Arterial switch procedure for D-transposition of the great arteries

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Patient families can visit our transposition of the great arteries page for more information and answers to common questions about the arterial switch procedure.

Pathophysiology

 

D-Transposition of the great vessels is a congenital cardiac anomaly in which the aorta arises from the right ventricle, and the pulmonary artery arises from the left ventricle. Desaturated venous blood returning from the peripheral tissue is pumped back to the systemic circulation, and oxygen-rich pulmonary venous blood is pumped back to the pulmonary artery. Patients present with cyanosis. Patients with transposition of the great vessels must have a communication between the systemic circulation and the pulmonary circulation to be consistent with life. Ideally, these patients will have a patent ductus arteriosus and an atrial septal defect. These work together to allow blood to shunt from the left atrium to the right atrium, allowing oxygenated blood to enter the systemic circulation. Intravenous infusion of prostaglandin E1 will usually open the ductus arteriosus, and a bedside balloon atrial septostomy is performed to create a communication between the atria when needed.

The arterial switch procedure is usually performed in the first two weeks of life. Following the early newborn period, left ventricular strength will begin to regress as pulmonary vascular resistance falls. It is for this reason that the operation is performed in the newborn period while the left ventricle remains adequately prepared to support the systemic circulation.

Surgical technique

The arterial switch procedure requires cardiopulmonary bypass and aortic cross clamping. The ascending aorta and main pulmonary artery are transected. The left and right coronary artery ostia are visualized and excised from the aortic root with adjacent aortic wall as “buttons.” The coronary artery buttons are then shifted posteriorly and implanted into the facing sinuses of the main pulmonary artery root. Next, the

distal pulmonary artery and its branches are brought forward (LeCompte maneuver), and the distal aorta is moved posteriorly. The distal aorta is now anastomosed to the “new” aortic root. Reconstruction of the pulmonary artery is undertaken next, utilizing a patch of cryopreserved pulmonary artery homograft. Closure of the atrial septal defect completes the arterial switch repair. Transesophageal echocardiography is performed to help assess adequacy of repair. Delayed sternal closure is sometimes required following surgery.

Postoperative considerations

The postoperative course following arterial switch surgery can be variable. This is an extensive operaion. Lengthy great vessel suture lines predispose these patients to postoperative bleeding. Myocardial dysfunction is sometimes encountered and may require moderate dose inotropic support. Patients who present late, following regression of neonatal pulmonary vascular resistance, are more likely to encounter left ventricular dysfunction. Invasive monitors used include arterial and central venous catheters. An LA line is used when needed for hemodynamic management. LA pressure acts as a surrogate for left ventricular end diastolic pressure, an excellent indicator of left ventricular performance. Non-invasive monitors include NIRS (near-infrared spectroscopy) probes to assess adequacy of regional and global perfusion and traditional pulse oximetry. Vasoactive agents might include epinephrine and/ or milrinone. Numerous other agents are available and are tailored to the specific needs of the patient, targeting adequate oxygen delivery to the tissues of the body and optimization of cardiac output. Cardiac arrhythmias are a rarely encountered postoperative complication. Intracardiac pressures following arte- rial switch surgery should be normal. Arterial oxygen saturation should be normal. Length of hospital stay following repair averages 1 to 2 weeks.