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13 YEARS EXPERIENCE

WITH ARTERIAL SWITCH OPERATION

FOR TRANSPOSITION OF GREAT ARTERIES

L. Arcieri, M. Melo, V. Pak, M. Cantinotti, M. Bernabei, R. Moschetti, N. Assanta, B. Murzi

Fondazione Toscana G. MonasterioMassa-Italy

XLIII Congress of the Italian Society of PediatricCardiology and Cardiac Surgery

Padua 16-19 October 2013


Population

Mean Age 7 days (3days – 6,7 years)

Mean Weight 3,4 kg ( 1,5 kg - 18 kg )

N° of patients: 142

VSD 32%

IVS 68%Male70%

Female30%

Population (> 45 days)

�46 days – 6 years

�24 Patients

•TGAvsd 14

•TGAivs 10

�13 Ventricular Retraining

•BAP+Shunt and/or Atrioseptectomy


N°°°° %

NO 109 76,8

Yes 33 23,2

Prenatal Echocardiographic Diagnosis

From 2009, 80% of operated patients have Prenatal D iagnosis


Preoperative Diagnosis

�Echocardiogram (100%)


Rashkind Procedure

NO 54(29 VSD) 38,0

Yes 88(24 VSD) 62,0

N° %

NO 29(16 VSD) 20,4

Yes 113(37 VSD) 79,6

PGE 1


Coronary AnatomyN°°°° % IMC

A-Yacoub 106 75,41

B-Yacoub 16 11,33

C-Yacoub 1 0,71

D-Yacoub 14 9,90

E-Yacoub 5 3,50

TOT 142 1005

IMC: Intramurac coronary Artery


Operative Technique

Punch 2.8 mmPunch

Trap Door

Punch+Trap Door

0 20 40 60 80 100 120 140

124

13

5

Coronary Reimplantation Tecnique

Coronary Artery Re-Implantation

�Innominate artery cannulation by goretex tube�Right Atrial(TGA IVS) or Bicaval(TGA VSD) venous ca nnulation�Pulmonary reconstruction with pericardial patch�Mean Rectal T°: 28(18-30)


Operative DataCardiopulmonary By-pass

TOT IVS VSD0

50

100

150

200

250

206193

228

125115

142

CPB(min)XClamp(min)

Operative DataCPB Time According to Cardioplegia

P < 0,0001Custodiol Blood

0

50

100

150

200

250

0

50

100

150

200

250

167

219

97

134CPB time(min)X Clamp time


Associate AnomaliesAssociate Anomalies: 7/142 pts(4.9%)

Associate Anomalies Associate Procedure

Subpulmonary Stenosis/LVOT obstruction LVOT Myectomy

Aortic Arch Hypoplasia Aortic Arch Enlargement



Aortic Coartation Resection and E-E anastomosis

Subpulmonary Stenosis/LVOT obstruction Anomalous Chordae Tendinae Resection

Subpulmonary Stenosis/LVOT obstruction Anterior Mitral Leaflet Plasty


Associate AnomaliesAssociate Anomalies: 7/142 pts(4.9%)

Associate Anomalies Associate Procedure

Subpulmonary Stenosis/LVOT obstruction LVOT Myectomy




Aortic Coartation Resection and E-E anastomosis

Subpulmonary Stenosis/LVOT obstruction Anomalous Chordae Tendinae Resection

Subpulmonary Stenosis/LVOT obstruction Anterior Mitral Leaflet Plasty

No Hospital Death was observed in this subgroup of patients


Associate Procedures-Reduction Aortoplasty


Coronary Ostia enlargement: 3 pts

Coronary Artery Bypass: 2 pts

Aortic Arch Enlargement: 1 pts

Superior Vena Cavae enlargement: 2 pts

Mitral Valvuloplasty(LAM): 1 pts

Diaphragm Plication: 3 pts

PM Implantation: 3 pts

Pulmonary Trunk Enlargement: 2 pts

Subaortic LVOT Obstruction( Monro Tecnique): 1 pts

Reoperation18/142

Left Ventricular RetrainingN°°°° of Patients 13/142(9.8%)

7 male6 female

Mean AgeMean Weight

105 days4,3 Kg

Interval between retraining and Arterial Switch 44,9 day s (min 2 – max 200)

LVEF at arterial Switch Operation >60%(12/13); 30-50 (1/13)

