ࡱ> hjg Abjbj 8XhhY9+N N 8<0$NpT:/N1N1N1N1N1N1N$ PRNUNUNjN/N/N\7*NN0N, S S SD.UNUNN SN n: EDITORIAL Titulo espaol The Arterial Switch Operation: A Tale of Great Expectations Marshall L. Jacobs MD Division of Cardiac Surgery Johns Hopkins University School of Medicine Baltimore, Maryland, USA Address for correspondence: Marshall L Jacobs MD Division of Cardiac Surgery The Johns Hopkins Hospital, Zayed 7107, 1800 Orleans Street, Baltimore, MD 21287, USA. Email:  HYPERLINK "mailto:marshall.jacobs@comcast.net" marshall.jacobs@comcast.net Forty years ago, when Adib Jatene, in Sao Paulo, Brazil performed the first successful arterial switch operation on an infant with transposition of the great arteries and ventricular septal defect, it was celebrated as an outstanding technical achievement. Jatene had studied the published literature concerning transposition of the great arteries, and had become convinced that the problem of ventriculo-arterial discordance could be solved by switching the flow at the level of the great arteries if the coronary arteries could be successfully transposed, as had been suggested by Dr. Harold Albert. After reviewing many dozens of pathologic specimens of hearts with transposition, Jatene was struck by the consistent observation that the coronary arteries arose from the aortic sinuses adjacent to the pulmonary artery, and he was convinced that transfer of the coronary arteries with part of the surrounding sinus of Valsalva tissue would be possible and would require little mobilization. Though the first child on whom Jatene performed a switch procedure died at the end of the operation, he remained convinced that the principle was sound and that the operation was feasible. The second operation, on a 40-day-old child with transposition of the great arteries and a ventricular septal defect, was successful [ 1]. Cardiac surgery had witnessed a milestone achievement, and the field would change dramatically. Today, the Jatene operation is performed at virtually all pediatric cardiac surgery centers, and for many surgeons and centers the outcomes from arterial switch surgery serve as a yardstick by which to measure individual and team performance. With adoption of the arterial switch operation in the first few weeks of life for transposition with intact ventricular septum, and over a slightly wider range of age for transposition with hemodynamically important ventricular septal defect, as well as for the Taussig-Bing anomaly (actually a form of double outlet right ventricle), the arterial switch operation has become the mainstay of contemporary surgical management of several of the most common and most challenging forms of congenital heart disease. The history of surgery for transposition was already a story of numerous fascinating innovations before the advent of anatomic repair. Varco and Lillehei, Baffes, and others had devised ingenious closed heart operations which achieved partial reversal of the systemic and pulmonary venous return to the atria. With refinement of the heart-lung bypass machine and application of cardiopulmonary bypass support to the youngest patients, the atrial baffle procedures developed by Senning and by Mustard were successfully performed by surgeons all over the world. By the time that arterial switch surgery had first been performed successfully, routine repair of simple and complex forms of transposition by means of atrial baffle repairs was commonplace, and the operations were being performed earlier and earlier in life, including routine repair of simple transposition in the newborn period at some centers. Why then, make the switch to the switch? Data on short-term and intermediate-term survival after Mustard and Senning operations were generally favorable. Technical improvements led to reduction in the incidence of important obstructions in the systemic and pulmonary venous pathways. There was, however, a troubling incidence of late rhythm disturbances, and increasing concern as to whether the right ventricle and the tricuspid valve could function adequately in the systemic circulation over a normal lifespan. These concerns, and the evidence that supported them, seemed even more compelling with respect to the population of patients with transposition and ventricular septal defect. So, the arterial switch operation, and whatever learning curve and associated incremental risk of operative mortality might be experienced in the early phase after its adoption, began gradually to supplant other surgical strategies as the primary approach to repair of transposition of the great arteries and related anomalies. Multi-institutional studies, such as those of the Congenital Heart Surgeons Society in North America provided evidence to support this transition [ 2,3 ]. The recognition that the natural preparedness of the left ventricle to assume the work of supporting the systemic circulation had a time-span that may be limited to the first few weeks of life, led to the routine performance of arterial switch repair for transposition with intact ventricular septum in the neonatal period. Demonstration of the feasibility and short-term success of this strategy led also to earlier and earlier surgery for more complex forms of transposition. There were, of course, many concerns that went beyond the challenge of the technical exercise itself. Would the transplanted coronary arteries function normally, and predictably? Would that be equally true regardless of the many different patterns of coronary origin and branching that are observed in patients with transposition? Would they be especially prone to coronary occlusive disease as a result of either surgical scarring or eventual atherosclerosis? Would the divided and switched great vessels exhibit appropriate growth at the level of the circumferential suture lines? What expectations were there with respect to the long-term durability of the native pulmonary valve in its new role as neo-aortic valve? And would this alternative to physiologic repair actually live up to predictions with respect to lower incidence of rhythm disturbances and durable functional status? In this issue of Revista Argentina de Cardiologa, Villalba and Capelli and associates present a review of their insitutional experience with arterial switch surgery for transposition of the great arteries and a detailed analysis of follow-up data pertaining to 224 patients operated on with the arterial switch technique at Hospital de Pediatra Prof. Dr. Juan P. Garrahan from January 1992 to December 2013. The cohort includes the full spectrum of variants (simple TGA, complex TGA with VSD and/or aortic arch obstruction, and the Taussig-Bing anomaly). Patients who died in the immediate postoperative period or were lost to follow-up (n=57) were excluded from the study. With respect to this being a study of intermediate and long-term status conditional upon initial operative survival, this is similar to some comprehensive single center studies, but differs from some others. In subtle ways, the exclusion of operative mortality may result in some mild, unintended bias in terms of the characteristics of the cohort. For example, the authors report that more than three-fourths of patients had the normal (or most common) coronary artery pattern. This is slightly more than the fraction of roughly