Surgical Treatment of Transposition of Great Arteries (TGA)€¦ · Surgical Treatment of...
Transcript of Surgical Treatment of Transposition of Great Arteries (TGA)€¦ · Surgical Treatment of...
Dr Loh Yee Jim
Head, Cardiothoracic Surgery
KK Women’s and Children’s Hospital
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Surgical Treatment of
Transposition of Great
Arteries (TGA)
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Introduction
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Blalock-Hanlon Septectomy
• Alfred Blalock and his then resident Rollins
Hanlon (John Hopkins Hospital)
• Observed that presence of VSD was favourable
for survivor, followed by ASD
• Combination of the 2 defects was most
favourable
• Like BT shunt, Vivien Thomas conceived the
idea and flawlessly executed it in animal models
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Baffes operation
• Thomas Baffes was a resident under Dr Willis Potts at Children’s Memorial Hospital, Chicago
• Instead of arterial switch, he proposed a venous switch. Avoiding a coronary transfer
• Prosthetic grafts were not available commercially, they decided to use aortic homograft
• Homograft was used to join the IVC to LA and the right PVs were anastomosed to RA
• In 1960, 5-year results were described for 117 such patients with 29% survival
• The Baffes operation remained the treatment option for infants with transposition over the next 10 years
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Senning Procedure
• In 1957, Dr Ake Senning who trained under Dr
Clarence Crafoord performed the first successful
atrial switch at Karolinska Hospital, Stockholm,
Sweden
• Porcedure unsuccessful in first 2 patients
• 3rd case – 9 yo boy survived
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Mustard Procedure
• On May 16, 1963 at Hospital for Sick Children,
Toronto
• Operated on 18 mth old girl
• Surgery was conceptually based on the Albert
principle
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Balloon Atrial Septostomy (BAS)
• Natural history of untreated TGA in neonate is
poor
• Complete correction was possible since 1959
with the atrial switch procedure
• Best results with both operations were achieved
in children beyond 6 months of age
• Therefore an early palliation by creation of an
intraatrial communication was imperative
• Rashkind and Miller from Philadelphia in 1966
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“...The initial response to this report varied
between admiration and horror but, in either case,
the procedure stirred the imagination of the
“invasive” cardiologists throughout the entire
cardiology world and set the stage for all future
intracardiac interventional procedures – the true
beginning of pediatric and adult interventional
cardiology.” (Charles E. Mullins, 1998)
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The Arterial Switch Operation
Historical Context 1980
• Atrial level repairs (Senning or Mustard) were
carried out with <5% mortality risk for
TGA/IVS
• Initial reports of successful arterial switch
operations for TGA/VSD
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Why Switch?
Problems with atrial repairs
• Venous pathway obstruction
• Atrial arrhythmias (<50% in sinus rhythm at 10
years)
• RV function late post repair (especially D-TGA
with VSD)
• Tricuspid valve function late post repair
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The Arterial Switch Operation
Potential Advantages
• Morphologic LV as the systemic ventricle
• Morphological mitral valve as systemic AV
valve
• Reduction in atrial arrhythmias
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The Arterial Switch Operation
Potential Disadvantages
• Potentially higher mortality related to neonatal
repair
• Fate of pulmonary valve as systemic semilunar
valve
• Fate of transferred coronary arteries
• Growth of great vessel anastomoses
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Jatene Operation
• Adib Dominos Jatene, Brazilian surgeon of
Lebanese origin
• Performed first successfu truly anatomical correction
in 1975 at University of Sao Paulo Heart Institute
• 1st patient – 11 day old female. Extubated 6 hr after
surgery, but expired at 3rd POD of renal failure
• 2nd patient – 40 day old male. Discharged 3 wks
after surgery
• Next 5 patients expired within few hours after
surgery
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History
• Technically perfect coronary artery transfer was
the most critical step in a successful ASO
• Most widely accepted system of classifying
coronary antomy is called the Leiden convention
• Initially proposed by Gittenberger-DeGroot et al,
working with Quaegebeur’s group based in
Leiden, Netherlands
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• 1981, Lecompte from Laennec Hospital, Paris,
France described surgically translocating the
great vessels, popularly called the Lecompte
maneuver
• 1984, Castaneda from Children’s Hospital,
Boston introduced the concept of neonatal ASO
which today remains treatment of choice
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Arterial Switch Operation
Early Phase Results
# Mortality
CHSS (1985-89) 895 17.9%
CUH (1989-92) 330 14.8%
PCCC (1984-93) 1272 22.0%
BCH (1988-92) 171 1.8%
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LV training
• ASO do not give acceptable results after few months of life
• Inability of LV to operate at a systemic pressure
• Sir Magdi Yacoub from Harefield Hospita, UK proposed a 2-stage repair by performing PA banding first and BT shunt
• Concept of “LV training”
• Rapid 2 stage for patients with TGA and intact septum presenting beyond neonatal period was introduced by Dr Jonas in 1989
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Other surgical variants
• TGA with LVOTO – Rastelli procedure, involving
the use of a conduit for reconstruction of
pulmonary outflow tract
• “REV” (reeparation a la larat ventriculaire) to
reconstruction pulm outflow tract without using
prosthetic conduit as an alternative
• Dr Hisashi Nikaidoh from Children’s Medical
Cener, Dallas, Texas in 1982 described aortic
translocation
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Summary
• Arterial switch operation is the treatment of
choice
• LV training or 2 stage procedure (<6 mths)
• ASO + ECMO
• TGA, VSD, PS
– Rastelli
– Rev
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Summary
• TGA, VSD, PS
– Nikaidoh
– Unsuitable for Rastelli or REV procedure
• Restrictive VSD
• Coronary artery crossing the RVOT
• DKS + RV-PA conduit if coronary transfer is not
possible
• Atrial switch procedure for older children
Dr Loh Yee Jim
Head, Cardiothoracic Surgery
KK Women’s and Children’s Hospital
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Thank you!