Decreased Incidence of Supravalvar Pulmonary Stenosis After Arterial Switch Operation

Abstract

Background-Supravalvar pulmonary stenosis (SVPS) is frequently observed after arterial switch. Traditionally the coronary arteries are removed from the neopulmonic root by excising the entire sinus of Valsalva. As a result, reconstruction of the neopulmonic root requires a pericardial patch encompassing two-thirds of the anastomosis between the neopulmonic root and pulmonary artery. We present a technique where the coronary arteries are removed as limited buttons of sinus tissue, leaving the transected edge of the neopulmonic root intact. We hypothesize that maintaining native arterial tissue in the anastomosis between the neopulmonic root and the pulmonary artery bifurcation reduces postoperative SVPS. Methods and Results-We performed a retrospective review of neonates with D-transposition of the great arteries undergoing arterial switch procedure from 1996 to 2009. Charts were reviewed, and clinical outcomes recorded for each patient. Most recent echocardiograms were evaluated for right ventricular outflow tract obstruction. A total of 120 patients received arterial switch using this technique. There was 99% survival and no injuries to the coronary arteries regardless of anatomy. Total follow-up was 564 patient-years. Mean follow-up at last clinical visit was 66Ϯ46 months. Evaluation of the most recent outpatient echocardiogram revealed an average peak instantaneous gradient across the neopulmonic root of 22.5Ϯ5 mm Hg. Only 7 (5%) patients required reintervention (balloon dilation, nϭ5; surgery, nϭ2). Conclusions-Our technique of removing the coronary arteries as limited buttons, and anastomosis of the pulmonary artery using only native arterial tissue provides excellent midterm results with minimal SVPS. (Circulation. 2012;126[suppl 1]:S118 -S122.)

Almanac 2014: Congenital Heart Disease.

“…Freedom from reoperation for SVPS was 97.1% at 14.75 years. 23 The authors attribute these outcomes to their technique that leaves the transected edge of the neopulmonic artery intact, but caution that future research is required to validate these findings.…”

“…U 97,1% slučajeva nakon 14,75 godina ponovna operacija za SVPS nije bila potrebna. 23 Autori takav ishod pripisuju vlastitoj tehnici u kojoj ostavljaju nedirnutim prerez ruba neopulmonalne arterije, no upozoravaju na to da su potrebna daljnja istraživanja kako bi se potvrdila njihova teza.…”

Arterial switch operation for transposition of great arteries: late results in adult patients

“…Both switched great arteries are then anastomosed into place, with pericardial patches placed into the neopulmonary trunk to fill the defects left by the coronary buttons 10 . subsequent technical modifications in coronary translocation and PA reconstruction have further improved the surgical outcome 11,12 . the procedure is usually performed within the first 2 weeks of life and should be undertaken no later than the 6th week.…”

“…PA stenosis is by far the most common sequela reported in adults after AsO, with an estimated prevalence ranging from 17% to 55% 12,32,33 . It is haemodinamically significant in approximately 10-25% of cases, irrespective of the type of repair.…”

Biology and bioresorbable materials in cardiac surgery: why could they be important in the current era of innovations and technology?

“…Also in the case of SPS, the main mechanisms underlying this complication need to be found in the inadequate biological adaptation of the heart vascular structures to the conduits and surgical materials used. Scar tissue formation and the presence of non-viable tissue at the anastomosis site 13 , impaired tissue viability of NPT and its inability to follow somatic growth are claimed to be the most significant factors 14 . Applying similar concepts, we thought to augment the biological properties of the autologous pericardium used to reconstruct NPT through the use of biocompatible materials able to confer increased resistance to dilation but also promoting its harmonious integration with cardiac structures and preventing progression to SPS.…”