Risk Factors for Reoperation After Arterial Switch Operation

Abstract

Objective: The timing and nature of and risk factors for reoperation after the arterial switch operation in the setting of d-transposition of the great arteries requires further elucidation. Methods: A total of 403 patients who underwent arterial switch operation from 1986 to 2017 were reviewed. Institutional preference was for pulmonary artery reconstruction using a pantaloon patch of fresh autologous pericardium. The targets for coronary artery reimplantation were identified by intermittent root distension. Multivariable analysis was used to identify risk factors for reoperation. Results: Median follow-up was 8.6 years (interquartile range [IQR]: 2-16.9). Pulmonary arterioplasty was the most common reoperation (n = 11, 2.7%) at 3.3 years (IQR: 1.4-11.4) postoperatively. Subvalvar right ventricular outflow tract reconstruction (RVOTR) was required in nine (2.2%) patients at 2.5 years (IQR: 1.1-5.3) postoperatively. Aortic valve repair or replacement (AVR/r) was required in seven (1.7%) patients at 13.6 years (IQR: 10.0-15.8) postoperatively. Aortic root replacement (ARR) and Coronary Artery Bypass Graft/coronary patch arterioplasty were required in five (1.2%) patients each at 13.6 years (IQR: 11.0-15.3) and 11.3 years (IQR: 2.3-13.6) postoperatively, respectively. Taussig-Bing anomaly was a risk factor for any reoperation ( P = .034). Risk factors for specific reoperations included ventricular septal defect for AVR/r ( P = .038), Taussig-Bing anomaly for RVOTR ( P = .004), and pulmonary artery banding for ARR ( P = .028). Conclusions: Pantaloon patch pulmonary artery reconstruction and intermittent neo-aortic root distension during coronary reimplantation have minimized respective outflow tract reoperations. Certain anatomic subsets carry different risks for late reoperation, and pulmonary artery and/or RVOT reinterventions tend to occur sooner than aortic reinterventions. Special attention to these higher risk subpopulations will be critical to optimizing lifelong outcomes.

Excellent Survival With a Focus on Pulmonary Artery Reinterventions After the Arterial Switch Operation

“…In others' experience, the use of pericardium pretreated with glutaraldehyde, irrespective of its concentrations, was associated with the development of PA stenosis postoperatively, and the authors recommended using a pantaloon patch of fresh autologous pericardium to minimize PA reinterventions. 16 Residual stenosis of the PA can be progressive. Indeed, a previous report 17 has shown that PA stenosis was more frequent and more severe in the patients who had undergone reintervention before.…”

“…In others’ experience, the use of pericardium pretreated with glutaraldehyde, irrespective of its concentrations, was associated with the development of PA stenosis postoperatively, and the authors recommended using a pantaloon patch of fresh autologous pericardium to minimize PA reinterventions. 16…”

Prevalence of Branch Pulmonary Artery Reintervention Following the Arterial Switch Operation

“…7 Along with prolonged CPB time, it has been shown that more complex anatomy—including Taussig-Bing anomaly—is a risk factor for any reoperation. 8…”

“…7 Along with prolonged CPB time, it has been shown that more complex anatomy-including Taussig-Bing anomaly-is a risk factor for any reoperation. 8 Studies show that other preoperative characteristics such as timing of the ASO may affect the outcomes and mortality of patients following the ASO. 9 This led us to hypothesize that age at the ASO, weight at the ASO, or other preoperative factors may be associated with reintervention, but the data did not find any associations with these preoperative factors.…”