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J Thorac Cardiovasc Surg 1995;109:289-302
© 1995 Mosby, Inc.
SURGERY FOR CONGENITAL HEART DISEASE |
Boston, Mass., and Birmingham, Ala.
Supported in part by grant HL41786 from the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md.
*Address for reprints and current address: Gil Wernovsky, MD, Children's Hospital of Philadelphia, 34th St. and Civic Center Blvd., Philadelphia, PA 19104.
Abstract
Between January 1983 and January 1992, 470 patients underwent an arterial switch operation at our institution. An intact (or virtually intact) ventricular septum was present in 278 of 470 (59%); a ventricular septal defect was closed in the remaining 192. Survivals at 1 month and 1, 5, and 8 years among the 470 patients were 93%, 92%, 91%, and 91%, respectively. The hazard function for death (at any time) had a rapidly declining single phase that approached zero by one year after the operation. Risk factors for death included coronary artery patterns with a retropulmonary course of the left coronary artery (two types) and a pattern in which the right coronary artery and left anterior descending arose from the anterior sinus with a posterior course of the circumflex coronary. The only procedural risk factor identified was augmentation of the aortic arch; longer duration of circulatory arrest was also a risk factor for death. Earlier date of operation was a risk factor for death, but only in the case of the senior surgeon. Reinterventions were performed to relieve right ventricular and/or pulmonary artery stenoses alone in 28 patients. The hazard function for reintervention for pulmonary artery or valve stenosis revealed an early phase that peaked at 9 months after the operation and a constant phase for the duration of follow-up. Incremental risk factors for the early phase included multiple ventricular septal defects, the rapid two-stage arterial switch, and a coronary pattern with a single ostium supplying the right coronary and left anterior descending, with a retropulmonary course of the circumflex. The need for reintervention has decreased with time. The arterial switch operation can currently be performed early in life with a low mortality risk (<5%) and a low incidence of reintervention (<10%) for supravalvular pulmonary stenosis. The analyses indicate that both the mortality and reintervention risks are lower in patients with less complex anatomy. (J THORACCARDIOVASCSURG1995; 109: 289-302)
In the past decade, the arterial switch operation has become the preferred surgical procedure for transposition of the great arteries (TGA) and transposition-like forms of double-outlet right ventricl. As previous reports from this and other institutions have indicated, 
1-7 this approach has rapidly become the standard one in many parts of the world. The theoretical advantages of anatomic correction over the physiologic repairs of Mustard and Senning—a lower incidence of arrhythmia and normal systemic ventricular and atrioventricular valve function—have been supported in many midterm follow-up studies. 6-17
Few reports have examined objectively and in detail the factors influencing (1) early mortality from the operation, (2) the intermediate-term freedom from death, and (3) freedom from other unfavorable outcome events. This report will describe the total experience with the arterial switch operation during a 9-year period, both in hospital and during follow-up, at Children's Hospital in Boston.
PATIENTS AND METHODS
Background
Between January 1983 and January 1, 1992, 470 patients have undergone an arterial switch. The first arterial switch in this institution was performed on January 20, 1983. 1 Previous studies from our institution have reported the results in the first 49 survivors of a primary arterial switch for TGA with intact ventricular septum (IVS), 8,9 the first 62 patients undergoing an arterial switch with a coexisting ventricular septal defect (VSD) 18 and the first 26 patients undergoing a rapid, two-stage arterial switch 19 ; these patients are included in this summary report.
Study group
About 60% (278/470) of the patients had an intact (or virtually intact) ventricular septum, with or without other anomalies of ventriculoarterial connection (Table I). Patients with hemodynamically insignificant VSDs (i.e., which were not surgically addressed) are considered in the TGA/IVS group. Thirty-four patients (5 total deaths) had coexisting aortic coarctation, among whom 3 had severe arch hypoplasia; 6 (0 deaths) had interrupted aortic arch; and 1 other (0 deaths) had important isolated hypoplasia of a portion of the aortic arch. Four patients (3 deaths) had dextrocardia with or without situs inversus.
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Table II). Coronary nomenclature is as previously described. 20-22 The leftward, more anterior "facing" sinus was alternatively designated as sinus 1 and the rightward, more posterior "facing" sinus as sinus 2 as previously described by Gittenberger-de Groot. 23 The usual coronary distribution for TGA and the most common variant (circumflex coronary from the right coronary artery) were seen in 83% of the patients. Unusual coronary patterns were more common in patients with TGA/VSD. 21
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21,24 Cardiac catheterization and angiography is reserved for complex cases with unusual coronary artery anatomy, 25,26 complicated ventricular septal anatomy, combined abnormalities of the aortic arch, and for cases in which the echocardiographic images are inadequate.
A prostaglandin E1 infusion (0.05 to 0.1 µg/kg per minute) is generally used to maintain ductal patency until balloon atrial septostomy is performed, 27,28 at which point the infusion is discontinued if the arterial saturation is acceptable (i.e., >70%). Balloon atrial septostomy was initially performed in all cases by means of fluoroscopic guidance, but recent success with bedside echocardiographic guidance has been encouraging. 29-31
Surgical and anesthetic management
The surgical techniques and perfusion methods that have evolved over the study period are reported in detail elsewhere. 32,33 All operations were performed through a median sternotomy incision, and most (96%) included a period, varying between 3 and 113 minutes (median 43 minutes) of profoundly hypothermic total circulatory arrest (Fig. 2). After initiation of cardiopulmonary bypass, the ductus arteriosus is divided and the pulmonary arteries are extensively mobilized into the hila of the right and left lung. The great arteries are transected in a manner that allows direct reanastomosis of the distal aortic segment to the proximal pulmonary artery (neoaorta) and the distal pulmonary artery to the neopulmonary root. The pulmonary artery is usually transected near its bifurcation. Transfer of the coronary arteries to the neoaortic root is facilitated by their excision from the aortic sinus with a cuff of adjacent aortic wall. The proximal neoaortic root is connected to the distal aorta by an end-to-end anastomosis; the innovative maneuver described by Lecompte and associates 34 passes the previously anterior aorta behind the bifurcation of the pulmonary artery. The coronary artery "donor sites" are patched with one or two 0.6% glutaraldehyde-treated pericardial patches. Finally, the distal pulmonary artery is directly anastomosed to the neopulmonary root. In cases of side-by-side great arteries, the distal incision in the main pulmonary artery may be partially closed, with extension of the incision rightward into the origin of the right pulmonary artery; this maneuver allows direct connection without tension on the neopulmonary root or distal pulmonary arteries.
