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 followup was completed in 72 survivors with the followup 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 TaussigBing 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.
Objective To evaluate the impact of an integrated management mode of prenatal diagnosis-postnatal treatment for congenital heart disease (CHD) on perioperative and long-term outcomes of the arterial switch operation (ASO), and to analyze the efficacy of ASO over six years in a single center. Methods This retrospective study analyzed the clinical data of 183 children who underwent ASO at Guangdong Provincial People's Hospital from January 2018 to December 2024. The cohort included 106 patients (57.9%) of transposition of the great arteries with intact ventricular septum (TGA/IVS), 61 patients (33.3%) of transposition of the great arteries with ventricular septal defect (TGA/VSD), and 16 patients (8.7%) of taussig-bing anomaly (TBA). Perioperative indicators were compared between 91 patients in the prenatal-postnatal integrated management group (an integrated group) and 92 patients in the traditional management group (a non-integrated group). Long-term survival and reoperation rates were analyzed using Kaplan-Meier curves. Results The overall perioperative mortality rate was 4.9% (9/183), showing a downward trend year by year. The primary cause of perioperative mortality was low cardiac output syndrome (LCOS), which occurred in 12 patients (6.6% incidence) with a mortality rate of 75%. The integrated group had a higher proportion of males (89% vs. 72.8%, P<0.05) and lower body weight [3.13 (2.75, 3.35) vs. 3.30 (3.00, 3.67), P<0.05] compared to the non-integrated group. The age at surgery was significantly earlier in the integrated group [7 (3, 10) vs. 14 (9, 48), P<0.05], and all children in the Integrated Group underwent ASO within the optimal surgical window (100% vs. 82.6%, P<0.05). Intraoperatively, cardiopulmonary bypass (CPB) time [173 (150, 207) vs. 186 (159, 237), P<0.05] and aortic cross-clamp (ACC) time [100 (90, 117) vs. 116 (97, 142), P<0.05] were significantly shorter in the integrated group. although the integrated group had longer postoperative mechanical ventilation time [145 (98, 214) vs. 116 (77, 147), P<0.05] and higher 48-hour maximum vasoactive inotropic score (VISmax) [15 (10, 21) vs. 12 (8, 16), P<0.05], there was no statistically significant difference in the incidence of severe complications (LCOS, NEC, ECMO) or mortality rate (3.3% vs. 6.5%, P=0.51) between the two groups, despite earlier surgical intervention and a higher proportion of critically ill cases in the integrated group. The length of hospital stay in the emergency surgery group was significantly shorter than that in the elective surgery group [20 (15, 28) vs. 25 (21, 30), P<0.05], suggesting that early surgery may be of potential benefit. A total of 163 patients were successfully followed up for a median of 4.7 years, with a 5-year survival rate of 95.1% and a freedom from reintervention survival rate of 95.1%. There were no late deaths, and the most common postoperative complication was pulmonary artery stenosis. Conclusion The integrated management model allowed critically ill children with lower body weights to safely undergo surgery, significantly optimizing the timing of surgery and shortening intraoperative times. The long-term risk of reoperation after ASO is primarily concentrated on pulmonary artery stenosis, necessitating long-term follow-up and monitoring.
Abstract： Objective To analyze risk factors for perioperative 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 (1LCX2R) 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, perioperative 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 perioperative 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 perioperative mortality. Conclusion The ASO can be performed with low perioperative mortality in our hospital currently. Occurrence of major coronary events, unusual coronary artery patterns and year of surgery before 2006 are independent predictors for perioperative mortality.
