Dextro-transposition of the great arteries corrective surgery
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Dextro-transposition of the great arteries/complete transposition of the great arteries Microchapters |
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Differentiating dextro-transposition of the great arteries from other Diseases |
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Diagnosis |
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Transposition of the great vessels Microchapters |
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Classification |
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Differentiating Transposition of the great vessels from other Diseases |
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Diagnosis |
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Treatment |
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Surgery |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3]; Keri Shafer, M.D. [4]; Assistant Editor(s)-In-Chief: Kristin Feeney, B.S. [5]
Overview
Recent advances in surgical correction of transposition of the great arteries have reduced the mortality drastically from 95% in uncorrected patients to 5% in corrected patients[1].
Corrective Surgery
Arterial switch operations (ASO) are now-days preferred over Atrial switch procedures (Mustard and Senning Operations) because of the following reasons-
- Arterial switch procedure are comparatively easier to perform
- ASO have similar survival benefits compared to atrial switch procedure
- Decreased risk of complications like arrhythmias and heart failure in ASO compared to atrial switch procedures
- Decreased peri-operative mortality in ASO compared to atrial switch procedures
Salient features of surgery are
- It is best to perform the ASO as early as possible in the children. Most infants undergo definitive repair within the first 2 weeks of life.
- The type of surgical procedure done depends on the type of lesion the child has i.e. simple or complex transposition of the great arteries.
- The general rules that are followed are-
- Simple D-TGA (D-TGA without any associated lesion)- Arterial switch operation (ASO).
- D-TGA plus ventricular septal defect-Arterial switch operation (ASO) and VSD closure.
- D-TGA plus large VSD plus pulmonary stenosis - Rastelli procedure
Arterial switch or Jatene Operation
- The successful anatomical correction of TGA was first described in 1975 by Jatene et al.
- It has become the preferred procedure for most of the D-TGA (see above for the conditions)
- An arterial switch operation involves the following steps-
- The baby will be placed under general anesthesia.
- The heart and vessels are accessed via median sternotomy.
- The heart/lung machine (cardiopulmonary bypass machine) is connected.
- Since, the heart/lung machine needs its "circulation" to be filled with blood, a child will require a blood transfusion for this surgery.
- The patient is cooled for 20 minutes to 20 Celsius degree rectal temperature.
- Once the heart is stopped and emptied, the aorta and the pulmonary artery are divided.
- The site of the aortic transection is marked before the cross clamp is applied.
- The aorta and pulmonary artery are transected at a level above the valve sinuses.
- The ostium of the coronary arteries are excised along with a large segment of surrounding aortic wall and sutured into place in the neo-aorta (basal part of the pulmonary artery).
- The pulmonary trunk is moved forward into its new position anterior to the aorta.
- Finally, the switched great arteries are sutured into place.
- The heart is then allowed to fill and take over its normal function. Temporary pacemaker wires and drainage tubes are then placed and the chest is closed.
- Some arterial switch recipients may present with post-operative pulmonary stenosis, which would then be repaired with angioplasty, pulmonary stenting via heart cath or median sternotomy, and/or xenograft.
- Lecompte maneuver - During this surgery the bifurcation of the pulmonary arteries are placed anterior to the aorta. This helps in straddling the ascending aorta to the left and right pulmonary arteries. This reduces the tension that could be there due to anterio translocation of the pulmonary arterial root. This has helped to decrease the pulmonary artery stenosis that may occur as an complication of ASO.
Atrial Switch Repair
Mustard and Senning Operations In 1959, Senning described the first definitive operation (physiological repair) for patients with TGA. In 1964, Mustard published his experience with the atrial switch. This operation became very popular due to an increase in survival of over 90%. Both of these procedures "correct" the physiologic abnormality of the TGA by forming a baffle within the atria in order to switch the flow of blood at inflow level. As a consequence the heart and lungs will be in series.
The Mustard Operation consist of an atrial septectomy and placement of a baffle that directs caval blood to the mitral valve, allowing the pulmonary veins to drain into the tricuspid valve. The baffle is created from pericardium or synthetic material.
The Senning operation, utilized right atrial wall and atrial septal tissue (without the use of extrinsic materials), to create the baffle or wall of the caval tunnel in order to achieve the same goal as in Mustard.
Although the early mortality rate for both procedures is low, between 1 and 10% in experienced hands, the long-term outcome is affected by late complications such as atrial dysrhythmia (with the highest incidence of more than 50% within 10 years), and a late right ventricular (systemic ventricular) dysfunction (approximately 10%).
The Seening repair is becoming more promising than Mustard due to the better long term outcomes in terms of venous obstruction and atrial haemodynamics. However, the procedure of choice for treatment of patients with d-TGA is the Arterial Switch or Jatene Operation.
Rastelli Operation
Is the most frequently used surgical option for patients with TGA, VSD, and pulmonary outflow tract obstruction. It depend on appropriate VSD anatomy (large and subaortic) because the it will be used as part of the left ventricular outflow tract (LVOT), involving placement of a baffle within the RV to direct blood flow from the VSD to the aorta. A conduit is inserted between the RV and the pulmonary artery, which has been oversewn.
The main advantage of this procedure is that the LV becomes the systemic ventricle, but the conduit will likely need to be replaced several times during the patient's life. The appropriate age for this operation is still debated, due to the higher risk with the early repair. The younger the patient the smaller the conduit, needing earlier reoperation.
References
- ↑ Hutter PA, Kreb DL, Mantel SF, Hitchcock JF, Meijboom EJ, Bennink GB (2002). "Twenty-five years' experience with the arterial switch operation". J Thorac Cardiovasc Surg. 124 (4): 790–7. PMID 12324738.
Acknowledgements and Initial Contributors to Page
Leida Perez, M.D.
External links
- Diagram at kumc.edu
- Diagram and description at umich.edu
- Overview at pediheart.org
- Royal Children's Hospital, Melbourne
- Mayo Clinic, Arizona - Florida - Minnesota, USA