two-thirds that is frequently observed in clinical or pathologic series. Whether this is related to a possible interaction between coronary anatomy and operative survival, or purely a matter of chance with respect to those that survived surgery but are lost to follow-up, or whether it is simply a reflection of the variation between one series and another is not knowable. It is unlikely however, that such subtle variations have important implications for the inferences drawn from the analysis. With respect to the questions that have time and again been asked about long-term concerns regarding those who have survived arterial switch surgery early in infancy, this large experience from Buenos Aires joins a growing body of literature that is mostly reassuring. Mortality during follow-up (mean of 7.6 years) is just 1% (two patients) and all surviving patients are in Functional Class I-II. Importantly, all have normal ventricular function. As in other reports, the most common late complication is pulmonary stenosis (PS) at some level (17.4%), with supravalvar stenosis being the most common site of obstruction. The observation that development of pulmonary stenosis was associated with both the era of surgery and the duration of follow-up leaves one uncertain as to whether evolution of the surgical technique has relegated the highest likelihood of developing pulmonary stenosis to those who underwent surgery in the earlier phase of the centers experience, or alternatively, whether there is some degree of inevitability to this problem, and that those operated in the more recent epoch are still at risk for further late acquisition of PS. As in reports from other centers, neo-aortic root dilatation (12% of patients) and time-related development of aortic valve regurgitation are clearly related to one another. Aortic regurgitation was associated with complex transposition and Taussig-Bing anomaly, prior left ventricular preparation, aortic root dilation, and presence of aortic regurgitation in the immediate postoperative period. Only five patients have undergone aortic valve replacements, including two composite root replacements (Bentall) and one switch-back Ross operation. Reoperations and catheter interventions directed at the right side of the heart were more numerous, as is true in most series. At 5, 10 and 15 years, 94%, 86% and 58% of patients, respectively, remained free from cardiac re-interventions of any type. Of five patients in whom there was evidence at any time of coronary artery problems, two presented within the first weeks or months following surgery, both with ventricular dysfunction. Three patients had late findings of coronary obstruction that was found during cardiac catheterization. But catheterization was not routinely performed as part of a follow-up protocol. One had additional residual lesions that were not related to the coronary issues, and did not survive a reoperation. The two remaining patients are asymptomatic, in FC I and with preserved ejection fraction. With this analysis, Villalba and associates have added to a rapidly growing body of information that one hopes will ultimately help us to answer questions about expectations regarding the long-term status of patients who have survived arterial switch repairs early in life. We know from this report and others that these patients are at risk for development of pulmonary outflow obsruction at various levels, and we suspect that improved surgical reconstructive strategies at the time of arterial switch surgery are likely to be associated with a reduction in the incidence of such problems, but it is doubtful that they will be eliminated entirely. It appears that aortic root dilation is related to identifiable risk factors including, among others, initial size discrepancy of the great vessels and pulmonary artery banding. Of patients who do develop aortic root dilatation, further progression of dilatation (increasing Z-score over time) is observed in some, but certainly not in all. And the factors that influence progression are incompletely understood. Most late interventions directed at the neo-aortic root are indicated on the basis of aortic valve regurgitation, as opposed to isolated root dilation. Risk factors for time-related development of significant aortic valve regurgitation include older age at arterial switch surgery, TGA with VSD, initial aortic/pulmonary size discrepancy, aortic arch anomalies, and presence of aortic regurgitation at discharge following arterial switch operation [ 4,5 ]. The incidence of arrhythmias in this and other arterial switch cohorts is low, but does include some patients with complex ventricular arrhythmias in the absence of an apparent anatomical substrate. Perhaps most concerning, is the fact that coronary obstructive lesions (2% in this series; 1-8 % in other reports) while uncommon, are often clinically silent, and frequently are associated with preserved ventricular function, at least for a period of time. One must ask whether there would be value in subjecting asymptomatic patients to periodic investigation of the status of the coronary arteries, and whether such surveillance would result in detection of obstructive lesions that have the potential to be the basis for future ischemic events. The significance of such obstructive lesions is incompletely understood. Many such lesions are likely to go undetected in the absence of a program of routine control cardiac catheterization or some alternative type of imaging and functional assessment of comparable yield and predictability. Studies such as this one, which examine and analyze late post-operative events, are important in terms of optimizing the management of enrolled patients. But they also help us to build an understanding of the unnatural history of patients following arterial switch surgery. That understanding is essential to our ability to formulate plans for rational practices in terms of routine surveillance and the timing of serial investigations. Thats an important part of enabling patients with transposition to achieve the maximal benefit from anatomic repair. References 1. Jatene AD, Fontes VF, Paulista PP, Souza LC, Neger F, Galantier M, et al. Anatomic correction of transposition of the great vessels. J Thorac Cardiovasc Surg 1976;72:36470. 2. Castaneda AR, Trusler GA, Paul MH, Blackstone EH, Kirklin JW. The early results of treatment of simple transposition in the current era. J Thorac Cardiovasc Surg. 1988;95:14-28. 3. Norwood WI, Dobell AR, Freed MD, Kirklin JW, Blackstone EH. Intermediate results of the arterial switch repair. A 20-institution study. J Thorac Cardiovasc Surg. 1988;96:854-63. 4. Schwartz ML, Gauvreau K, Del Nido P, Mayer JE, Colan SD. Long term predictors of aortic dilatation and aortic regurgitation after arterial switch operation. Circulation. 2004;110:12832.  HYPERLINK "http://doi.org/dkcf9f" http://doi.org/dkcf9f 5. Losay J, Touchot A, Capderou A, Piot JD, Belli E, Planche C, et al. Aortic valve regurgitation after arterial switch operation for transposition of the great arteries: incidence, risk factors, outcome. J Am Coll Cardiol 2006;47:205762.  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Cirugía de switch arterial: una historia de grandes esperanza;
The Arterial Switch Operation: A Tale of Great Expectations

