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Risk Factors for Mortality in the Arterial Switch Operation

Abstract： Objective To analyze risk factors for perioperative mortality in the arterial switch operation (ASO), in order to provide better operation and decrease the mortality rate. Methods We enrolled 208 ASO patients including 157 males and 51 females at Fu Wai Hospital between January 1, 2001 and December 31, 2007. The age ranged from 6 h to 17 years with the median age of 90 d and the weight ranged from 3 kg to 43 kg with the median weight of 5 kg. Among the patients, 127 had transposition of great artery (TGA) with ventricular septal defect (VSD), and 81 patients had TGA with intact ventricular septum (IVS) or with the diameter of VSD smaller than 5 mm. Coronary anatomy was normal (1LCX2R) in 151 patients and abnormal in the rest including 15 patients with single coronary artery, 6 with intramural and 36 with inverse coronary artery. Preoperative, perioperative and postoperative clinical data of all patients were collected to establish a database which was then analyzed by univariate analysis and multivariate logistic regression analysis to find out the risk factors formortality in ASO. Results There were 24 perioperative deaths (11.54%) in which 12 died of postoperative infection with multiple organ failure (MOF), 10 died of low cardiac output syndrome, 1 died of pulmonary hypertension, and 1 died of cerebral complications. Among them, 20 patients (18.30%) died in early years from 2001 to 2005, while only 4 (4.00%) died in the time period from 2006 to 2007, which was a significant decrease compared with the former period (Plt;0.05). The univariate analysis revealed that cardiopulmonary bypass (CPB) time was significantly longer in the death group than in the survival group（236±93 min vs. 198±50 min, P=0.002）, and occurrence of major coronary events (33.3% vs. 2.2%, P=0.000) and unusual coronary artery patterns（33.3% vs. 6.5%,P=0.000） were much more in the death group than in the survival group. Multivariate logistic regression analysis showed that early year of [CM(159mm]operation (OR=7.463, P=0.003), unusual coronary artery patterns (OR=6.303,P=0.005) and occurrence of majorcoronary events (OR=17.312, P=0.000) were independent predictors for perioperative mortality. Conclusion The ASO can be performed with low perioperative mortality in our hospital currently. Occurrence of major coronary events, unusual coronary artery patterns and year of surgery before 2006 are independent predictors for perioperative mortality.

Comparative study of rapid and long-term two-stage arterial switch operation in treatment of transposition of the great arteries with intact ventricular septal

ObjectiveTo summarize the experience of surgical treatment of transposition of the great arteries with intact ventricular septal (TGA-IVS) after left ventricular regression by comparing the characteristics of rapid and long-term two-stage arterial switch operation (ASO).MethodsForty-one patients who were mainly diagnosed with TGA-IVS from January 2007 to January 2019 and underwent two-stage ASO were included. They were divided into a rapid two-stage ASO group (19 patients) and a long-term two-stage ASO group (22 patients) according to the interval of left ventricular training surgery and ASO. The clinical effectiveness of the two groups was compared.ResultsThere was a statistical difference in age, body weight, blood oxygen saturation before ASO, end diastolic diameter of left ventricle before training, and thickness of posterior left ventricular wall before ASO (P<0.05). Children older than 1 year was an independent risk factor for long-term two-stage ASO.ConclusionLong-term two-stage ASO is suitable for children who are older than 1 year and who have severe left ventricular regression.

