Criteria for two-staged arterial switch operation for simple transposition of great arteries.

Abstract

We analyzed hemodynamic variables in patients with transposition of the great arteries with intact ventricular septum (simple transposition) after pulmonary artery banding and BlalockTaussig anastomosis to establish the criteria for two-staged arterial switch operation. The study included 35 patients who underwent the switch operation after banding and anastomosis; two died shortly after surgery, and one died of tachycardia 31 days after the operation. The left-to-right ventricular pressure ratio was above 0.83 in all surviving patients, 0.68 and 0.63 in the two operative deaths, and 0.84 in the other death. In the 32 surviving patients, angiographically determined left ventricular (LV) end-diastolic volume and ejection fraction averaged 147 ± 46(SD)% of normal and 0.64 ± 0.12, respectively. We also measured LV mass using angiographic LV semiaxes and end-diastolic LV posterior wall thickness obtained from an echocardiogram. These variables of the patients who died were not different from those of the surviving patients. The wall thickness was greater than 4 mm in the surviving patients, while it was 3.5 mm in the two patients who died early and 5 mm in the patient who died later. From the semiaxes, the wall thickness, and aortic diastolic pressure, all of which were obtained before the anatomic repair, we calculated the predictive LV wall stress. This wall stress would indicate the LV wall stress at the time of aortic valve opening immediately after the arterial switch operation. Predictive wall stress was less than 120 x 103 dynes/cm2 in all but one of the surviving patients, whereas it was 151, 153, and 186 x 103 dynes/cm2 in the three patients who died. From these data, we propose the following criteria for the safe two-staged arterial switch operation: left-to-right ventricular pressure ratio greater than 0.85; LV end-diastolic volume greater than 90% of normal; LV ejection fraction greater than 0.5, or it may be greater than 0.4; posterior wall thickness greater than 4 mm or very safely greater than 4.5 mm; and the predictive wall stress less than 120 x 103 dynes/cm2. (Circulation 1988;78:124-131) ith regard to postoperative physiology, it W is now increasingly accepted that the arterial switch operation is better than the atrial switch procedures in the surgical management of transposition of the great arteries (TGA). The basic concept is that the left ventricle (LV) supports the systemic circulation after the arterial switch operation; thus, systemic ventricular function should be normal in those patients, whereas the right (systemic) ventricular (RV) function is known From the

Our surgical experience and mid-term results with the Senning procedure

“…[5] After the neonatal period of life, in approximately half of the infants with d-TGA and an intact ventricular septum the left ventricle functions deteriorates. [6] In this situation, the Senning procedure could be an alternative surgical procedure to arterial switch operation in the early infancy period. The Senning operation was first performed by Ake Senning in 1959.…”

Late Presenters with Dextro-transposition of Great Arteries and Intact Ventricular Septum: To Train or Not to Train the Left Ventricle for Arterial Switch Operation?

“…Nakazawa et al 10 trained all patients who presented at 2 to 3 months of age. Both volume overload (provided by BTS or PDA) and pressure after-load (induced by PAB) are required for the LV training.…”

“…They also found an increase in the LV mass and LV volume, and mass to volume ratio on echocardiography after BTS and PAB. Nakazawa et al 10 proposed that the LV was prepared when the following criteria were met: LV/RV pressure ratio >0.85, left ventricular end-diastolic volume >90% of normal, LV EF >0.5, and end-diastolic LV posterior wall thickness >4 mm.…”

“…The initial studies advocated months of training and this was progressively shortened to weeks then to days then to intraoperative assessment of the ability of the ventricle to sustain systemic circulation. [3][4][5][6][7][9][10][11] Dabritz et al 9 found that a trial of intraoperative PAB was a reliable indicator as to whether an ASO would be tolerated or not. They found that patients would tolerate ASO by applying PAB for 15 to 30 minutes and achieving a pulmonary to systemic pressure ratio of more than 0.85 without the patient developing failure.…”

Preparo do ventrículo subpulmonar através de dois diferentes modelos ajustáveis de bandagem do tronco pulmonar: estudo experimental

“…Com o passar do tempo o ventrículo foi ganhando massa e suportando cada vez mais pressões intraventriculares maiores, como podemos observar na curva de pressão do VD e na curva da razão VD/VE. Estudos clínicos prévios (7,36,37) , utilizando a bandagem convencional, demonstraram hipoxemia e acidose metabólica e a necessidade de realização de uma comunicação sistêmico-pulmonar em grande parte dos casos. KATAYAMA et al (25) , em 1993, demonstraram pequena hipoxemia nos animais estudados, bastante tolerada e rapidamente corrigida com a desinsuflação do cateter balão, utilizado em seu estudo.…”