D-transposition of great vessels with intact ventricular septum presenting at 3–8 weeks: Should all go for rapid two stage arterial switch or primary arterial switch

Abstract

Background: Fontan procedure and its modifications are established procedures for the treatment of anatomical defects with a single ventricle physiology.Methods: Thirty-two patients underwent extra-cardiac Fontan procedure between Feb 2004 and Oct 2005. Pre-operative cardiac catheterization was done in all patients. All cases were operated on cardiopulmonary bypass with beating heart. ePTFE conduit (Gore-Tex) was used to create an extra cardiac connection between inferior vena cava and the pulmonary artery. A fenestration was created between the conduit and right atrium in twenty-seven patients (91%) Results: The average age was 8.7 years (range 3-21yrs). Ten females underwent the operation. The pre-operative diagnosis was tricuspid atresia (n=15), DORV (n=8), DILV (n=3) and others (n=6). Three patients had PA banding and eight had a BT shunt prior to the bidirectional Glenn. The average pre-procedure pulmonary artery pressure was 11.9 mm Hg (range 7-16) and LVEDP was 10.6 mm Hg (range 7-18). The average branch PA size was 12.6 mm/m 2 (range 8.9-15). 20mm (n=10) or 22 mm (n=12) PTFE conduits were used. Twenty-nine patients (91%) survived the procedure. Postoperative complications were pleural effusion (n=9), renal failure (n=3) and bleeding (n=1). Technical problems during re-sternotomy (aortic injury in one and coronary artery injury in another) and poor PA anatomy were the causes for mortality. Arterial oxygen saturation increased from an average of 76.33% (pre-operative) to 94.5% (postoperative).Conclusions: Extra cardiac Fontan is a technically simple procedure that avoids an atrial suture line resulting in a theoretical reduction in the risk of atrial arrhythmias. However, careful selection of cases is mandatory to avoid early mortality.

Primary arterial switch operation in children presenting late with d-transposition of great arteries and intact ventricular septum. When is it too late for a primary arterial switch operation?

“…In children presenting up to 6 weeks, we found primary ASO to be a better surgical option than rapid two-stage ASO [8]. Similar studies from other centres show encouraging results of primary ASO in children more than 3 weeks of age [1].…”

“…Conventionally, these children are offered atrial level switch, which has been proved to be an inferior operation as compared to arterial switch [2,3]. Another option is to carry out ventricular training and then switch the arteries, which has evolved over a period of time from being a two-stage to a rapid two-stage operation; but our earlier study revealed primary arterial switch to be a better alternative [8]. Published literature has already established the ASO to be far better than atrial switch in physical functioning, mental health, self-esteem and general health perception.…”

“…In 2006, we compared the rapid two-stage ASO with primary ASO and found primary ASO was beneficial in infants of dTGA, IVS presenting between 21 and 60 days of age as compared to rapid two-stage ASO [8]. The ability to offer ECMO added safety in adopting such an approach, especially in the older patients.…”

Does late primary arterial switch operation with extracorporeal membrane oxygenator support change the surgical approach in simple transposition of the great arteries?

“…In the following years, late ASO performance was reported at an increasing rate. [11] Furthermore, a study comparing the results of infants older than three weeks who underwent two-stage ASO and primary ASO suggested that the results were in favor of primary ASO. [11] In the literature review, it can be concluded that late ASO can be performed successfully in the older months and even at around the age of eight.…”

“…[11] Furthermore, a study comparing the results of infants older than three weeks who underwent two-stage ASO and primary ASO suggested that the results were in favor of primary ASO. [11] In the literature review, it can be concluded that late ASO can be performed successfully in the older months and even at around the age of eight. [4] On the other hand, it was reported that performing primary ASO with ECMO support was a safe and appropriate approach to ensure postoperative LV support in infants aged above 21 days.…”