ObjectiveTo analyze the risk factors and re-intervention strategies for mid- and long-term residual after arterial switch operation (ASO). MethodsThe clinical data of children with complex congenital heart disease who underwent ASO surgery in Shanghai Children’s Medical Center from January 2006 to June 2022 were retrospectively collected, and the factors for mid- and long-term residual after ASO were analyzed. ResultsA total of 952 children undergoing ASO were enrolled in this study, including 654 males and 298 females with an average age of 102.9±90.1 d and weight of 4.6±1.6 kg. There were 421 patients with D-transposition of the great arteries with intact ventricular septum (D-TGA/IVS), 357 patients with D-transposition of the great arteries with ventricular septal defect (D-TGA/VSD), and 174 patients with right ventricle double outlet combined with inferior pulmonary artery absence (Taussig-Bing malformation). Eighty-nine patients died early after the surgery, the mortality rate was 9.3%. The 746 surviving children were regularly followed up after the surgery (follow-up rate 86.4%), with a median follow-up time of 79.4 (12.0-188.0) months. During the follow-up, 53 children underwent surgical re-intervention due to residual, including 33 males and 20 females, with a median age of 62.5 (17.0-214.0) months. The median surgical weight was 19.0 (8.2-86.0) kg, and the mean time of re-intervention was 28.0-170.0 (77.5±45.4) months after the ASO. Residual problems included common trunk and branch stenosis of the pulmonary artery in 34 patients, right outflow tract stenosis in 11 patients, left outflow tract stenosis in 6 patients, aortic arch restenosis in 5 patients, aortic insufficiency in 5 patients, residual shunt of ventricular septal defect in 2 patients, and tricuspid valve insufficiency in 1 patient. Two patients died early after the re-intervention because of acute left heart failure, and the mortality rate was 3.8% (2/53). The mean follow-up time of the surviving children was 52.4±28.6 months, and no mid- and long-term death occurred. Two patients underwent the third operations due to pulmonary restenosis. The multivariate analysis result showed that combined aortic arch surgery and early postoperative right ventricular outlet tract (RVOT) velocity>3 m/s were independent risk factors for mid- and long-term residual after ASO. ConclusionASO is an ideal surgical method for the treatment of D-TGA/IVS, D-TGA/VSD and Taussig-Bing malformations. Combined aortic arch surgery and early postoperative RVOT velocity>3 m/s are independent risk factors for mid- and long-term residual after ASO.
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.
Objective To analyze the outcome of arterial switch operation （ASO） for surgical repair of complete transposition of the great arteries （TGA）, and to investigate the risk factors influencing the mortality of ASO. Methods The clinical data of patients suffered from TGA and treated with ASO from the January 2003 to December 2004, and the clinical records in hospital including eehoeardiogram and operation record were collected. The clinical data were analyzed by chi-squared test and logistic muhivariable regression analysis, including the age undergone operation, body weight, diagnosis, anatomic type of coronary artery, cardiopulmonary bypass time, aortic crossclamping time, circulation arrest time, assisted respiration time after operation, the delayed closure of sternum and so on. The risk factors influencing the early mortality of the ASO were analyzed. Results Sixty seven patients were operated with ASO, five patients died during the peri-operative period. The outcome of univariate analysis indicated that risk factors influencing the mortality of ASO included： age（P=0. 004）, body weight （P=0. 042）, anatomic type of coronary artery （P= 0. 006） and extracorporeal circulation time （P= 0. 048）, the length of the CICU stay（P= 0. 004） and the hospital stay（P=0. 007） after operation in the TGA/VSD patients were longer than those in TGA/ IVS patients. The logistic muhivariable regression analysis indicated that the age at operation （P= 0. 012）, coronary arteries anomaly （P = 0.001 ）and the longer cardiopulmonary bypass time （P = 0. 002） were correlated with the increase of death rate. Conclusion It could be good results for TGA patients who was repaired with ASO. The age at operation, the coronary arteries anomaly and the longer cardiopulmonary bypass time are the risk factors influencing the mortality.
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.
