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.
Abstract： Objective?To summarize the clinical experience，surgical technique and indication of coronary artery implantation with double flap extension technique in arterial switch operations （ASO） in D-transposition of the great arteries （D-TGA） and Taussig-Bing anomalies.?Methods?From January 2006 to June 2011， 21 patients （13 males and 8 females；age 110.0±84.5 d；weight 5.4±4.2 kg） with D-TGA or Taussig-Bing anomalies associated with complex coronary artery malformations underwent ASO with double flap extension technique for coronary artery implantation in Shanghai Children’s Medical Center affiliated to Medical College of Shanghai Jiaotong University. All the patients had a main trunk of right coronary artery or dilated right ventricular conus branch originated from the left or right aortic sinus，with abnormal course of anterior looping to the aorta. The double flap extension technique was described as followed： a long coronary button was excised as a flap from the aorta; another pedicle flap on the pulmonary artery （neoaorta） was cut to extend to the button of coronary artery with an equal distance; the side edges of the flap and the button were sutured together to form a lengthened coronary artery tube.?Results?No operative death occurred in hospital. The postoperative duration of mechanical ventilation was 101.6±53.6 h. The duration of ICU stay was 9.5±4.9 d. Postoperatively，low cardiac output syndrome occurred in 9 cases，pulmonary hypertension crisis in 2 cases，pneumonia in 6 cases，and acute kidney failure in 2 cases. Eleven patients underwent delayed sternum closure. All the patients were discharged after proper treatment. Follow-up was complete in 17 cases. The duration of follow-up was 2 months to 5 years. Growth and development were significantly improved in all the patients during follow-up. No patient had ischemic ECG changes. One patient underwent reoperation for supravalvular pulmonary stenosis 2 years after ASO.?Conclusion?Double flap extension technique for coronary implantation in complicated ASO can significantly decrease postoperative death due to coronary artery malformations，especially for patients who have two-stage ASO and patients whose main trunk of right coronary artery or dilated right ventricular conus branch originates from the left or right aortic sinus with abnormal course of anterior looping to the aorta.
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.
ObjectiveTo evaluate clinical results of left ventricular retraining followed by double switch operation (DSO) for patients with congenitally corrected transposition of the great arteries (CCTGA) and a deconditioned morphologically left ventricle (mLV). MethodsClinical data of 14 patients with CCTGA and a deconditioned mLV who underwent surgical therapy in Fu Wai Hospital from May 2005 to May 2011 were retrospectively analyzed. There were 8 male and 6 female patients with their age of 2.5-72.0 (34.4±24.0) months and body weight of 5.1-23.0 (12.7±4.9) kg. Preoperative diagnosis was confirmed by echocardiography, angiography or cardiac catheterization. Major concomitant anomalies included tricuspid regurgitation (TR) in 13 patients, restrictive ventricular septal defect in 10 patients, atrial septal defect or patent foramen ovale in 7 patients, mild pulmonary valve stenosis in 4 patients, patent ductus arteriosus in 4 patients, and third-degree atrioventricular block in 1 patient. All the patients underwent first-stage morphologic left ventricular retraining under general anesthesia followed by second-stage atrial switch and arterial switch operations (DSO) under cardiopulmonary bypass with the interval of 0.67-34.0(10.23±9.47)months. ResultsAfter the first-stage morphologic left ventricular retraining, there was no postoperative complication or death. During follow-up, mLV end-diastolic diameter (mLVEDd) and posterior wall thickness of mLV were significantly larger than preoperative parameters (P < 0.05). The interventricular septum moved partially towards morphologically right ventricle (mRV). TR degree was significantly decreased, the pressure gradient across the pulmonary artery band was significantly increased (P < 0.05), and left ventricular ejection fraction (LVEF) was not statistically different from preoperative LVEF. And mLV/mRV pressure ratio was significantly increased (P < 0.05). After the second-stage DSO, 2 patients died with the in-hospital mortality of 14.3% (2/14). The causes of death included serious arrhythmia, circulatory collapse and sudden death. Early postoperative complications included pulmonary infection in 6 patients, atrial arrhythmias in 2 patients, pleural effusion in 2 patients, pneumothorax in 1 patient, diaphragmatic paralysis cured by diaphragm placation in 1 patient, respiratory tract hemorrhage in 1 patient, mild aortic insufficiency in 1 patient, peritoneal dialysis for 1 patient, extracorporeal membrane oxygenation for 1 patient, and tracheal intubation for a second time for 1 patient. All the 12 patients who were discharged alive were followed up for 2 to 8 years. One patient died during follow-up with the late mortality of 8.33% (1/12), and the cause of death was serious arrhythmia and circulatory collapse. Eight patients were in New York Heart Association (NYHA) classⅠ, and 3 patients were in NYHA class Ⅱ. Major late complications included left ventricular dysfunction in 3 patients, moderate aortic valve regurgitation in 3 patients, and moderate mitral valve regurgitation in 1 patient. ConclusionShort-term clinical results of left ventricular retraining followed by DSO for patients with CCTGA and a deconditioned mLV are satisfactory, and its middleand long-term results need further follow-up. But postoperative left ventricular dysfunction and new-onset aortic valve regurgitation deserve more attention.
