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Risk Factors for Reoperation After Arterial Switch Operation

World Journal for Pediatric and Congenital Heart Surgery
First Published July 19, 2021 https://doi.org/10.1177/21501351211009768

Parth M. Patel, MD, Jeremy L. Herrmann, MD, Eric Bain, BS, Joseph M. Ladowski, MD, PhD, Cameron Colgate, MS, Mark D. Rodefeld, MD, Mark W. Turrentine, MD, John W. Brown, MD

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.

Full Article

Commentary

Patel and colleagues have reported a retrospective analysis of 403 patients in a single institution who underwent arterial switch operation (ASO) to explore the timing, nature and risk factors for re-operation. The study period was over a period of 4 decades and analysing the data by dividing the groups into 4 eras. They have shown that the survival has improved in each decade. However, patients remain at risk for reoperation over time. The most common type of re-intervention was right ventricular outflow tract (RVOT) reinterventions. The study also found that patients with ventricular septal defect (VSD) and pre-operative pulmonary artery  band are at higher risk for left sided re-intervention. Their series also reveals that cumulative incidence of coronary interventions is higher in patients with anomalous coronary anatomy. Taussig-Bing anomaly, given its anatomy are at risk for any re-operation.

The findings are in line with similar studies and provide additional evidence that right-sided reinterventions are required sooner than left-sided reinterventions. It further reiterates the fact that all though ASO patients require lifelong follow-up, some anatomical subsets may need additional imaging and testing, particularly as they enter the “high-risk” time to reintervention.

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