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Postoperative care
Since about 1985, neuromuscular blockade and continuous narcotic sedation with fentanyl (10 to 15 micrograms/kg per minute) have been routinely continued for at least the first 24 hours after the operation; the anesthetic period is prolonged further if there has been delayed sternal closure or if there is hemodynamic instability. 28 Monitoring includes a standard surface electrocardiogram, pulse oximetry, arterial line, and transthoracically placed right and left atrial and (in most cases with TGA/VSD) pulmonary arterial catheters. Temporary ventricular wires are placed in all patients; most have temporary atrial wires as well.
Inotropic support is typically given as dopamine (5 to 10 micrograms/kg per minute); epinephrine (005 to 0.4 micrograms/kg per minute) is added when necessary. Amrinone lactate (5 to 10 micrograms/kg per minute) has become our second-line drug to provide a combination of inotropic support and afterload reduction. 35 Sodium nitroprusside is occasionally used for afterload reduction. Nitroglycerin and isoproterenol, frequently used in our early experience, have recently been used only in selected cases.
Follow-up
A formal cross-sectional follow-up was conducted between May 1 and September 1, 1991, for patients operated on before January 1, 1991; a similar follow-up was conducted between July 1 and September 1, 1992, for patients operated on in 1991. Among 430 patients not known to be dead, only 2 could not be traced after hospital discharge. An inquiry letter with a form was sent initially to the parents (or guardians) of each patient; when no answer was received within 3 weeks, strenuous attempts were made to locate and interrogate, by telephone, the family or other responsible persons. After these efforts, current information was still not obtained in 22 patients not known to be dead. These 22 patients were known to be alive in 1987 (n = 1), 1988 (n = 2), 1989 (n = 1), 1990 (n = 5), 1991 (n = 7), and 1992 (n = 6). The mean follow-up time for patients not known to be dead was 32.9 ± 22.7 (standard deviation) months. Median follow-up time was at least 27.2 months; the 75th and 25th percentiles were at least 14.2 and 47.4 months, respectively, and the 90th and 10th percentiles were 9.3 months and 62.1 months or longer, respectively. Details of our recommended prospective follow-up protocol, including echocardiography, cardiac catheterization, and electrophysiologic studies have been previously reported. 8,9
Data analysis
For each patient, copies of the pertinent parts of the hospital chart for all admissions, including reports of diagnostic and imaging studies, of the operations, and of any autopsy, as well as summaries of the preoperative and postoperative course, were evaluated both at Children's Hospital, Boston, and at the Data and Analysis Center at the University of Alabama in Birmingham. Concurrent data assessment was performed at both institutions, with cross-checks made to assure accuracy and completeness.
All available data concerning each patient were transferred into a computer database. From this an SAS data set was constructed, and the SAS software was used for the analysis. The analyses used the generally accepted technique of censoring incompletely traced patients after the time of last follow-up. The usual contingency tables, plots, and numeric descriptions of the cumulative frequency distributions were used for initial study of the data. Univariable analyses were used to compute the actual and risk-unadjusted prevalence of unfavorable outcome events. The Kaplan-Meier method 36 gave time-related estimates, which were considered to approximate actual values. Multivariable linear regression analyses were used to determine correlates of postoperative gradients; a P value less than 0.05 was required for a variable to be retained in the equation. The hazard function regression method 37 was used to estimate the time-related freedom and hazard function of unfavorable outcome events; when used for multivariable analysis, an iteratively determined P value of less than 0.1 was required for retention of a variable in an equation. This value, rather than the traditional 0.05, was used because of the relatively small number of patients and outcome events. All multivariable analyses were done sequentially (first, considering only patient variables; next considering patient and procedure variables; then patient, procedural, and support variables; finally, experience variables--see Appendix B); each step produced an equation, many of which are not shown.
RESULTS
Survival
Survivals at 1 month and 1, 5, and 8 years among the 470 patients were 93%, 92%, 91%, and 91%, respectively (Fig. 3, A). The hazard function for death (at any time) had a rapidly declining single phase that approached zero by 1 year after the operation (Fig. 3, B). The risk-unadjusted total mortality among patients with TGA/IVS was 7% (70% CL* 5% to 9%) and was 11% (CL 9% to 14%) in those TGA/VSD (P( 
2 ) = 0.12). The presence and/or repair of a VSD was not a risk-adjusted risk factor for death by multivariable analysis. Age at repair was not a risk-adjusted risk factor for death by multivariable analysis of all patients when only preoperatively present variables were examined. Yet older age at repair was a risk-adjusted risk factor (P = 0.08) in patients with TGA/IVS (Fig. 4).
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Table III).
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Among the support techniques, longer duration of total circulatory arrest was a risk factor for death in both a risk-unadjusted (P[logistic] = 0.0004) and a risk-adjusted sense (Fig. 6 and 
Table III).
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Table IV), as well as a strong risk-adjusted risk factor for death in the case of surgeon P (see Table III), but not in the case of any other surgeon (Fig 7).
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Early postoperative complications in the 440 hospital survivors included reoperations for bleeding (n = 3), resection of obstructive muscle bundles in the right ventricular outflow tract (n = 1), primary closure of VSD (thought preoperatively to be "small", n = 1), residual VSD (n = 1), residual atrial septal defect (n = 1) and interventional catheterizations for device closure of a residual VSD (n = 1), device closure of residual atrial septal defect (n = 1), and balloon valvuloplasty of neoaortic valve stenosis (n = 1) One patient with severe left ventricular dysfunction (with TGA/IVS repaired at 2 months of age with 75% systemic left ventricular pressure) received postoperative extracorporeal life support for 5 days and survived.
