Impact of pulmonary artery reduction during arterial switch operation: 14 years follow-up

Abstract

OBJECTIVES Pulmonary artery/aorta (PA/Ao) size discrepancy plays an important role in the development of neoaortic root growth and valve regurgitation. Since 2004, we started using PA reduction to manage severe great vessels root mismatch at the time of arterial switch operation. The purpose of this study is to evaluate the impact of this technique in the mid- and long-term follow-up. METHODS Patients considered to have severe PA/Ao mismatch (>2:1 ratio) underwent resection of a 3- to 4-mm flap of the posterior PA wall. Patients submitted to this technique were followed up with clinical and image examinations. Echocardiographic findings were reviewed, and Z-scores were recorded to evaluate the incidence and progression of neoaortic root dilatation and valve regurgitation. RESULTS The median (Q1–Q3) follow-up time was 8 years (3–11). Before arterial switch operation, the median (Q1–Q3) Z-score of the PA annulus was 2.90 (2.75–3.75). At the latest follow-up, the median Z-score of the neoaortic annulus was 1.34 (0.95–1.66). The mean difference between the Z-scores of PA annulus and neoaortic annulus was 1.56 (P < 0.0001). The mean value of the sinus of Valsalva was +0.29 ± 1, that of sinotubular junction was +0.71 ± 0.6 and that of ascending Ao was +1.09 ± 0.7. There was no severe dilatation of the neoaortic annulus, neoaortic root or ascending Ao during follow-up. Neoaortic valve regurgitation was none or mild in 93% of patients. CONCLUSIONS PA reduction proved to be a feasible and low-risk procedure to approach PA/Ao mismatch in arterial switch operation. Mid- and long-term follow-up showed a tendency towards stabilization of the neoaortic root dilatation and satisfactory valve performance after the procedure. Further investigation is required with a larger population and longer-term follow-up.

Neoaortic Regurgitation Detected by Echocardiography After Arterial Switch Operation

“…A proposed preventative measure for NeoARD is pulmonary artery reduction during the initial ASO for those with severe forms of Ao/PA size discrepancy (>2:1 ratio of PA to Ao). 44 Additionally, if reliable means could be developed to prevent neoaortic dilation, it could also favorably impact NeoAR by reducing intercommisural distance and promoting more effective leaflet coaptation. Patients with progressive aortic dilatation may develop problems related to external compression of main and branch PAs, resulting in a decreased pulmonary blood flow and PA stenosis.…”

Is slim better than paunchy?

“…Pulmonary plasty techniques have been described for the purpose of achieving a better arterial root anastomosis, with good initial results, but lack of long-term period of observation. [14][15][16][17] Arcieri et al 1 report their experience to approach APM by resecting a conal fragment of the pulmonary artery wall with direct linear closure. Coronary arteries were reimplanted by punch technique, avoiding trap-door incisions in the suture line.…”

“…In 2019 our group published our results over 14 years of follow‐up using a very similar technique to approach APM 17 . Instead of a conal shape fragment of the pulmonary artery, the reduction is achieved by resecting a rectangular fragment that extends down to the annulus of PA.…”

“…In 2019 our group published our results over 14 years of follow-up using a very similar technique to approach APM. 17 Instead of a conal shape fragment of the pulmonary artery, the reduction is achieved by resecting a rectangular fragment that extends down to the annulus of PA. This provides an extended reduction plasty of the neoaortic root including the valve annulus, possibly preventing further annulus dilatation.…”

“…Techniques to approach APM at the time of ASO have been published sporadically and are very rarely employed by surgeons. Pulmonary plasty techniques have been described for the purpose of achieving a better arterial root anastomosis, with good initial results, but lack of long‐term period of observation 14–17 . Arcieri et al 1 report their experience to approach APM by resecting a conal fragment of the pulmonary artery wall with direct linear closure.…”