Past, present, and future of the arterial switch operation: historical review

Abstract

The arterial switch operation is the extant surgical correction after a long series of palliations attempted and/or successfully achieved for the treatment of discordant ventriculoarterial connections. As early as 1954, pioneers such as Mustard, Bailey, Kay, and Idriss led the way with at first disheartening failures, temporarily leading to abandoning the procedure. The first successful atrial baffle procedure in 1958 established itself as the procedure of choice for treating discordant ventriculoarterial connections, but tenacity, courage, and vision to pursue anatomic correction finally led to the first successful arterial switch in 1975 by Jatene. After a decade to perfect surgical technique and timing indications for the various anatomic subtypes, the new era of the neonatal arterial switch since the late 1980s set the very high standards that we all know and expect today. Despite excellent early and long-term survival, important residual lesions are increasingly being recognised. Expected anatomic residuals include supravalvar pulmonary stenosis, neoaortic valve insufficiency, and coronary ostial stenosis. Reinterventions and rare, but challenging surgical reoperations address these residual findings with satisfactory outcomes. Quality of life into young adulthood is satisfactory, but functional problems include reduced exercise capacity, diffuse coronary insufficiency, and neurodevelopmental shortcomings, of which the true incidence and potential clinical implications are still unknown. The arterial switch is a spectacular anatomic correction for a once lethal condition and currently the best surgical solution for patients with discordant ventriculoarterial connections. It is, however, far from a true cure; closer and ongoing follow-up for future care will continue to be required.

Outcomes of Patients After Arterial Switch Operation: 18 Years of Experience in a Single Medium-Volume Center

“…Pedra et al [10] found proximal eccentric proliferation in the coronary arteries of all of 20 asymptomatic patients studied after ASO. Although we may have not diagnosed asymptomatic coronary lesions, clear guidelines for coronary evaluation and re-intervention are lacking [3,15].…”

Preoperative Coronary Anatomy Assessment with Echocardiography and Morbidity After Arterial Switch Operation of Transposition of the Great Arteries

“…A major step in this regard has been the adoption of the arterial switch operation (ASO) instead of the previously used atrial switch [1]. ASO is an anatomical correction; the aorta and pulmonary trunk are switched and the coronary arteries are transferred to the neo-aorta.…”

“…Transposition of the great arteries (TGA) is a congenital heart defect that, in terms of both diagnosis and surgical management, has undergone important advances with significant improvement in mortality and morbidity. A major step in this regard has been the adoption of the arterial switch operation (ASO) instead of the previously used atrial switch [ 1 ]. ASO is an anatomical correction; the aorta and pulmonary trunk are switched and the coronary arteries are transferred to the neo-aorta.…”

“…Thus, recognized factors for mortality and morbidity include institutional and surgeon’s inexperience, prematurity, lower weight at ASO, presence of ventricular septal defect, and left ventricle outflow obstruction including arch anomaly [ 2 – 9 ]. One additional risk factor involves the surgical translocation of the coronary arteries [ 1 ]. Certain types of coronary anatomy (CA) have been suggested to influence surgical indices such as bypass and aortic clamping time as well as early postoperative morbidity.…”

Exercise Capacity Long-Term after Arterial Switch Operation for Transposition of the Great Arteries

“…Transposition of the great arteries (d‐TGA) is a congenital heart defect (CHD) characterized by a combination of concordant atrioventricular and discordant ventricle arterial connections, representing around 3% of all CHD and 20% of all cyanotic CHD . Some of the earliest surgical procedures developed for this condition were aimed at achieving anatomical correction; nevertheless, the results of such approaches were limited . In 1975, Jatene and colleagues reported the first successful Arterial Switch Operation (ASO) in an older infant with an associated ventricular septal defect .…”