Abstract： Objective To investigate the longterm complications and preventions of rapid twostage arterial switch operation through longterm follow-up. Methods We reviewed the clinical information of 21 patients of rapid twostage arterial switch operation from September 2002 to September 2007 in Shanghai Children’s Medical Center. Among them, there were 13 males and 8 females with an average age of 75 d (29-250 d) and an average weight of 5 kg (3.5-7.0 kg). The data of left ventricle training period and the data before and after the twostage arterial switch operation were analyzed, and the risk factors influencing the aortic valve regurgitation were analyzed by the logistic multivariable regression analysis. Results The late diameter of anastomosis of pulmonary and aortic artery were increased compared with those shortly after operation (0.96±0.30 cm vs. 0.81±0.28 cm, t=-1.183,P=0.262; 1.06±0.25 cm vs. 0.09±0.21 cm, t=-1.833,P=0.094), but there was no significant difference. The late velocity of blood flow across the anastomoses was not accelerated, which indicated no obstruction. The late heart function was better than that shortly after operation, while there was no significant difference between left ventricular ejection fraction(LVEF) during these two periods (62.88%±7.28% vs. 67.92%±7.83%,t=1.362,P=0.202). The late left ventricular end diastolic dimension(LVDd) was significantly different from that shortly after operation (2.16±0.30 cm vs.2.92±0.60 cm，t=-5.281，P=0.003). Compared with earlier period after operation, the thickness of left ventricular posterior wall thickness（LVPWT）was also increased (0.39±0.12 cm vs. 0.36±0.10 cm,t=0.700,P=0.500), but there was no significant difference. The postoperative aortic valve regurgitation was worsened in 4 patients (30.77%, 4/13), not changed in 7 patients and alleviated in 2 patients compared with that before operation. There was no severe regurgitations during the followup. The logistic regression analysis showed that the small preoperative diameter ratio of aortic valve to pulmonary valve and long follow-up time were two risk factors for the [CM(159mm]aggravation of aortic regurgitation. Conclusion There is a relatively high aortic regurgitation rate after rapid two stage arterial switch operation, but there is no later death or reoperation and the survival conditions are satisfactory. All patients must be followed up periodically to check the anastomosis of pulmonary and aortic arteries and the aortic valve.
Abstract: The complete transposition of the great arteries (TGA) is one of the commonest congenital cardiac anomalies in cyanosis. In untreated patients, death occurs early in infancy. Nowadays arterial switch operation (ASO) has been widely proposed to treat TGA without pulmonary valve stenosis. Meanwhile, surgical risks and mortality will be increased if TGA is accompanied by coronary arterial anomalies. So proper surgical management of abnormal coronary artery has a significant influence on the outcome of ASO. The classification, operation methods and surgical results were reviewed in this article.
ObjectiveTo examine changes of in-hospitalization mortality for arterial switch operation (ASO) for the patients with D-transposition of the great arteries (TGA) in our hospital. MethodsWe retrospectively analyzed the clinical data of 473 consecutive TGA patients undergoing ASO to assess temporal trends of in-hospital mortality between 2001 and 2012 year. The patients in every 2 years were brought together into a group. By this way, all the patients were divided into 6 groups. In risk-adjusted analyses, mortality of each group between 2001 and 2012 year were compared within the 6 groups. ResultsAmong all the patients, 29 in-hospital deaths occurred. Between 2001 and 2012 year, the prevalence of preoperative factors-including age (P=0.13), gender (P=0.94), height (P=0.29), weight (P=0.21), combined with pulmonary hypertension (P=0.59), training for left ventricle (P=0.14), and anatomy of coronary arteries (P=0.27) did not significantly change. Crude mortality significantly decreased during that period (17.4% in the first group vs. 4.1% in the sixth group, P<0.001). Adjusted mortality also significantly became better in the ten years (the sixth group vs. the first group, odds ratio 0.098, 95% confidence interval, 0.018-0.550，P=0.01). ConclusionBetween 2001 and 2012 year, the prevalence of risk factors among TGA patients undergoing ASO remains unchanged, but the in-hospital mortality substantial decreases.