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Transposition of the Great Arteries Preoperative Diagnostic Considerations
John Simpson Evelina Children’s Hospital
London, UK
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Euroecho , Copenhagen 2010
Areas to be covered
Definitions
Scope of occurrence of transposition of the great arteries
Echocardiographic findings
Important considerations
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Euroecho , Copenhagen 2010
Transposition of the great arteries
The aorta arises predominantly / exclusively from the morphologic right ventricle
The pulmonary artery arises predominantly / exclusively from the morphologic left ventricle
The relationship of the great arteries to each other does not define the condition e.g. aorta anterior
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Euroecho , Copenhagen 2010
Morphologies
Transposition of the great arteries may occur in association with a wide range of morphologies
As an example, Pascal et al (2007)
120 consecutive cases of prenatal transposed Gas
56 cases had concordant atrioventricular connection
64 cases had other subarterial morphologies
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Euroecho , Copenhagen 2010
Morphologies
Pascal 2007
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Euroecho , Copenhagen 2010
“Simple” transposition of the great arteries
Image : www.umich.edu
Differential sats : UL < LL
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Euroecho , Copenhagen 2010
Prenatal diagnosis
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Euroecho , Copenhagen 2010
Paris Data
Bonnet et al, Circulation, 1999
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Euroecho , Copenhagen 2010
“Simple” transposition of the great arteries
Inadequate mixing
Restrictive PFO
Restrictive duct
Has a significant impact on outcome
Image : www.umich.edu
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Euroecho , Copenhagen 2010
Cardiac Situs
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Euroecho , Copenhagen 2010
Interatrial Communication
Restrictive Unrestrictive
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Euroecho , Copenhagen 2010
Balloon Atrial Septostomy
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Euroecho , Copenhagen 2010
Four Chamber View
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Euroecho , Copenhagen 2010
Subcostal Views of Great Arteries
LV to PA Ao from RV
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Euroecho , Copenhagen 2010
Transposition of the Great Arteries
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Euroecho , Copenhagen 2010
Parasternal Long Axis
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Euroecho , Copenhagen 2010
Parasternal short axis
Ao
PA
Ao
PALR
Ant
Post Both of these examples taken from infants with TGA
The spatial relationship of the great arteries does not define
the lesion
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Euroecho , Copenhagen 2010
Suprasternal Views
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Euroecho , Copenhagen 2010
Late presentation Once PVR falls postnatally, the LV faces pulmonary vascular resistance
LV involutes
Primary arterial switch impossible
Careful evaluation if presentation beyond 4-6 weeks of age with simple TGA
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Euroecho , Copenhagen 2010
Late presentation of TGA
Note septal appearance “Hyperdynamic” LV
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Euroecho , Copenhagen 2010
The Coronary Arteries
Key point: Draw a labelled diagram of the coronaries
Coronaries almost invariably from “facing” sinuses
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Euroecho , Copenhagen 2010
Coronary arteries
Ao PA
RCA
LAD Anterior
Posterior
LR
Do not be fooled by pericardial folds
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Euroecho , Copenhagen 2010
Coronary Arteries
Coronary artery abnormalities are important prognostically
e.g Can an arterial switch operation be performed ?
Identification of :
Intramural
Single coronary artery
particularly important
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Euroecho , Copenhagen 2010
Associated Lesions
Ventricular septal defect
AV valve abnormalities
Pulmonary / Subpulmonary Stenosis
Aortic obstruction
Coronary artery abnormalities
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Euroecho , Copenhagen 2010
Ventricular Septal Defect
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Euroecho , Copenhagen 2010
Ventricular Septal Defect
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Euroecho , Copenhagen 2010
Watch for multiple VSDs
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Euroecho , Copenhagen 2010
Mitral Valve Abnormalities
RA
LA
LV
RV
MV
Attachments
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Euroecho , Copenhagen 2010
Cleft Mitral Valve
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Euroecho , Copenhagen 2010
Cleft Mitral Valve
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Euroecho , Copenhagen 2010
Subpulmonary Obstruction
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Euroecho , Copenhagen 2010
Subpulmonary Obstruction
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Euroecho , Copenhagen 2010
Doppler Assessment
Day 1 : Vmax 1.5m/s
Day 10 : Vmax 3.2m/s
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Euroecho , Copenhagen 2010
Arch Views in TGA
Aortic arch above ductal arch
Aortic and ductal arches similar plane
Ductal patency may obscure
coarctation of the aorta
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Euroecho , Copenhagen 2010
Relative size and relationship of GAs
Ao
PA
PA
Ao Ao
PA
Long Axis Short Axis
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Euroecho , Copenhagen 2010
Careful Assessment of Aortic Arch
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Euroecho , Copenhagen 2010
Tips and tricks : Transposition Initial assessment
1. Know the upper and lower limb saturations
The upper limbs are most important – brain sats
2. Baby should be on PGE to maintain ductal patency
3. If sats v. low, get senior help early
4. Know the baby’s age !
Rapidly assess main diagnostic points
VA discordance
Mixing status
Atrial mixing
Duct
Ventricular septal defects
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Euroecho , Copenhagen 2010
Further assessment
Ventricular septum
VSDs often slit like, take multiple views / 3D
Watch out for multiple VSDs , check the apex !
AV Valves
Do not assume normal AV valve morphology e.g. MV cleft
Careful exclusion of outflow tract obstruction
CF: reassess when PVR falls
Identify “potential” obstruction
Check the aortic arch particularly carefully
Exclusion of coarctation difficult in TGA
Occasionally septostomy + leave off PGE