Abstract： Objective?To evaluate clinical experiences and long-term outcome of morphologic left ventricle （mLV） retraining for congenitally corrected transposition of the great arteries （cCTGA）. Methods From May 2005 to May 2011, 24 patients with cCTGA anomaly underwent left ventricle retraining by means of pulmonary artery banding in Fu Wai Hospital. There were 13 males and 11 females with their age of 0.17-22.00 （3.73±4.35） years and body weight of 5.10-61.00（15.71±10.95）kg. Major concomitant malformations included tricuspid valve insufficiency （TR）in 23 patients （mild in 11 patients, moderate in 7 patients, severe in 5 patients）, restrictive ventricular septal defect in 18 patients, atrial septal defect in 5 patients, patent foramen ovale in 5 patients, patent ductus arteriosus in 4 patients, mild pulmonary stenosis in 5 patients, and aortic coarctation in 1 patient. All the patients were preoperatively diagnosed by echocardiography, cardiovascular angiography or cardiac catheterization. The mLV end diastolic diameter （mLVEDD） was 8-32（21.56±6.60）mm, posterior wall thickness of mLV was 2-7 （4.29±1.52）mm , mLV to morphologic right ventricle （mRV） pressure ratio （mLV/mRV） was 0.12-0.65 （0.41±0.12）. Pulmonary artery banding operation was performed through upper partial sternotomy or median sternotomy without circulatory arrest. Results The mLV/mRV pressure ratio reached to 0.57-0.93 （0.76±0.10） under direct pressure monitoring after surgery. There was no in-hospital death in this group. Echocardiography before discharge showed that the structure and function of the two ventricles were good, the interventricular septum moved partially towards mRV, mLVEDD was increased slightly, and there was a tendency of reduced TR. Postoperative follows-up was from 1 to 35 months, and there was no late death during follow-up. All the patients were in good general condition with stable vital signs and New York Heart Association （NYHA） classⅠ-Ⅱ. The mLVEDD was 14-40 （26.17±7.11） mm, posterior wall thickness of mLV was 4-9 （4.95±1.44）mm, mLV/mRV pressure ratio was 0.52-0.98 （0.72±0.16） , and TR was significantly decreased. Fourteen patients successfully underwent staged complete double-switch procedure. Conclusion Left ventricle retraining is a safe and effective method to train mLV for cCTGA patients. Pressure load and posterior wall thickness of mLV are increased, mLV cavity is dilated, and TR is significantly reduced after the surgery.
Objective To compare the early and mid-term results between Fontan operation and anatomic correction for congenitally corrected transposition of the great arteries (ccTGA). Methods The clinical data of 53 patients with ccTGA who underwent anatomic correction and Fontan operation from January 2009 to September 2021 in our hospital were reviewed, including 41 males and 12 females with a mean age of 55.02 (3-168) months. They were divided into an anatomic correction group (16 patients) and a Fontan operation group (37 patients) according to the operation. The hospitalization mortality, survival rate, postoperative complications, and free rate from re-intervention between the two groups were compared. Another 180 healthy children were recruited as a control group, and 14 children were matched with the propensity score matching method as a Fontan control group. The results of cardiopulmonary exercise testing (CPET) between the Fontan operation group and the Fontan control group were compared. Results There were 2 (12.5%) early deaths and 3 (18.8%) early re-intervention in the anatomic correction group, while 1 death and 2 re-intervention in the Fontan operation group. In addition, there were 9 patients (56.3%) in the anatomic correction group and 6 (16.2%) patients in the Fontan operation group suffering from arrhythmia after operation, respectively. Compared with the anatomic correction group, cardiopulmonary bypass time, aortic cross-clamping time, intubation time and ICU stay were significantly shortened in the Fontan operation group (P<0.05). CPET results showed that, percent predicted max VO2 in the Fontan operation group was lower than that in the Fontan control group (0.84±0.11 vs. 0.99±0.12, P＜0.05). The patients were followed up for 0.5-126.0 months. Two patients were lost in the Fontan operation group. There was no death and 1 re-intervention in the anatomic correction group, while no death or re-intervention in the Fontan operation group. The 1-year, 5-year and 10-year transplant-free survival rate of the anatomic correction group and the Fontan operation group was 87.5%, 87.5%, 87.5% and 97.3%, 97.3%, 97.3%, respectively (P＞0.05). The 48 patients were classified as grade Ⅰ-Ⅱ in cardiac function in the last follow-up. Conclusion There is no statistical difference in the transplant-free survival rate between the anatomic correction and the Fontan operation group. The postoperative complications in the Fontan operation group are decreased than those in the anatomic correction group. The Fontan operation is also a good choice, even though the patients with ccTGA meet the condition of the procedure of anatomic correction.