135例动脉转位术患者围手术期监护

目的 总结动脉转位术（ASO）围手术期监护的经验，为提高其疗效提供借鉴。 方法 回顾性分析2000年1月至2009年6月广东省人民医院收治的135例完全型大动脉转位（TGA）患者行ASO的临床资料，男110例，女25例；手术时日龄1～160 d（27.24±26.49 d），体重2.4~5.0 kg（3.52±0.66 kg）。室间隔完整61例，室间隔缺损74例。术前动态监测血乳酸水平，纠正心功能不全，对98例（72.59%）明显低氧血症患者给予持续静脉注射前列腺素E1［PGE1，2~200 ng/（kg·min）］。手术在低温体外循环下施行，同期矫治合并畸形。术后严密监测凝血指标、左心功能，以间歇指令通气+容量保证通气（SIMV+VG）模式进行呼吸支持。22例术后应用PGE1［4~20 ng/（kg·min）］。 结果 全组体外循环时间36~423 min（189.20±59.94 min），主动脉阻断时间0~219 min（120.07±31.09 min），118例术后即时血氧饱和度95%~100%。术后机械通气时间24~792 h（168.24±154.80 h），总住院时间1~89 d（30.31±17.21 d）。生存108例，死亡27例（20.00%），主要死亡原因为低心排血量综合征。2001~2003年病死率为50.00%，2004~2006年为36.36%，2007~2009年后为8.43%，明显下降（χ2=18.323，Plt;0.001）。术后并发症：感染30例（22.22%），肺不张35例（25.93%）；心电图检查示：STT改变50例（37.04%），心律失常44例（32.59%）；超声心动图提示：吻合口狭窄36例（26.67%），肺动脉狭窄33例（24.44%）。 结论 ASO应用于TGA手术效果良好，除手术、麻醉操作外，术前维持内环境稳定、控制血乳酸水平，术后注意呼吸管理、维护左心功能是成功的关键。

The operative strategy after palliative shunt for corrected transposition of great artery (cTGA) with left ventricular outflow tract obstruction and cardiac malpostion

ObjectiveTo explore the operative strategy after palliative shunt for correcting congenitally corrected transposition of great artery (cTGA) patients with left ventricular outflow tract obstruction (LVOTO) and cardiac malpostion.MethodsWe retrospectively analyzed the clinical data of 54 patients with onsecutive cTGA with LVOTO and cardiac malpositon from June 2011 to May 2019. The patients were devided into two groups. There were 24 patients (16 males and 8 females at mean age of 5.4±2.2 years) who underwent one and a half ventricle repair as a one and half ventricle group. And there were 30 patients (19 males and 11 females at age of 8.6±6.2 years) who underwent one ventricle repair operation as a one ventricle group. Follow-up data were collected by telephone interviews.ResultsThere was no statistical difference in systemic atrioventricular valve regurgitation and systemic ventricular ejection fraction between the two groups (P>0.05). Compared with one and a half ventricle group, the cardiopulmonary bypass time (CPB) time, mechanical ventilation time and intensive care unit stay were significant shorter than those in the one ventricle group (P<0.05), but prolonged pleural effusions developed more frequently in the one ventricle repair group (P<0.05). There was no in-hospital death but 1 follow-up death in each group. The follow-up time was 49 (17-38) months in the one and half ventricle group at follow-up rate of 93.9%, and 47 (12-85) months at follow-up rate at 90.9% in the one ventricle group. One and a half ventricle group had better systemic ventricular ejection fraction (EF) than that in the one ventricle repair group. And the rate of heart function (NYHA) class Ⅲ and class Ⅳ in one and a half ventricle group was lower than that in the ventricle group. No significant difference of survival and freedom from re-intervention probability between the two groups was found.ConclusionFor patients of correction of cTGA with LVOTO and cardiac malposition after palliative shunt, the one-and-a-half ventricular repair procedure is ideal operative strategy.

老年先天性矫正型大动脉转位行心瓣膜置换术一例

Arterial switch operation: A double cohort study of 20 years’ outcomes of 571 patients in a single center

