Original article: cardiovascular
Arterial switch operation: factors impacting survival in the current era

Presented at the Thirty-sixth Annual Meeting of the Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 31–Feb 2, 2000.
https://doi.org/10.1016/S0003-4975(01)02529-2Get rights and content

Abstract

Background. The arterial switch procedure has become the preferred procedure for the transposition of the great arteries (TGA) and Taussig-Bing anomaly. This analysis is intended to identify potential factors affecting survival in the current era.

Methods. From 1986 to 1999, 201 consecutive patients underwent an arterial switch operation for TGA or Taussig-Bing anomaly. Multivariate analysis of perioperative variables was performed for operative morbidity/mortality. Patients were separated into two groups. Phase 1 (n = 29) included patients before mid-1989 who underwent an open coronary reimplantation technique. Phase 2 (n = 172) included the patients undergoing a technique of reimplanting coronary buttons after neoaortic reconstruction.

Results. The patient population included TGA with intact ventricular septum (58.7%, 118 of 201), with ventricular septal defect (31.3%, 61 of 201), and Taussig-Bing anomaly (10.0%, 22 of 201). Overall, early mortality was 9.5% (19 of 201) and there were five late deaths (2.7%). One-month, 1-year, and 5-year actuarial survival rates were 90.4%, 87.9%, and 87.9%, respectively. Reoperation rate for late pulmonary stenosis was 2.7% (5 of 182). The freedom from reoperation at 3 and 5 years was 97.5% and 93.3%, respectively. In the analysis by time period, the operative mortality declined from 27.6% (8 of 29) to 6.4% (11 of 172) (p = 0.002). Risk factors for operative death were coronary artery patterns (usual vs retropulmonary left coronary artery, p = 0.009) in phase 1 and preoperative instability in phase 2 (p = 0.002).

Conclusions. The arterial switch operation for TGA and Taussig-Bing anomaly has early low and late mortality and reoperation rates. Technical modifications in coronary reimplantation have minimized coronary artery pattern-related risks.

Section snippets

Material and methods

Between September 1986 and December 1999, 201 patients who had the ASO performed by two surgeons were included in this review. Informed consent and institutional approvals were obtained for this study. The operative experience is divided into two periods separated by the technique of coronary artery placement into the neoaorta. In phase 1 (1986 to 1989), reimplantation of coronary button into open sinuses was done before neoaortic reconstruction. In phase 2 (1989 to 1999), reimplantation of the

Results

Overall, early mortality for the entire study period was 19 of 201 (9.5%). Mortality for phase 1 was 8 of 29 (27.6%) and reflected our learning curve for complex coronary patterns and other complex anatomy. The coronary reimplantation technique changed in phase 2 and the mortality fell to 11 of 172 (6.4%) (p = 0.002) (Table 3). The early mortality for TGA-VSD was, as expected, higher than for TGA-IVS (13.1% vs 7.6%) for the entire series but lower for Taussig-Bing DORV (9.1%). These differences

Comment

A review of the literature and the retrospective analysis of our data demonstrate a progressive decrease in mortality over time for the ASO 10, 11, 12, 13, 14, 15, 16. The low incidence of late complications as compared with the atrial switch (Mustard and Senning) procedure is well documented and does not require further discussion 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18. The early mortality of ASO of 4.8% for TGA-IVS and the 10.0% mortality for TGA-VSD in phase 2 of our

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