Objective To investigate the surgical indications and the mid and long term results of morphologic tricuspid valve replacement for corrected transposition of the great arteries（cTGA）. Methods From September 1997 to September 2007, 18 cases with cTGA were treated in Fu Wai Hospital. There were 15 male and 3 female, aged from 16 to 51 years（33.3±12.8 years）, and weighed from 47 to 90 kg(60.9±14.7 kg). There were 10 cases with isolated morphologic tricuspid valve insufficiency, 3 complicated with ventricular septal defect, 2 complicated with ventricular septal defect and pulmonary valve stenosis, 2 with morphologic tricuspid valve insufficiency after septal defect repair, and 1 with mechanical valve dysfunction after morphologic tricuspid valve replacement. The preoperative mean morphologic right ventricle ejection fraction was 562%±11.6%. Of the 18 cases, 12 were in grade Ⅱ and 6 were in grade Ⅲ according to New York Heart classification（NYHA）.All the cases had undergone morphologic tricuspid valve replacement. Postoperative indices such as cardiac function and morphological right ventricle ejection fraction were followed up. Results One patient died of postoperative low cardiac output syndrome. Two had pervavlvular leak, which were cured by pervavlvular leak repair at 7th and 30th day after operation, respectively. Sixteen were followed up with a followup time of 57.0±407 months. There was no statistical significance between preoperative and postoperative mean morphologic right ventricle ejection fraction（52.8%±9.2% vs.56.2%±11.6%; t=2.062, Pgt;0.05）. The followup showed that 12 were in NYHA grade Ⅰ or Ⅱ, and 4 were in NYHA grade Ⅲ. There was no statistical significance between preoperative and postoperative percentage of cases in NYHA grade Ⅲ（χ2=1.532，Pgt;0.05）. Conclusion Morphologic tricuspid valve replacement can prevent the further damage to morphologic right ventricular function caused by morphologic tricuspid valve insufficiency. The mid and long term results were satisfying. During the followup, the morphologic right ventricle can function appropriately.
ObjectiveTo compare and analyze the effect of myocardial protection between HTK and del Nido cardioplegia solutions in neonates with surgeries for transposition of the great arteries. MethodsThe clinical data of 208 neonates with complete transposition of the great arteries in our institution from 2014 to 2020 were retrospectively analyzed. According to the cardioplegia solutions utilized in the operations, the patients were divided into two groups: a HTK group and a del Nido group. Propensity score matching was conducted to eliminate the biases. The cardiopulmonary bypass time, aortic cross-clamping time, total amount of cardioplegia solutions, transfusion frequency of cardioplegia, ICU stay time, mechanical support time, inotropic score, hospital stay, left ventricular ejection fraction, N-terminal proBNP and troponin I were compared and analyzed between the two groups after matching. ResultsAfter 1:1 propensity score matching, a total of 54 patients were analyzed with 27 patients in each group. In the HTK group, there were 22 males and 5 females with a median age of 7.0 (2.0, 11.0) d. In the del Nido group, there were 23 males and 4 females with a median age of 8.0 (3.0, 11.0) d. A total of 3 children died after the surgery: 2 (7.4%) patients in the HTK group and 1 (3.7%) patient in the del Nido group. There was no significant difference in hospital mortality between the two groups (P=1.000). The total amount of cardioplegia solutions in the HTK group was significantly higher than that of del Nido group (P<0.001). Transfusion frequency of cardioplegia in del Nido group was significantly higher than that of the HTK group (P=0.043). There was no significant difference in the postoperative ICU time, mechanical support time, length of hospital stay, inotropic score, left ventricular ejection fraction, N-terminal B-type natriuretic peptide precursor or troponin I between the two groups (P>0.05). ConclusionFor neonates with surgeries for complete transposition of the great arteries, HTK cardioplegia solutions can provide effective and safe myocardial protection, which is similar to del Nido cardioplegia solutions.
A 23-year-old male patient was diagnosed with congenitally corrected transposition of the great arteries (ccTGA) at the age of 3 during a routine physical examination. Due to the absence of significant symptoms, the patient was managed conservatively with follow-up without surgical treatment. He developed chest tightness one year prior to admission, with symptom exacerbation in the recent month. Echocardiography demonstrated significantly worsened morphological tricuspid regurgitation. The patient presented to Guangdong Provincial People’s Hospital for surgical evaluation. Given the patient’s age and clinical presentation, a totally thoracoscopic morphological tricuspid valve replacement was performed. Postoperative assessment showed good prosthetic valve function, with no regurgitation or paravalvular leakage; the electrocardiogram confirmed sinus rhythm without atrioventricular block. Extubation occurred within 12 hours postoperatively, and the patient was transferred from the intensive care unit (ICU) on postoperative day 2. At the three-month follow-up, the patient was asymptomatic and had resumed normal activities. This report describes the first case of a totally thoracoscopic morphological tricuspid valve replacement in a ccTGA patient in China. This initial experience suggests that the totally thoracoscopic approach for morphological tricuspid valve replacement in ccTGA patients is a feasible, safe, and effective minimally invasive option associated with rapid recovery.
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.