Left-Sided Reoperations After Arterial Switch Operation: A European Multicenter Study

Vida, Vladimiro L.; Zanotto, Lorenza; Zanotto, Lucia; Stellin, Giovanni; Padalino, Massimo A.; Sarris, Georges; Protopapas, Eleftherios; Prospero, Carol; Pizarro, Christian; Woodford, Edward; Tlaskal, Thomas; Berggren, Håkan; Kostolny, Martin; Omeje, Ikenna; Asfour, Boulos; Kadner, Alexander; Carrel, Thierry; Schoof, Paul H.; Nosál, Matej; Fragata, José; Kozłowski, Michał; Maruszewski, Bohdan; Vricella, Luca A.; Cameron, Duke E.; Soják, Vladimír; Hazekamp, Mark G.; Salminen, Jukka; Mattila, Ilkka; Cleuziou, Julie; Myers, Patrick Olivier; Hraška, Viktor

doi:10.1016/j.athoracsur.2017.04.026

Cited by 22 publications

(24 citation statements)

References 26 publications

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“…The threshold and timing for aortic root repair are mainly based on absolute diameters rather than indexed aortic diameters (Z-scores) and are adapted from guidelines for aortopathy due to bicuspid aortic valve or connective tissue disease. The current incidence of neo-aortic reoperations in this study and in a recent multicentre study is low 30. However, in the present study, already 47 patients (14%) developed a root diameter ≥40 mm, and moderate AR was present in 26% of them.…”

Section: Discussioncontrasting

confidence: 60%

Progression of aortic root dilatation and aortic valve regurgitation after the arterial switch operation

Palen

Bom

Dekker

et al. 2019

Heart

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ObjectiveTo study neo-aortic growth and the evolution of neo-aortic valve regurgitation (AR) in patients with transposition of the great arteries (TGA) after arterial switch operation (ASO) from newborn to adulthood and to identify patients at risk.MethodsNeo-aortic dimensions (annulus/root/sinotubular junction) and neo-aortic valve regurgitation were assessed serially in 345 patients with TGA who underwent ASO between 1977 and 2015. Linear mixed-effect models were used to assess increase of neo-aortic dimensions over time and to identify risk factors for dilatation. Risk factor analysis for AR by using time-dependent Cox regression models.ResultsAfter a rapid increase in the first year after ASO and proportional growth in childhood, neo-aortic dimensions continue to increase in adulthood without stabilisation. Annual diameter increase in adulthood was 0.39±0.06, 0.63±0.09 and 0.54±0.11 mm for, respectively, neo-aortic annulus, root and sinotubular junction, all significantly exceeding normal growth. AR continues to develop over time: freedom from AR ≥moderate during the first 25 years post-ASO was 69%. Risk factors for root dilatation were complex TGA anatomy (TGA-ventricular septal defect (VSD), double outlet right ventricle with subpulmonary VSD) and male gender. Risk factors for AR ≥moderate were: complex TGA anatomy and neo-aortic growth. Per millimetre increase in aortic root dimension, there was a 9% increase in the hazard of AR ≥moderate. Bicuspid pulmonary valve did not relate to the presence of root dilatation or AR.ConclusionAfter ASO, neo-aortic dilatation proceeds beyond childhood and is associated with an increase in AR incidence over time. Careful follow-up of the neo-aortic valve and root function is mandatory, especially in males and in patients with complex TGA anatomy.

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Section: Discussioncontrasting

confidence: 60%

Progression of aortic root dilatation and aortic valve regurgitation after the arterial switch operation

Palen

Bom

Dekker

et al. 2019

Heart

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“…Currently, no cases have been documented with aortic rupture or dissection after ASO, but in several reoperated patients the anterior wall of the aneurysmatic aorta was observed to be paper-thin and fragile. 21,22 These regions correspond to the areas of elevated WSS, as found in our study, and the combined CFD and in vitro 4D flow study by Biglino et al 29 Whether this hemodynamic parameter may add to the prediction of progressive aortic dilatation, aortic wall thinning, or imply a higher lifetime risk of adverse aortic events (aortic rupture or dissection) at that site is unknown and requires further longitudinal follow-up. This is of high importance as, to date, indications for reoperation for neoaortic root dilatation after ASO to prevent rupture, dissection, or progressive neo-aortic regurgitation are unclear.…”

Section: Discussionsupporting

confidence: 71%

“…The flow displacement direction from root to mid‐AAo also corresponded to the peak systolic WSS distribution in the mid‐AAo, but the contribution of FD on WSS distribution more upstream in the distal AAo was less compared with the effect of vessel tapering. The regions of abnormal increased WSS in the distal AAo clinically correlates with the location of the paper‐thin and fragile anterior wall of the AAo that has been found in ASO patients during root reoperations …”

