 5 years after discharge. ConclusionFor TGA patients with LVOTO, ASO can produce satisfactory mid-and long-term results if proper surgical indications and strategies are chosen according to different severity of LVOTO which can be evaluated by anatomic features of TGA and systolic left ventricular-aortic pressure gradient.
ObjectiveTo examine changes of in-hospitalization mortality for arterial switch operation (ASO) for the patients with D-transposition of the great arteries (TGA) in our hospital. MethodsWe retrospectively analyzed the clinical data of 473 consecutive TGA patients undergoing ASO to assess temporal trends of in-hospital mortality between 2001 and 2012 year. The patients in every 2 years were brought together into a group. By this way, all the patients were divided into 6 groups. In risk-adjusted analyses, mortality of each group between 2001 and 2012 year were compared within the 6 groups. ResultsAmong all the patients, 29 in-hospital deaths occurred. Between 2001 and 2012 year, the prevalence of preoperative factors-including age (P=0.13), gender (P=0.94), height (P=0.29), weight (P=0.21), combined with pulmonary hypertension (P=0.59), training for left ventricle (P=0.14), and anatomy of coronary arteries (P=0.27) did not significantly change. Crude mortality significantly decreased during that period (17.4% in the first group vs. 4.1% in the sixth group, P<0.001). Adjusted mortality also significantly became better in the ten years (the sixth group vs. the first group, odds ratio 0.098, 95% confidence interval, 0.018-0.550，P=0.01). ConclusionBetween 2001 and 2012 year, the prevalence of risk factors among TGA patients undergoing ASO remains unchanged, but the in-hospital mortality substantial decreases.
Objective To investigate the risk factors of neoaortic regurgitation (NAR) after the arterial switch operation (ASO) for transposition of the great arteries (TGA). Methods This retrospective study enrolled 229 patients with TGA who underwent ASO from January 2008-2013 in Fu Wai Hospital, including 173 males and 56 females with an average age of 7.8±15.9 months (range, 3 days to 93.9 months; median, 47 days) and an average weight of 6.3±4.2 kg (range, 4 to18 kg; median, 2.4 kg). Results The mean follow-up was 62.5±31.1 months and the shortest was 36 months. Twenty eight patients (12.2%) suffered at least moderate NAR. In Kaplan-Meier survival analysis, probability of freedom from at least moderate NAR was 100.0%, 100.0%, 99.6%, 95.3% at year 1, 2, 3 and 5, respectively. Univariate analysis revealed that weight and frequency of preoperative pulmonary arterial hypertension and previous pulmonary artery banding in patients with at least moderate NAR before ASO were more than those of other patients (8.3±5.6 kgvs. 5.8±4.3 kg,P=0.006; 50.0%vs. 20.4%,P=0.001; 28.6%vs. 10.4%,P=0.013). Multivariate analysis showed that previous pulmonary artery banding (HR=3.8,P=0.005) and preoperative pulmonary arterial hypertension (HR=16.5,P<0.001) were risk factors of NAR. Conclusion The incidence of at least moderate NAR after ASO is favorable. At least moderate NAR is associated with preoperative pulmonary arterial hypertension and previous pulmonary artery banding.
ObjectiveTo summarize the experience of surgical treatment of transposition of the great arteries with intact ventricular septal (TGA-IVS) after left ventricular regression by comparing the characteristics of rapid and long-term two-stage arterial switch operation (ASO).MethodsForty-one patients who were mainly diagnosed with TGA-IVS from January 2007 to January 2019 and underwent two-stage ASO were included. They were divided into a rapid two-stage ASO group (19 patients) and a long-term two-stage ASO group (22 patients) according to the interval of left ventricular training surgery and ASO. The clinical effectiveness of the two groups was compared.ResultsThere was a statistical difference in age, body weight, blood oxygen saturation before ASO, end diastolic diameter of left ventricle before training, and thickness of posterior left ventricular wall before ASO (P<0.05). Children older than 1 year was an independent risk factor for long-term two-stage ASO.ConclusionLong-term two-stage ASO is suitable for children who are older than 1 year and who have severe left ventricular regression.
ObjectiveTo summarize the early clinical features and perioperative management strategies for patients with transposition of the great arteries (TGA) after one-stage arterial switch operation (ASO), and investigate the risk factors for prolonged recovery in ICU, with a focus on the age structure and deformity complexity.MethodsThe clinical data of 231 consecutive TGA patients who underwent one-stage ASO were retrospectively analyzed. There were 165 males and 66 females, aged from 3 d to 10 years. The patients were sequenced by the length of ICU stay. The time at the 75th percentile was defined as the critical value for grouping. Patients with an ICU stay time over this point were allocated to a prolonged recovery group (n=54), while the rest were allocated to a normal recovery group (n=177). The perioperative clinical data were compared between the two groups, and the risk factors for prolonged recovery were evaluated.ResultsAbout half (49.6%) of the patients received late operation. The mean ICU stay time was 23.9±15.6 d in the prolonged recovery group, and 4.9±2.3 d in the normal recovery group. Complication of aortic arch lesion, delayed chest closure and postoperative pulmonary infection were independent risk factors for prolonged recovery after ASO in ICU. However, late operation had no significant effect on the overall recovery.ConclusionWith strict surgery indications and excellent postoperative management, most patients can have satisfactory early-stage outcomes, but are confronted with increased complications, which is associated with prolonged recovery. Complication of aortic arch lesion, delayed chest closure and postoperative pulmonary infection are independent factors for delayed recovery of ASO.
ObjectiveTo summarize the surgical experience of infants with transposition of the great arteries (TGA) and intramural coronary artery (IMCA) in our center, and analyze the early and mid-term outcomes.MethodsWe retrospectively analyzed the clinical data of 384 infants with TGA undergoing arterial switch operation (ASO) from June 2010 to December 2018 at Fuwai Hospital. According to operative records, 21 (5.5%) infants had IMCA, among whom 20 were males, with a median age of 33 (9-319) d. Coronary transfer using double coronary buttons with unroofed intramural course was performed in all 21 infants.ResultsThere was no statistical difference in the early mortality after ASO between infants with IMCA and infants with normal coronary anatomy (9.5% vs. 3.0%, P=0.15). In the IMCA group, 2 dead patients presented inadequate coronary artery perfusion after first aortic unclamping. In addition, 1 patient underwent extracorporeal membrane pulmonary support for myocardial dysfunction. The follow-up was available for all 19 survivors, with an average follow-up time of 29.0-120.0 (74.8±27.3) months. During the follow-up, all patients had no obvious symptoms, death, reoperation, or coronary complications. One patient developed moderate pulmonary valve regurgitation and another patient developed distal stenosis of the right pulmonary artery.ConclusionFor infants with TGA and IMCA, coronary transfer using double coronary buttons with unroofed intramural course is a safe and reliable technique, with satisfactory early and mid-term outcomes.