Sternal closure was delayed in 26 (5.9%) patients, usually in the cardiac intensive care unit, at a median of 3 days after the arterial switch. Clinical seizures were detected in 18 (4%) patients (though this almost certainly underestimates the incidence of electroencephalographic seizures). 33 Additional postoperative complications included diaphragm paresis (n = 9, none received diaphragm plication), chylothorax (n = 5), sepsis (n = 3), myocardial infarction (n = 2), and mediastinitis (n = 2). Shortly after discharge, pyloric stenosis was diagnosed in 3 patients and hypothyroidism in 2.
Supraventricular tachycardia was seen in 29 patients In 14 patients the supraventricular tachycardia was sustained and necessitated therapy (either medical or overdrive atrial pacing). In addition, 10 patients had hemodynamically significant junctional ectopic tachycardia and 10 had ventricular tachycardia, all of whom required medical intervention or cardioversion. Complete heart block was seen in 5 hospital survivors (all with TGA/VSD); all received permanent pacemakers. A detailed analysis of rhythm and conduction abnormalities in this patient population is the subject of a separate report. 38
Reintervention
Reinterventions for relief of right ventricular and/or pulmonary artery stenoses were made in 28 patients. In 24 of the 27 patients in whom the type of reintervention was known, the stenoses were in the pulmonary trunk and/or the bifurcation or proximal portions of the right and/or left pulmonary arteries or pulmonary valve. Only 3 of the 27 patients had subvalvular obstruction that resulted in an infundibular patch to reconstruct the right ventricular outflow tract.
The hazard function for reintervention for pulmonary artery or valve stenosis revealed an early phase that peaked at 9 months after operation and a constant phase for the duration of follow-up (Fig 8). Incremental risk factors (Table V) for the early phase included a rapid two-stage arterial switch and a coronary pattern with a single ostium supplying the right coronary and left anterior descending arteries, with a retropulmonary course of the circumflex artery ("inverted right and circumflex coronary arteries," p = 0.02). Incremental risk factors associated with the constant hazard phase for late reintervention included younger age at operation (p = 0.002) and surgeon Q (p = 0.03). The number of patches used to fill the coronary donor sites was not associated with either the early or constant hazard phase for reintervention.
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Table VI. Both earlier and later date of operation were associated with a higher gradient at postoperative catheterization. The date of operation effect was much stronger earlier in the study (Fig. 11). Younger age at operation was associated with a higher gradient, although this effect was minimized by 1 week of age. Surgeon Q had significantly higher gradients, and surgeon S had slightly lower gradients.
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Table VII).
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DISCUSSION
A 10-year survival of 93%, including hospital mortality, is predicted for most patients with morphologically uncomplicated TGA, with or without VSD, operated on by any surgeon in the institution (see Fig. 7). The analyses indicate, with a reasonable degree of certainty, that the survival will be even better than this for patients with more usual coronary artery patterns (see Fig. 5).
The increased risk resulting from earlier date of operation was neutralized by the end of 1985 (see Fig 7), 3 years and 56 patients into the study period. This "learning curve" suggests that overall institutional improvements occurred in the approach to these patients; after 1985 three "new" surgeons began performing the operation without a higher mortality risk than the senior surgeon.
As many institutional changes took place nearly simultaneously from 1984 to 1985, it is difficult to sort out the relative contributions of each, even with a multivariable analysis. The striking improvement that occurred in about 1985 undoubtedly resulted from multiple factors, some of which probably were not available for analysis in this study. We believe that these changes occurred in three general areas: (1) surgical technique (with increasing experience in coronary translocation in particular), (2) patient selection (elective repair at younger age in particular), and (3) perioperative care.
The inference was gradually developed during the first few years of the study that the coronary-related mortality could be at least partially neutralized by modifications in surgical technique. These include more extensive epicardial mobilization of the proximal coronary arteries, division of small conal branches that may hinder posterior mobilization to the neoaorta, and small modifications of the reimplantation site if necessary.
The increased risk of death (and neurologic complications) from long periods of hypothermic circulatory arrest were also gradually appreciated, and this also may have contributed to the lower mortality after 1985. A more in-depth assessment of the neurologic 33 and nonneurologic morbidity related to circulatory arrest is reported elsewhere 39 and is beyond the scope of this report.
The preoperative management protocols 27,28 developed and matured in the early part of the experience. For example, balloon atrial septostomy was more frequently performed at the bedside, with the elimination of angiographic studies, toward the latter part of the study period. We recommend balloon atrial septostomy in all patients without a large, native atrial septal defect. An adequate atrial communication allows for (1) improved intercirculatory mixing and oxygen delivery before the operation, (2) the ability (in most cases) to discontinue prostaglandin infusion, thereby limiting total body edema and maintaining tissue integrity, (3) more "elective" timing of the arterial switch, during which time nutrition may be instituted and other potential neonatal problems (e.g., sepsis) may be ruled out, and (4) adequate decompression of the left atrium during cardiopulmonary bypass via a single venous cannula placed in the right atrium.
Elective repair was performed in the first 1 to 2 weeks of life whenever possible. Although earlier in the experience some patients (usually with TGA/VSD) underwent elective repair in later infancy, at the current time the arterial switch is recommended during the same admission as the diagnosis is made, even in the presence of a large VSD with adequate systemic oxygen saturation (see Fig. 4). The newborn infant with TGA/IVS should be repaired within the first weeks of life while the left ventricle is still capable of systemic work. Early, neonatal repair is also performed for the patient with TGA/VSD. In TGA/VSD, early repair is recommended to minimize the adverse systemic effects of prolonged cyanosis or congestive heart failure, limit the likelihood of spontaneous closure of VSDs (which would result in a low-pressure left ventricle that may be "unprepared" for systemic work), and to decrease the likelihood of pulmonary vascular disease.
