Die Behandlung supravalvulärer Pulmonalstenosen nach Arteriellen Switch-Operationen (ASO)

Abstract

The aim of this study was to evaluate the incidence of postoperative pulmonary supravalvular stenosis in patients with d-TGA and to assess the rate of success or failure of balloon angioplasty. Out of 70 patients with d-TGA 67 patients underwent successful arterial switch operation. Twelve children developed severe supravalvular pulmonary stenosis with a peak gradient above 50 mmHg (range: 50-120 mmHg). In these patients 19 high pressure dilatations were performed up to a diameter of 130% of the native valve dimension. The mean age at angioplasty was 17 months (range: 3-36 months). Successful intervention was defined as a > 50% decrease of predilatation peak pressure gradient or right ventricular pressure < 50 mmHg. Dilatations were performed without complications. Complete resolution was primarily achieved in 1 patient. In 7 patients the pressure gradients could be reduced to 10-45 mmHg (mean: 25 mmHg). In another two patients a palliative stent-implantation into the pulmonary trunk was necessary to reduce the pressure gradient. Because unsuccessful intervention, two patients needed subsequent operation. During follow-up of 6-9 months after intervention severe restenosis occurred in 3 patients (2 after stent-implantation; 1 after re-re-dilatation) who then also needed operation. Balloon dilatation should be the first treatment in patients with pulmonary stenosis after ASO in TGA owing to the low complication rate and the potential benefit of this procedure. Recurrent and combined stenoses with narrow pulmonary valve annulus should be treated surgically.

Prediction of Early Pulmonary Artery Stenosis after Arterial Switch Operation: The Role of Intraoperative Transesophageal Echocardiography

“…The use of balloon angioplasty to relieve neo-PS is necessary and not rare [10, 13,27,28,29]. It is our policy to perform balloon angioplasty first for the treatment of neo-PS.…”

“…ASO is the procedure of choice for neonates with simple TGA with or without VSD, but the onset of supravalvular pulmonary stenosis, with incidence varying from 17 to 55% according to different criteria, was an important postoperative complication during long-term follow-up [8,9,10]. Several parameters, including surgical techniques, coronary artery patterns [12], age at operation and preoperative pulmonary stenosis were reported to be risk factors for the development of postoperative pulmonary stenosis [11, 12].…”

“…The incidence of neo-PS after ASO varied from 17 to 55%, depending on the different criteria in several reports [8,9,10,11]. Several factors including surgical techniques, age at operation, preoperative PA pressure and stenosis were suggested to be correlated with the development of postoperative neo-PS [11, 12].…”

“…The reintervention rate for neo-PS also varied in different interventional approaches. The need for balloon angioplasty ranged from 17 to 28% [10], and the need for surgical reoperation ranged from 2 to 6%, respectively [12,13,14,15]. …”

Decreased Incidence of Supravalvar Pulmonary Stenosis After Arterial Switch Operation

“…1 However, despite its improved outcomes over the mustard and atrial switch procedures, 1,2 postoperative supravalvar pulmonary stenosis (SVPS) is common. Supravalvar pulmonary stenosis occurs in 17% to 55% of patients [3][4][5][6] and is related to surgical technique, as well as age at operation. 7 Historically, the coronary arteries are removed from the neopulmonic root by excising the entire associated sinus of Valsalva.…”