ObjectiveTo define the patient characteristics and perioperative management, and to define the mortality and its risk factors after arterial switch operation (ASO).MethodsWe conducted a bidirectional cohort study with 571 consecutive patients undergoing ASO from 1997 to 2016 in our hospital. We enrolled patients who underwent ASO before 2012 retrospectively and after 2012 prospectively and followed up all the patients prospectively. Demographic characteristics, clinical information and mortality of these patients were summarized. Joinpoint regression analysis was used to identify the time trend of the overall mortality. Kaplan-Meier survival analysis was used to evaluate the mid- and long-term survival rate after ASO. Cox proportional hazards regression models were used to explore the potential factors associated with mortality. The cumulative incidence of complications after ASO was predicted using competing risk models.ResultsSeveral aspects of patients’ characteristics and perioperative management in our center differed from those in the developed countries. The overall mortality and in-hospital mortality after ASO was 16.3% and 15.1%, respectively. The overall cumulative survival rate at 5, 10 and 15 years after ASO was 83.3%, 82.8% and 82.8%, respectively. A significant decrease of overall mortality from 1997 to 2016 was observed. Independent risk factors of mortality included earlier ASO (1997-2006), single or intramural coronary anatomy and longer cardiopulmonary bypass time. Ten years after ASO, re-intervention, arrhythmia, pulmonary and anastomotic stenosis were the most common complications with a cumulative incidence over 10%.ConclusionSignificant improvements in the results of the ASO were observed and the postoperative mortality rate is close to reports from developed countries. Nonetheless, we have identified the need for further improvement in the early and late postoperative periods after ASO. Pulmonary stenosis, anastomotic stenosis and arrhythmia should be paid attention to during the long-term follow-up after ASO.

Aortic Root Reconstruction with the Remaining Coronary Buttons in Arterial Switch Operation

Objective To summarize the clinical experiences of using the remaining coronary buttons to reconstruct the neoaortic root in the arterial switch operation (ASO) and discuss the clinical significance of preserving the morphology of aortic sinus in improving postoperative coronary artery perfusion. Methods From January 2003 to June 2009, 110 patients with transposition of great arteries (TGA) combined with ventricular septal defect (VSD ) or the Taussig Bing anomaly treated in our hospital were enrolled in this study. The patients were at the age between 2 days and 2 years averaged 91.1 days, and their body weight varied between 1.79 and 9.50 kg with an average weight of 4.70 kg. The patients were divided into two groups based on different surgical strategies. For group A (n=78), we reconstructed the neoaortic root with the remaining coronary buttons by shortening the diameter of the proximal neoaorta. While for group B (n=32), we excised the remaining coronary buttons with the aortopulmonary diameter mismatched. The risk factors of hospital mortality were analyzed with stepwise logistic regression. Results Twelve patients died early after operation with a death rate of 10.9% (12/110). Mortality in group A was significantly lower than that in group B ［6.4%(5/78) vs. 21.9%(7/32)，P= 0.019］. Clinical followup was completed in 72 survivors with the followup time of 3 months to 5 years after operation. Late death occurred in 3 patients including 1 in group A and 2 in group B. Five patients underwent reoperations. Univariate logistic regression analysis showed that risk factors for early postoperative death were TaussigBing anomaly (χ2=4.011,P=0.046), aortic arch anomaly (χ2=4.437,P=0.036), single coronary artery pattern (χ2=5.071,P=0.025) and patients in group B (χ2=5.584, P= 0.019). Multivariate analysis confirmed that the aortic arch anomaly (χ2= 5.681, P=0.010 ) and patients in group B (χ2=3.987, P=0.047 ) were two independent risk factors for early mortality after operation. Conclusion The modified technique which uses the remaining coronary buttons to reconstruct the neoaortic root can preserve the morphology of neoaortic root better. The special anatomical morphology of aortic sinus has close relation to the perfusion of coronary arteries. The lowering hospital mortality may be due to the better perfusion of the coronary arteries.

Pulmonary Artery Banding for Morphologic Left Ventricular Training in Corrected Transposition of the Great Arteries