Section: Discussionmentioning

confidence: 99%

“…The regions of abnormal increased WSS in the distal AAo clinically correlates with the location of the paperthin and fragile anterior wall of the AAo that has been found in ASO patients during root reoperations. 21,22 Neo-aortic root dilatation is a key problem in long-term follow-up in patients after ASO for TGA because of its ongoing progression beyond the age of 18 years. 2,3,23 The neo-aortic root after ASO dilates and elongates and the STJ becomes more distally-displaced over time.…”

Section: Discussionmentioning

confidence: 99%

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Altered Ascending Aorta Hemodynamics in Patients After Arterial Switch Operation for Transposition of the Great Arteries

Palen

Deurvorst

Kroft

et al. 2019

Magnetic Resonance Imaging

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Background Patients with transposition of the great arteries (TGA) have an altered aortic geometry after an arterial switch operation (ASO), with neo‐aortic root dilatation as an important complication. Geometry‐related aortic hemodynamics have been assumed to contribute to pathology of the ascending aorta (AAo). Purpose To evaluate aortic flow displacement (FD) and regional wall shear stress (WSS) in relation to ascending neo‐aortic geometry in children after ASO. Study Type Prospective. Population Twenty‐eight TGA patients after ASO and 10 healthy volunteers. Field Strength/Sequence 3.0T/4D flow (segmented fast‐spoiled echo pulse), noncontrast‐enhanced MR angiography (Dixon), and anatomic images (SSFP). Assessment Aortic diameters and body surface area‐indexed aortic dimensions (Z‐scores), normalized FD and planar ascending aortic WSS. Statistical Tests Mann–Whitney and chi‐square tests for differences in FD magnitude, WSS, and FD directionality between groups, respectively. Spearman rank correlation to assess the degree of association between aortic geometry, FD and WSS parameters. Shapiro–Wilk test to evaluate distribution normality on the absolute differences in octant location between FD and WSS. Results TGA patients showed a significantly dilated proximal AAo and relatively small mid‐AAo dimensions at the level of the pulmonary arteries (Z‐scores neo‐aortic root: 4.38 ± 1.96 vs. 1.52 ± 0.70, P < 0.001; sinotubular junction: 3.48 ± 2.67 vs. 1.38 ± 1.30, P = 0.010; mid‐AAo: 0.32 ± 3.06 vs. 1.69 ± 1.24, P = 0.001). FD magnitude was higher in TGA patients (neo‐aortic root: 0.048 ± 0.027 vs. 0.021 ± 0.006, P < 0.001; sinotubular junction: 0.054 ± 0.037 vs. 0.029 ± 0.013, P < 0.05) and was related to the neo‐aortic Z‐score. Clear areas of higher WSS at the right and anterior aortic wall regions along the distal AAo were detected in TGA patients, most pronounced in those with relatively smaller mid‐AAo diameters. Data Conclusion TGA‐specific geometry related to the ASO, evidenced by neo‐aortic root dilatation and a sudden change in vessel diameter at mid‐AAo level, leads to more aortic flow asymmetry in the proximal AAo and WSS distribution with higher WSS at the right and anterior aortic wall regions along the distal AAo. Level of Evidence: 1 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2020;51:1105–1116.

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“…Late coronary complications requiring re-intervention have been reported to occur in <3% of patients [2], although a recent European multicentre study with a median follow-up of 16 years, found a reoperation rate of only 0.3% for late coronary complications [3]. However asymptomatic coronary lesions may be found in up to 8% of patients [2] and previously silent ischaemia may present as a late cardiac event or sudden death [4].…”

Section: Discussionmentioning

confidence: 99%

Late complication of intramural coronary transfer during the arterial switch operation

Stoll

Hudsmith

Drury

et al. 2018

Interactive CardioVascular and Thoracic Surgery

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switch operation for transposition of the great arteries. We report a 27-year old woman presenting with an acute coronary syndrome late after arterial switch with a complex coronary pattern (intramural left and right coronary from sinus two). CT demonstrated that the pericardial 'saddle bag' used to reconstruct the intramural coronary was compressed between the neo-aortic root and neo-pulmonary trunk. At surgery, the coronary system was laid open into the neo-aorta with patch enlargement and the patient made an uneventful recovery.

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Left-Sided Reoperations After Arterial Switch Operation: A European Multicenter Study

Cited by 22 publications

References 26 publications

Progression of aortic root dilatation and aortic valve regurgitation after the arterial switch operation

Progression of aortic root dilatation and aortic valve regurgitation after the arterial switch operation

Altered Ascending Aorta Hemodynamics in Patients After Arterial Switch Operation for Transposition of the Great Arteries

Late complication of intramural coronary transfer during the arterial switch operation

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