The intraoperative and postoperative management protocols also appeared to have matured by late 1985 and thereafter were applied routinely. 28 Extension of the anesthetic period through the first postoperative night has been previously shown to decrease mortality and morbidity. 40 The use of extensive intracardiac monitoring allowsearly identification and treatment of low cardiac output, 19,28,39 with more rational use of inotropic agents and afterload reduction.
Supravalvular pulmonary stenosis is widely recognized as the most frequent complication of the arterial switch. In our institution, the risk-adjusted prevalence of postoperative right ventricular outflow tract obstruction also decreased after about 1984 (see Fig. 11) and was probably the result of a gradual appreciation of the need to avoid tension on the anastomosis of the neopulmonary artery. This led to more extensive mobilization of the distal pulmonary arteries and the use of more generous pericardial patches (single or double), not only for filling in the defects left by coronary explanation, but also to add length to the proximal neopulmonary root.
Although there appeared to be an adverse effect of later date of operation on postoperative gradients, this is probably due to catheterization selection bias. The majority (> 90%) of patients operated on early in the study underwent an "elective" postoperative catheterization, 9 whereas less than half of the hospital survivors were catheterized in the later part of the study period. Those studied later in the study period were likely to have had more concerning noninvasive (examination or Doppler echocardiographic) findings.
A variety of mechanisms have been implicated in the cause of supravalvular pulmonary stenosis. Most of the increase in the gradient between the right ventricle and the pulmonary arteries occurs during the first year after repair, commensurate with significant somatic growth. There may be inadequate growth of the main pulmonary artery resulting in "flattening" of the reconstructed right ventricular outflow tract. 9 Circumferential narrowing at the suture line may cause discrete supravalvular narrowing. Ductal tissue present in the origin of the left pulmonary artery may later constrict, causing a "coarctation" of the left pulmonary artery. In side-by-side great arteries when the Lecompte maneuver is used, the left pulmonary artery may "bowstring" over the neoaorta, causing significant asymmetry of blood flow. 27
In this report, we have identified a particular coronary pattern (inverted right and circumflex coronary arteries) that is related to a higher incidence of reintervention for supravalvular pulmonary stenosis in our experience. This unusual coronary distribution is present in only about 4% of patients with TGA 22 and is more frequently associated with side-by-side great arteries 21 and abnormalities of conal alignment. 41 The higher incidence of supravalvular stenosis in this group may be due to (1) smaller patches placed in the anterior coronary "donor site" to avoid compression on the translocated coronary, (2) to the additional underlying conotruncal abnormalities, or to a combination of factors.
Even with the current surgical modifications, reintervention for right ventricular outflow tract obstruction may be necessary in 5% to 10% of patients during the first year after the operation. The increase in the gradient between the right ventricle and the pulmonary arteries during the year after repair, occurring in about one fourth of patients, and the constant hazard phase for right-sided reintervention emphasize the need for continued long-term observation and concern.
Treatment for supravalvular pulmonary stenosis includes both reoperation and balloon angioplasty. Balloon angioplasty has been less successful in these types of lesions than have other types of right ventricular outflow tract obstruction. 42-44 Discrete branch pulmonary artery stenoses or circumferential stenoses in the main pulmonary artery are more likely to be relieved with balloon angioplasty, as compared with obstruction resulting from diffuse hypoplasia of the main pulmonary artery trunk. 44 Surgical techniques 9,32,45-48 for relieving supravalvular pulmonary stenosis usually involve patch angioplasty; the patch may occasionally need to extend through the neopulmonary anulus into the infundibulum. In these cases, it is crucial that the course of the right coronary artery be known before the operation, because the right coronary may be difficult to identify during the operation because of adhesions. If the right coronary artery has an anterior course to reach the right atrioventricular groove, transannular patching is contraindicated and a conduit may be necessary.
In contrast to postoperative right ventricular outflow tract obstruction, left ventricular outflow tract obstruction is rare. Supravalvular aortic stenosis is extremely uncommon, perhaps because of the limited tension on the suture line. When left ventricular outflow tract obstruction occurs, it is usually related to the presence of preoperative obstruction (arch hypoplasia or a restrictive VSD in double-outlet right ventricle) and is usually recognized and treated relatively early after repair.
SUMMARY
A continuation of the application of the arterial switch operation to patients with transposition of the great arteries with or without VSD, as early in life as is possible, is indicated.
This manuscript represents the combined work of many individuals. We thank the medical and nursing staffs of the Cardiovascular Program at Children's Hospital in Boston for their care of these patients; Drs. Paul R. Hickey, David L. Wessel, Redmond P. Burke, and Steven D. Colan for their comments and suggestions for the final manuscript; Erin Carroll, Amy Itzkovitz, Cheryl King, Barbara Lock, and Amy Walsh, RN, for help with data management at Children's Hospital; Mary Lynn Clark and Rob Brown at University of Alabama, Birmingham, for their tireless efforts during the cross-sectional follow-up and data analysis; and Debbie Nuby, Matthew Martin, and Tannis Bolton for help with data acquisition, management, and manuscript preparation.
Appendix: DISCUSSION
Dr. Jan M. Quaegebeur (New York, N.Y.).
I agree that the arterial switch operation can be applied to different subsets of TGA very early in life and that the risk of death is very low. Since my arrival at Columbia Presbyterian Hospital, we have performed 100 consecutive arterial switch operations with a mortality rate of 1%. In many ways, our experience with this operation parallels the Boston experience. On several occasions did we conduct the same type of analysis that Dr. Wernovsky presented here, and several risk factors are similar--the older age at operation and the early date of operation, for example. However, in our experience the coronary arterial distribution pattern, especially the retropulmonary course of the left coronary artery, never was an incremental risk factor. Instead, intramural coronary artery was the only risk factor for death after the arterial switch operation, and the only patient dying in our recent experience had a single coronary ostium in sinus 2, with an intramural course of the right and left coronary arteries. I would like to ask you by which mechanism retropulmonary course of the left coronary artery increases the risk of the operation, because the reimplantation technique for this particular coronary anatomy is quite standardized. I have never understood this difference between our experiences.
