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J Thorac Cardiovasc Surg 2009;137:354
© 2009 The American Association for Thoracic Surgery
Invited Commentary |
First, in your title you mention freedom from reoperation, but what about other reinterventions? I'm sure that the cardiologists in Germany must be performing percutaneous interventions, just as they are here in North America. How many of the patients in the arterial switch group had balloon or stent interventions, or something of that nature?
Dr Hörer. For the arterial switch group, I do not know the exact number, but so far not more than 10 patients have undergone reintervention. Our data are limited to reoperation, not reintervention.
Dr Wells. I bring this up because in the long-term follow-up study conducted by the Congenital Heart Surgeons Society, there were a significant number of reinterventions in addition to the reoperations, particularly in the arterial switch group.
Second, did you test for the occurrence of reoperation against time? In other words, if you looked at the group operated on early as opposed to late in the experience, was there a difference in the need for reoperation?
Dr Hörer. Yes, there was a difference. But we tested this only in the overall group, including all 913 patients. We found that a more recent operation was an independent risk factor for reoperation. The reason is that the patients who underwent the arterial switch operation were operated on within the last 15 years, as opposed to the patients who underwent the atrial switch operation mainly between 1975 and 1985. Patients who underwent the arterial switch operation underwent reoperation more frequently, mainly for pulmonary stenosis. I think that we have overcome this problem, in part, because now we use a trouser-shaped patch to reconstruct the pulmonary arteries. We have not seen those early pulmonary stenoses within the last 5 years of our experience with the arterial switch operation.
Dr Wells. I suggest that within the arterial switch group itself you test for year of operation to see whether the incidence of reoperation went down as the team gained greater experience with the procedure. Another thing that comes out in your data is that there were a fair number of late reoperations. If I recall your actuarial curve for freedom from reoperation, the freedom went from 87% down to around 70% between 10 years and 20 years. What were these late reoperations?
Dr Hörer. The late reoperations in the arterial switch group are related to neoaortic insufficiency. The rate of reoperation for neoaortic insufficiency, however, is still below 3%. In the atrial switch group, we saw late reoperations in the Mustard group for baffle stenosis but mainly for systemic ventricular dysfunction. These operations included tricuspid valve repair, banding of the pulmonary artery, and conversion to the arterial switch operation.
Dr Wells. In the arterial switch group, among those with a late reoperation for neoaortic insufficiency was there a correlation with VSD? If so was the VSD repaired through the neoaortic valve in most cases?
Dr Hörer. There was no correlation in multivariate analysis. There were correlations in univariate analysis with LVOTO, VSD, previous banding, and the diagnosis of Taussig–Bing. There was, however, no correlation with presence of a VSD in multivariate analysis. VSD closure was not performed through the neoaortic valve.
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