Long-Term Predictors of Aortic Root Dilation and Aortic Regurgitation After Arterial Switch Operation

Abstract

Background-Neo-aortic root dilation (ARD) and neo-aortic regurgitation (AR) may be progressive after arterial switch operation (ASO) for d-loop transposition of the great arteries (dTGA). We sought to identify predictors of ARD and AR after ASO. Methods and Results-335 patients were identified who underwent ASO for dTGA with intact ventricular septum or ventricular septal defect (VSD), including double-outlet right ventricle (DORV), before 2001 with at least 1 postoperative echocardiogram at our institution, at least 1 year after ASO, and no previous atrial switch procedure (median follow-up of 5.0 years). Probability of freedom from ARD was 97%, 92%, 82%, and 51%, from at least moderate AR was 98%, 97%, 96%, and 93%, and from neo-aortic valve or root surgery was 100%, 100%, 99%, and 95%, at 1, 2, 5, and 10 years, respectively. For patients in whom ARD developed, progressive dilation was not observed during late follow-up. By Kaplan-Meier method, independent predictors of ARD, with neo-aortic root z-score of Ն3.0, were previous pulmonary artery band (PAB) (Pϭ0.002, hazard ratio [HR]ϭ2.4) and later time period when ASO was performed (PϽ0.002, HRϭ19.0). Risk factor for at least moderate AR was age Ն1 year at ASO (Pϭ0.002, HRϭ5.8), which was closely related to VSD repair at ASO (PϽ0.001) and previous PAB. Conclusions-Significant ARD and AR continue to develop over time after ASO, but ARD does not tend to be progressive during late follow-up. Previous PAB was a significant risk factor for ARD. Older age at time of ASO, presence of VSD, and previous PAB were risk factors for AR.

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

“…It is now clear that a certain percentage of patients will need further reintervention/ reoperation [10,15,[17][18][19], which in the majority of patients is on the right side of the heart, for neopulmonary stenosis either at the anastomosis site or at the pulmonary artery bifurcation (after the LeCompte maneuver) [7,9,10]. Less commonly, reoperations involve the left side of the heart, such as the neoaortic valve, the aortic root, the subaortic area, and the coronary arteries [4,5,9].…”

“…Conversely, the progression of the degree of neoaortic valve insufficiency rarely occurs during the first 10 to 15 years after ASO, but it was found that it increases significantly later, and this is associated with the degree of postoperative neoaortic valve insufficiency at discharge soon after ASO [14,20,21]. Anatomic causes identified to be responsible for aortic root dilatation and neoaortic valve insufficiency included the presence of a ventricular septal defect and aortic/pulmonary mismatch and the postoperative geometry of the aortic root [19]. In addition, previous pulmonary artery banding and coronary reimplantation techniques (ie, the trapdoor technique) were also previously identified as significant risks for aortic root dilatation and neoaortic valve insufficiency [14,12].…”

ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease

“…Significant neoaortic root dilatation and neoaortic valve regurgitation may develop over time, in part related to older age at the time of ASO or to an associated VSD with previous pulmonary artery banding. 568 …”

Histopathological Changes in Aorta and Pulmonary Artery in Patients with Dextro- Transposition of Great Arteries undergoing Arterial Switch Operation: A Prospective Study

“…The natural history of neoaortic root dilation in this setting is unclear. Previous studies have demonstrated data, with reports of the indexed neo-aortic root dimensions progressively increasing over time [17]. Neo-aortic valve regurgitation may also be an important late complication, and although uncommon, the need for aortic valve repair or replacement has now been reported in several series late after ASO [18].…”