Dr. Wernovsky.
Thank you, Dr. Quaegebeur. I do not understand the difference either. As you know, this is a rare type of coronary variant, occurring in only 3% to 5% of the total experience. I suspect that the increased risk has to do with angulation of the retropulmonary course of the left coronary artery, especially in patients with a single coronary ostium. The left coronary artery must make a 180-degree turn and tension on the right coronary may be a problem. Exactly why in any individual experience certain patterns fall out as risk factors is unclear to me as well. Your study, as well as ours, emphasizes the importance of a critical analysis of one's results, to identify risk factors and ideally modify their effects.
Dr. Carl Lewis Backer (Chicago, Ill.).
These are great results, Dr. Wernovsky. Was there a change in the technique of right ventricular outflow tract reconstruction during the reported time period? It sounds as if your results with this aspect of the arterial switch have improved considerably since the original series of 11 infants.
Dr. Wernovsky.
Yes, I think that the most important technical change after the early experience was the recognition of the importance of avoiding tension on the pulmonary anastomosis. My surgical colleagues tell me that extensive dissection and mobilization of the distal pulmonary arteries well out into the hilum, as well as placement of a generous pericardial patch to add length to the proximal neopulmonary artery, were the two major changes that were done after the early experience. At the current time, it appears that patient-related anatomic factors are responsible for the small but continued risk of late supravalvular pulmonary stenosis.
Appendix B.
Patient variables
Demographic.
Age at operation, gender, birth weight, height, weight, and body surface area at arterial switch.
Previous procedures
Previous balloon septostomy, use of prostaglandin E1, pulmonary artery banding, "rapid" pulmonary artery banding, "one-stage" repair (actual or with short banding), duration of banding, previous repair of aortic arch abnormality.
Morphologic variables (other than coronary pattern).
Situs, isolated dextrocardia, mesocardia, TGA/IVS, TGA/VSD (including double-outlet left ventricle, double-outlet right ventricle, and the Taussig-Bing anomaly), number of VSDs, interruption of the aortic arch, coarctation of the aorta, hypoplasia (moderate or severe) of the aortic arch, left ventricular outflow tract obstruction (dynamic, "flow-related," anatomic [pulmonary valve stenosis, tricuspid valve excrescences, other]), severity of left ventricular outflow tract obstruction, aortic valve stenosis, right ventricular outflow tract obstruction, juxtaposition of the atrial appendages, patent ductus arteriosus (and its size), position of the great arteries.
Coronary artery pattern
Individual patterns (as previously reported) 22 and grouped patterns: (1) all coronary arteries arising from a single sinus, (2) all variations of intramural coronary arteries, (3) patterns with a retropulmonary course of the entire left coronary system (1-;2LadCxR* and 1R;2LadCx), (4) patterns with a retropulmonary course of the circumflex only (1Lad;2CxR* and 1RLad;2Cx), (5) any left coronary supply from the posterior facing sinus.
Procedural variables.
Atrial septal defect repair, VSD repair, revision of coronary anastomosis, left ventricular outflow procedure, right ventricular outflow procedure, augmentation of the aortic arch, Lecompte maneuver, Lecompte maneuver in side-by-side great arteries, coronary donor site repair technique (one versus two patches [or one patch in cases of single coronary artery]), coarctation repair.
Support technique variables.
Use and duration of circulatory arrest and myocardial ischemic time (total elapsed time of cardiopulmonary bypass and total support time [bypass time plus circulatory arrest time] were analyzed but not permitted to enter multivariable analyses of death).
Experience variables.
Date of operation, sequence number of arterial switch, surgeon, temporal experience, and sequence number for each surgeon.
Postoperative variables.
Use of neuromuscular blockade/continuous narcotic sedation.*R, Right coronary artery; Lad, left anterior descending; Cx, circumflex.
Footnotes
Read at the Seventy-fourth Annual Meeting of The American Association for Thoracic Surgery, New York, N.Y., April 24-27, 1994. 
*R, Right coronary artery; Lad, left anterior descending; Cx, circumflex.