Creators:Marshall, Jacobs L.
2017-01-05

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Metadatos destacados

Colecciones
Argentine Journal of Cardiology

Editor

Sociedad Argentina de Cardiología

Fuente

Revista Argentina de Cardiología; Vol 84, No 5 (2016); 419-421, Argentine Journal of Cardiology; Vol 84, No 5 (2016); 419-421

Citación

Marshall, Jacobs L., “Cirugía de switch arterial: una historia de grandes esperanza,” Archivo PPCT, consulta 2 de abril de 2026, http://archivoppct.caicyt.gov.ar/items/show/9278.

Dublin Core

Autor

Marshall, Jacobs L.

Fuente

Revista Argentina de Cardiología; Vol 84, No 5 (2016); 419-421
Argentine Journal of Cardiology; Vol 84, No 5 (2016); 419-421

Editor

Sociedad Argentina de Cardiología

Fecha

2017-01-05

Derechos

Los que firman al pié, certificamos que tenemos total responsabilidad por la conducción de este estudio y por el diseño y la interpretación de los datos. Nosotros escribimos el manuscrito y somos responsables por la decisión acerca del mismo. Cada uno de nosotros cumple la definición de autor como se afirma en el Comité Internacional de Editores de Revistas Médicas (International Committee of Medical Journal Editors, ver www.icmje.org). Nosotros hemos visto y aprobado el manuscrito final. Ni el artículo, ni ninguna parte esencial del mismo, incluido las tablas y las figuras, será publicado o admitido para arbitrar a otra parte antes de aparecer en la Revista.También notificamos haber leído la sección “conflicto de intereses”, y revelaríamos cualquiera que existiera. Dejamos constancia que si nuestro artículo se publicara en la RAC, cederíamos los derechos (copyright) a la Revista.Los documentos publicados en esta revista están bajo la licencia Creative Commons Atribución-NoComercial-Compartir-Igual 2.5 Argentina.
Those signing below certify that we have full responsibility for the conduction of this study and for the design and interpretation of the information. We wrote the manuscript and are responsible for its decision. Each of us fulfills the definition of authorship as stated by the International Committee of Medical Journal Editors ( www.icmje.org). We have signed and approved the final manuscript. Neither the manuscript, nor any essential part thereof, including tables and figures, will be published or accepted for refereeing elsewhere before being published in the Journal. We have also read the "Conflict of Interest" section and would disclose any existing. We state that if our manuscript is published in the RAC, we shall transfer the copyright to the Journal.

Formato

Idioma

spa
eng

Tipo

info:eu-repo/semantics/article
info:eu-repo/semantics/publishedVersion