Abstract：　Objective　To evaluate clinical outcomes of pulmonary artery banding for morphologic left ventricular training in corrected transposition of the great arteries.?Methods?A total of 89 patients with corrected transposition of the great arteries underwent surgical repair in Shanghai Children’s Medical Center from January 2007 to December 2011 year. Among them, 11 patients underwent pulmonary artery banding, whose clinical records were retrospectively analyzed. Except that one patient was 12 years, all other patients were 3 to 42 （16.40±11.67） months old and had a body weight of 6 to 32 （11.70±7.20）kg. All the patients were diagnosed by echocardiogram and angiocardiogram.?Results?There was no postoperative death after pulmonary artery banding in 11 patients. The pulmonary arterial pressure/systemic blood pressure　ratio （Pp/Ps） was 0.3 to 0.6 （0.44±0.09） preoperatively and 0.6 to 0.8 （0.70±0.04） postoperatively with statistical　difference （P＜0.01）. Tricuspid regurgitation was mild in 2 （18.2%） patients, moderate in 5 （45.4%）, severe in 4 （36.4%）preoperatively，and none in 2（18.2%）patients, mild in 7 （63.6%），and mild to moderate in 2 （18.2%）postoperatively. Five patients underwent staged double-switch operation after pulmonary artery banding at 15.20±8.31 months, and 1 patient died. The other 6 patients were followed up for 18.83±3.43 months, and echocardiogram showed tricuspid regurgitation as trivial in 2 （33.3%）, mild in 3 （50.0%）, and moderate in 1 （16.7%）patient.?Conclusions?In patients with corrected transposition of the great arteries, pulmonary artery banding is helpful to reduce tricuspid regurgitation, and morphologic left ventricle can be trained for staged double-switch operation with good clinical outcomes. It is important to follow up these patients regularly to evaluate their morphologic left ventricular function and tricuspid regurgitation after pulmonary artery banding.

Rapid two-stage arterial switch operation for neonatal D-transposition of the great arteries

Objective To review and summarize the clinical outcomes of neonatal D-transposition of the great arteries by rapid two-stage arterial switch operation. Methods Between September 2002 and May 2003, five neonates with D-transposition of the great arteries were repaired by rapid two-stage arterial switch operation. The operative age was 83.0±72.2 day and weight was 4.7±0.9 kg. Because these patients came to the hospital late, the left ventricle was unable to accommodate the systemic pressure, so the left ventricle had to be prepared by pulmonary artery banding and systemic-pulmonary arterial shunt. After 6-9 days, the arterial switch procedure was performed. Results At first stage, one patient died of supraventricular tachycardia and oliguria after peritoneal dialysis. Four patients were repaired by arterial switch operation with no death. These patients were followed up for 2 to 10 months and had good development. The echocardiogram showed that there were no intracardiac residual shunt , the aorta and pulmonary artery anastomosis had no obstruction . The heart function was good, ejection fraction 0.68-0.77,fractional shortening 0.24-0.37. One patient had mild aortic valve regurgitation. Conclusion Rapid two-stage arterial switch operation is the best way for neonatal D-transposition of the great arteries that the left ventricle was unable to accommodate the systemic pressure.

Surgical treatment of infants with transposition of the great arteries and intramural coronary artery

ObjectiveTo summarize the surgical experience of infants with transposition of the great arteries (TGA) and intramural coronary artery (IMCA) in our center, and analyze the early and mid-term outcomes.MethodsWe retrospectively analyzed the clinical data of 384 infants with TGA undergoing arterial switch operation (ASO) from June 2010 to December 2018 at Fuwai Hospital. According to operative records, 21 (5.5%) infants had IMCA, among whom 20 were males, with a median age of 33 (9-319) d. Coronary transfer using double coronary buttons with unroofed intramural course was performed in all 21 infants.ResultsThere was no statistical difference in the early mortality after ASO between infants with IMCA and infants with normal coronary anatomy (9.5% vs. 3.0%, P=0.15). In the IMCA group, 2 dead patients presented inadequate coronary artery perfusion after first aortic unclamping. In addition, 1 patient underwent extracorporeal membrane pulmonary support for myocardial dysfunction. The follow-up was available for all 19 survivors, with an average follow-up time of 29.0-120.0 (74.8±27.3) months. During the follow-up, all patients had no obvious symptoms, death, reoperation, or coronary complications. One patient developed moderate pulmonary valve regurgitation and another patient developed distal stenosis of the right pulmonary artery.ConclusionFor infants with TGA and IMCA, coronary transfer using double coronary buttons with unroofed intramural course is a safe and reliable technique, with satisfactory early and mid-term outcomes.