References
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G. E. Sarris, A. C. Chatzis, N. M. Giannopoulos, G. Kirvassilis, H. Berggren, M. Hazekamp, T. Carrel, J. V. Comas, D. Di Carlo, W. Daenen, et al. The arterial switch operation in Europe for transposition of the great arteries: A multi-institutional study from the European Congenital Heart Surgeons Association. J. Thorac. Cardiovasc. Surg., September 1, 2006; 132(3): 633 - 639. [Abstract] [Full Text] [PDF]
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 J. Losay, A. Touchot, A. Capderou, J.-D. Piot, E. Belli, C. Planche, and A. Serraf Aortic Valve Regurgitation After Arterial Switch Operation for Transposition of the Great Arteries: Incidence, Risk Factors, and Outcome J. Am. Coll. Cardiol., May 16, 2006; 47(10): 2057 - 2062. [Abstract] [Full Text] [PDF]
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A. A. Alghamdi, B. W. McCrindle, and G. S. Van Arsdell Physiologic Versus Anatomic Repair of Congenitally Corrected Transposition of the Great Arteries: Meta-Analysis of Individual Patient Data Ann. Thorac. Surg., April 1, 2006; 81(4): 1529 - 1535. [Abstract] [Full Text] [PDF]
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H. Y. Hwang, W.-H. Kim, J. G. Kwak, J. R. Lee, Y. J. Kim, J. R. Rho, E. J. Bae, and C. I. Noh Mid-term follow-up of neoaortic regurgitation after the arterial switch operation for transposition of the great arteries Eur. J. Cardiothorac. Surg., February 1, 2006; 29(2): 162 - 167. [Abstract] [Full Text] [PDF]
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Y. H. Chang, S. C. Sung, H. D. Lee, S. Kim, J. S. Woo, and Y. S. Lee Coronary Reimplantation After Neoaortic Reconstruction Can Yield Better Result in Arterial Switch Operation: Comparison With Open Trap Door Technique Ann. Thorac. Surg., November 1, 2005; 80(5): 1634 - 1640. [Abstract] [Full Text] [PDF]
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C. Kampmann, W. Kuroczynski, H. Trubel, M. Knuf, M. Schneider, and M. K. Heinemann Late Results After PTCA for Coronary Stenosis After the Arterial Switch Procedure for Transposition of the Great Arteries Ann. Thorac. Surg., November 1, 2005; 80(5): 1641 - 1646. [Abstract] [Full Text] [PDF]
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M. Pocar, E. Villa, A. Degandt, P. Mauriat, P. Pouard, and P. R. Vouhe Long-Term Results After Primary One-Stage Repair of Transposition of the Great Arteries and Aortic Arch Obstruction J. Am. Coll. Cardiol., October 4, 2005; 46(7): 1331 - 1338. [Abstract] [Full Text] [PDF]
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S. C. Sung, Y. H. Chang, H. D. Lee, S. Kim, J. S. Woo, and Y. S. Lee Arterial Switch Operation for Transposition of the Great Arteries With Coronary Arteries From a Single Aortic Sinus Ann. Thorac. Surg., August 1, 2005; 80(2): 636 - 641. [Abstract] [Full Text] [PDF]
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S. Jaillard, E. Belli, T. Rakza, B. Larrue, E. Magnenant, C. Rey, and L. Storme Preoperative ECMO in Transposition of the Great Arteries With Persistent Pulmonary Hypertension Ann. Thorac. Surg., June 1, 2005; 79(6): 2155 - 2158. [Abstract] [Full Text] [PDF]
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 S. G Raja, A. Shauq, and M. Kaarne Outcomes after Arterial Switch Operation for Simple Transposition Asian Cardiovasc Thorac Ann, June 1, 2005; 13(2): 190 - 198. [Abstract] [Full Text] [PDF]
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 N. Kang, M. R. de Leval, M. Elliott, V. Tsang, E. Kocyildirim, I. Sehic, J. Foran, and I. Sullivan Extending the Boundaries of the Primary Arterial Switch Operation in Patients With Transposition of the Great Arteries and Intact Ventricular Septum Circulation, September 14, 2004; 110(11_suppl_1): II-123 - II-127. [Abstract] [Full Text] [PDF]
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M. L. Schwartz, K. Gauvreau, P. del Nido, J. E. Mayer, and S. D. Colan Long-Term Predictors of Aortic Root Dilation and Aortic Regurgitation After Arterial Switch Operation Circulation, September 14, 2004; 110(11_suppl_1): II-128 - II-132. [Abstract] [Full Text] [PDF]
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S. Mohammadi, A. Serraf, E. Belli, B. Aupecle, A. Capderou, F. Lacour-Gayet, I. Martinovic, D. Piot, A. Touchot, J. Losay, et al. Left-sided lesions after anatomic repair of transposition of the great arteries, ventricular septal defect, and coarctation: Surgical factors J. Thorac. Cardiovasc. Surg., July 1, 2004; 128(1): 44 - 52. [Abstract] [Full Text] [PDF]
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B. W. Duncan, N. C. Poirier, R. B. B. Mee, J. J. Drummond-Webb, A. Qureshi, C. I. Mesia, J. A. Graney, C. L. Malek, and L. A. Latson Selective timing for the arterial switch operation Ann. Thorac. Surg., May 1, 2004; 77(5): 1691 - 1696. [Abstract] [Full Text] [PDF]
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J. Wetter, N. Sinzobahamvya, H. C. Blaschczok, M.-Y. Cho, A. M. Brecher, L. M. Gravinghoff, and A. E. Urban Results of arterial switch operation for primary total correction of the Taussig-Bing anomaly Ann. Thorac. Surg., January 1, 2004; 77(1): 41 - 46. [Abstract] [Full Text] [PDF]
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A. Legendre, J. Losay, A. Touchot-Kone, A. Serraf, E. Belli, J. D. Piot, V. Lambert, A. Capderou, and C. Planche Coronary Events After Arterial Switch Operation for Transposition of the Great Arteries Circulation, September 9, 2003; 108(90101): II-186 - 190. [Abstract] [Full Text] [PDF]
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V. Hraska, T. Podnar, P. Kunovsky, L. Kovacikova, M. Kaldararova, E. Horvathova, J. Masura, and J.E. Mayer Jr. Is a learning curve for arterial switch operation in small countries still acceptable? Model for cooperation in Europe Eur. J. Cardiothorac. Surg., September 1, 2003; 24(3): 352 - 357. [Abstract] [Full Text] [PDF]