CPB time(mean) at ASOXCLAMP time(mean) at ASO

211 min135,8 min

Mortality after ASO 2/13 (14%)

Reoperation NO


Mortality Hospital mortality : 7/142 pts (4,9%)

Causes of Deathwere in all patients low cardiac

output/myocardial ischemia

Hospital mortality from 2003 to 2013: 2/107 pts (1,8%)

Late death: 2/135 pts (1,4%)

1 Pts LAD occlusion . Surgical revascularization ( 45 days)

1 Pts Chronic heart failure ( 95 days )

Risk Factors and PredictorsFor Mortality

(at univariate statistical analysis)

Preoperative risk factors

Risk Factor p-Value

Preoperative LV Funtion < 60% 0,031

VSD 0,029

Prenatal Diagnosis 0,079

Great Vessels Position 0,067

Coronary Anatomy 0,072



Intraoperative risk factors

Risk Factor p-Value

Blood Cardioplegia 0,031

Surgeon Experience 0,032

VSD closure 0,029

CEC time 0,027

Cross Clamp Time 0,037

Intramural Artery 0,032

Trap Door Coronary Implantation 0,034



Postoperative risk factors

Risk Factor p-Value

Inotropic Drugs Time 0,021

Ventilation Time 0,012

MB fraction-CPK 0,019

Lactate Level 0,017

Reoperation 0,034

•Statistics-Multivariate Analysis

RISK FACTORS p-Value

VSD closure 0,028

Low Cardiac Output 0,016

Prolonged ICU stay(>10 gg) 0,005


Survival Curve

Months

IVS

VSD

Follow-Up�Available for all survived patients

�(Mean FU 4,5 yr; min 20 dys-max 13 yrs)

Quality of Life > 90% of Patients have normal quality of life

(Sport activity, School)

Ventricular Function Normal in 96% of patients

Cardiac Rhythm Sinus Rhythm in 90% of patients

Echo Dipyridamole 52/142

Echo Dipyridamole Results 49 pts (94%) negative

Aortic Valve insufficiencyAt last Follow UP

33

35

3,5

NO AIMILD AIMODERATE AI

%

%

%


Follow- Up

Degree of PA stenosis

Reoperation for Pulmonary stenosis: 2 pts

< 30 mmhg

> 30 mmhg

Follow up – Coronary Artery

�Coronary Angiography performed in 55 pts (38%)

� Pathological findings 4 pts ( 7,2 % )

�Normal development and function 95 %


CONCLUSIONWhat made the difference ?

Punch Technique 2003

Cardioplegia ( Custudiol ) 2009


CONCLUSIONWhat made the difference?

Experience

Simplification

Experience + Simplification= Results

•Statistics-Univariate AnalysisRISK FACTORS p-Value

Preoperative LV function <60% 0,032

VSD closure 0,029

Intamural Coronary Artery 0,032

Postoperative LV function <30% 0,004

Low Cardiac Output 0,000

ECMO 0,000

Prolonged CPB time 0,004

Prolonged Cross Clamp time 0,008

Prolonged ICU stay(>10 gg) 0,006

Prolonged use of inotrope (>7 gg) 0,03

Max MB-CPK value 0,027


Surgical DataAssociate Procedures

N° %

No 122 82,3

YES 20 17,7

TYPE:

�SUBPULMONARY/SUBAORTIC MUSCULAR RESECTION

�MITRAL CHORDAE REIMPLANTATION

�MITRAL CLEFT CLOSURE

�TRICUSPID VALVULOPLASTY

�AORTIC ARCH ENLARGEMENT

�DECOARCTATION

�REDUCTION AORTOPLASTY

No Deaths were observed in this subgroup of patients

lCoronary Ostia enlargement: 3 pts

lCoronary Artery Bypass: 2 pts

lAortic Arch Enlargement: 1 pts

lSuperior Vena Cava enlargement: 2 pts

lDiaphragm Plication: 4 pts

lPM Implantation: 3 pts

lPulmonary Trunk Enlargement: 2 pts

lSubaortic LVOT Obstruction: 1 pts

Early and Late Reoperation18/142

Late Pulmonary Valve Insufficiency

67

12

20

NO 1+ 2+

%

%

%75

15

55

NO 1+ 2+ 3+

% %

%

%

TGAivs TGAvsd

13 years experience with arterial switch … · impossibile trovare nel file la parte immagine con...

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