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H. H. Hovels-Gurich, M.-C. Seghaye, Q. Ma, M. Miskova, R. Minkenberg, B. J. Messmer, and G. von Bernuth Long-term results of cardiac and general health status in children after neonatal arterial switch operation Ann. Thorac. Surg., March 1, 2003; 75(3): 935 - 943. [Abstract] [Full Text] [PDF]
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E. Prifti, A. Crucean, M. Bonacchi, M. Bernabei, B. Murzi, S. V. Luisi, and V. Vanini Early and long term outcome of the arterial switch operation for transposition of the great arteries: predictors and functional evaluation Eur. J. Cardiothorac. Surg., December 1, 2002; 22(6): 864 - 873. [Abstract] [Full Text] [PDF]
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H. Imura, P. Modi, A. Pawade, A. J. Parry, M.-S. Suleiman, G. D. Angelini, and M. Caputo Cardiac troponin I in neonates undergoing the arterial switch operation Ann. Thorac. Surg., December 1, 2002; 74(6): 1998 - 2002. [Abstract] [Full Text] [PDF]
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 H H Hovels-Gurich, K Konrad, M Wiesner, R Minkenberg, B Herpertz-Dahlmann, B J Messmer, and G von Bernuth Long term behavioural outcome after neonatal arterial switch operation for transposition of the great arteries Arch. Dis. Child., December 1, 2002; 87(6): 506 - 510. [Abstract] [Full Text] [PDF]
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S. K. Pasquali, V. Hasselblad, J. S. Li, D. F. Kong, and S. P. Sanders Coronary Artery Pattern and Outcome of Arterial Switch Operation for Transposition of the Great Arteries: A Meta-Analysis Circulation, November 12, 2002; 106(20): 2575 - 2580. [Abstract] [Full Text] [PDF]
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P. Massoudy, A. Baltalarli, M. R. de Leval, A. Cook, U. Neudorf, G. Derrick, K. P. McCarthy, and R. H. Anderson Anatomic Variability in Coronary Arterial Distribution With Regard to the Arterial Switch Procedure Circulation, October 8, 2002; 106(15): 1980 - 1984. [Abstract] [Full Text] [PDF]
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P. A. Hutter, D. L. Kreb, S. F. Mantel, J. F. Hitchcock, E. J. Meijboom, and G. B. W. E. Bennink Twenty-five years' experience with the arterial switch operation J. Thorac. Cardiovasc. Surg., October 1, 2002; 124(4): 790 - 797. [Abstract] [Full Text] [PDF]
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A. M. Scheule, D. Zurakowski, E. D. Blume, C. Stamm, P. J. del Nido, J. E. Mayer Jr, and R. A. Jonas Arterial switch operation with a single coronary artery J. Thorac. Cardiovasc. Surg., June 1, 2002; 123(6): 1164 - 1172. [Abstract] [Full Text] [PDF]
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S. K. Gandhi, F. A. Pigula, and R. D. Siewers Successful late reintervention after the arterial switch procedure Ann. Thorac. Surg., January 1, 2002; 73(1): 88 - 95. [Abstract] [Full Text] [PDF]
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R. Lange, C. Schreiber, T. Gunther, M. Wottke, F. Haas, F. Meisner, J. Hess, and K. Holper Results of biventricular repair of congenital cardiac malformations: definitive corrective surgery? Eur. J. Cardiothorac. Surg., December 1, 2001; 20(6): 1207 - 1213. [Abstract] [Full Text] [PDF]
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J. Wetter, E. Belli, N. Sinzobahamvya, H. C. Blaschzok, A. M. Brecher, and A. E. Urban Transposition of the great arteries associated with ventricular septal defect: surgical results and long-term outcome Eur. J. Cardiothorac. Surg., October 1, 2001; 20(4): 816 - 823. [Abstract] [Full Text] [PDF]
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J. Losay, A. Touchot, A. Serraf, A. Litvinova, V. Lambert, J. D. Piot, F. Lacour-Gayet, A. Capderou, and C. Planche Late Outcome After Arterial Switch Operation for Transposition of the Great Arteries Circulation, September 18, 2001; 104 (2009): I-121 - I-126. [Abstract] [Full Text] [PDF]
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J. W. Brown, H. J. Park, and M. W. Turrentine Arterial switch operation: factors impacting survival in the current era Ann. Thorac. Surg., June 1, 2001; 71(6): 1978 - 1984. [Abstract] [Full Text] [PDF]
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R. S. Boneva, L. D. Botto, C. A. Moore, Q. Yang, A. Correa, and J. D. Erickson Mortality Associated With Congenital Heart Defects in the United States : Trends and Racial Disparities, 1979-1997 Circulation, May 15, 2001; 103(19): 2376 - 2381. [Abstract] [Full Text] [PDF]
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Z. Amin, D. B. McElhinney, P. Moore, V. M. Reddy, and F. L. Hanley Coronary arterial size late after the atrial inversion procedure for transposition of the great arteries: Implications for the arterial switch operation J. Thorac. Cardiovasc. Surg., December 1, 2000; 120(6): 1047 - 1052. [Abstract] [Full Text] [PDF]
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C. Rickers, K. Sasse, R. Buchert, H. Stern, J.o. van den Hoff, M. Lubeck, and J. Weil Myocardial viability assessed by positron emission tomography in infants and children after the arterial switch operation and suspected infarction J. Am. Coll. Cardiol., November 1, 2000; 36(5): 1676 - 1683. [Abstract] [Full Text] [PDF]
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S. H. Daebritz, G. Nollert, J. S. Sachweh, W. Engelhardt, G. von Bernuth, and B. J. Messmer Anatomical risk factors for mortality and cardiac morbidity after arterial switch operation Ann. Thorac. Surg., June 1, 2000; 69(6): 1880 - 1886. [Abstract] [Full Text] [PDF]
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 L. C. Erickson, P. H. Wise, E. F. Cook, A. Beiser, and J. W. Newburger The Impact of Managed Care Insurance on Use of Lower-Mortality Hospitals by Children Undergoing Cardiac Surgery in California Pediatrics, June 1, 2000; 105(6): 1271 - 1278. [Abstract] [Full Text]
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M. Jahangiri, D. Zurakowski, J. E. Mayer, P. J. del Nido, and R. A. Jonas REPAIR OF THE TRUNCAL VALVE AND ASSOCIATED INTERRUPTED ARCH IN NEONATES WITH TRUNCUS ARTERIOSUS J. Thorac. Cardiovasc. Surg., March 1, 2000; 119(3): 508 - 514. [Abstract] [Full Text] [PDF]
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 M. E. Brickner, L. D. Hillis, and R. A. Lange Congenital Heart Disease in Adults- Second of Two Parts N. Engl. J. Med., February 3, 2000; 342(5): 334 - 342. [Full Text] [PDF]
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V. Shukla, R. M. Freedom, and M. D. Black Single coronary artery and complete transposition of the great arteries: a technical challenge resolved? Ann. Thorac. Surg., February 1, 2000; 69(2): 568 - 571. [Abstract] [Full Text] [PDF]
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F. Haas, M. Wottke, H. Poppert, and H. Meisner Long-term survival and functional follow-up in patients after the arterial switch operation Ann. Thorac. Surg., November 1, 1999; 68(5): 1692 - 1697. [Abstract] [Full Text] [PDF]
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E. Belli, F. Lacour-Gayet, A. Serraf, A. M. Alkhulaifi, A. Touchot, J. Bruniaux, and C. Planche Surgical management of transposition of great arteries associated with multiple ventricular septal defects Eur. J. Cardiothorac. Surg., July 1, 1999; 16(1): 14 - 20. [Abstract] [Full Text] [PDF]
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E. D. Blume, K. Altmann, J. E. Mayer, S. D. Colan, K. Gauvreau, and T. Geva Evolution of risk factors influencing early mortality of the arterial switch operation J. Am. Coll. Cardiol., May 1, 1999; 33(6): 1702 - 1709. [Abstract] [Full Text] [PDF]
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Y. V. Maeno, S. A. Kamenir, B. Sinclair, M. E. van der Velde, J. F. Smallhorn, and L. K. Hornberger Prenatal Features of Ductus Arteriosus Constriction and Restrictive Foramen Ovale in d-Transposition of the Great Arteries Circulation, March 9, 1999; 99(9): 1209 - 1214. [Abstract] [Full Text] [PDF]
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M. Masuda, H. Kado, Y. Shiokawa, K. Fukae, Y. Kanegae, Y. Kawachi, S. Morita, and H. Yasui Clinical results of arterial switch operation for double-outlet right ventricle with subpulmonary VSD Eur. J. Cardiothorac. Surg., March 1, 1999; 15(3): 283 - 288. [Abstract] [Full Text] [PDF]
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A. J. Parry, M. Thurm, and F. L. Hanley The use of `pericardial hoods' for maintaining exact coronary artery geometry in the arterial switch operation with complex coronary anatomy Eur. J. Cardiothorac. Surg., February 1, 1999; 15(2): 159 - 165. [Abstract] [Full Text] [PDF]
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W. Tworetzky, D. B. McElhinney, M. M. Brook, V. Mohan Reddy, F. L. Hanley, and N. H. Silverman Echocardiographic diagnosis alone for the complete repair of major congenital heart defects J. Am. Coll. Cardiol., January 1, 1999; 33(1): 228 - 233. [Abstract] [Full Text] [PDF]
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J. Soongswang, I. Adatia, C. Newman, J. F. Smallhorn, W. G. Williams, and R. M. Freedom Mortality in potential arterial switch candidates with transposition of the great arteries J. Am. Coll. Cardiol., September 1, 1998; 32(3): 753 - 757. [Abstract] [Full Text] [PDF]
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D. B. McElhinney MS, V. M. Reddy, G. P. Reddy, C. B. Higgins, and F. L. Hanley Esophageal Compression by the Aorta After Arterial Switch Ann. Thorac. Surg., January 1, 1998; 65(1): 246 - 246. [Abstract] [Full Text] [PDF]
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W. G. Williams, J. M. Quaegebeur, J. W. Kirklin, and E. H. Blackstone OUTFLOW OBSTRUCTION AFTER THE ARTERIAL SWITCH OPERATION: A MULTIINSTITUTIONAL STUDY J. Thorac. Cardiovasc. Surg., December 1, 1997; 114(6): 975 - 990. [Abstract] [Full Text]
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S. Kleinert, T. Sano, R.G. Weintraub, R.B.B. Mee, T.R. Karl, and J.L. Wilkinson Anatomic Features and Surgical Strategies in Double-Outlet Right Ventricle Circulation, August 19, 1997; 96(4): 1233 - 1239. [Abstract] [Full Text]
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H. Yaku, G. R. Nunn, and G. F. Sholler Internal Mammary Artery Grafting in a Neonate for Coronary Hypoperfusion After Arterial Switch Ann. Thorac. Surg., August 1, 1997; 64(2): 543 - 544. [Abstract] [Full Text]
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J. L. Myers Transposition of the Great Arteries Ann. Thorac. Surg., March 1, 1997; 63(3): 895 - 898. [Full Text]
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K. Bando, M. W. Turrentine, T. G. Sharp, Y. Sekine, T. X. Aufiero, K. Sun, E. Sekine, and J. W. Brown PULMONARY HYPERTENSION AFTER OPERATIONS FOR CONGENITAL HEART DISEASE: ANALYSIS OF RISK FACTORS AND MANAGEMENT J. Thorac. Cardiovasc. Surg., December 1, 1996; 112(6): 1600 - 1609. [Abstract] [Full Text]
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G. B. Luciani, A. C. Chang, and V. A. Starnes Surgical Repair of Transposition of the Great Arteries in Neonates With Persistent Pulmonary Hypertension Ann. Thorac. Surg., March 1, 1996; 61(3): 800 - 804. [Abstract] [Full Text]
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G. Wernovsky, D. Wypij, R. A. Jonas, J. E. Mayer Jr, F. L. Hanley, P. R. Hickey, A. Z. Walsh, A. C. Chang, A. R. Castaneda, J. W. Newburger, et al. Postoperative Course and Hemodynamic Profile After the Arterial Switch Operation in Neonates and Infants : A Comparison of Low-Flow Cardiopulmonary Bypass and Circulatory Arrest Circulation, October 15, 1995; 92(8): 2226 - 2235. [Abstract] [Full Text]
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L. A. Rhodes, G. Wernovsky, J. F. Keane, J. E. Mayer Jr., A. Shuren, C. Dindy, S. D. Colan, and E. P. Walsh Arrhythmias and intracardiac conduction after the arterial switch operation J. Thorac. Cardiovasc. Surg., February 1, 1995; 109(2): 303 - 310. [Abstract] [Full Text]
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