REOPERATION AFTER THE ARTERIAL SWITCH OPERATION FOR TRANSPOSITION OF THE GREAT-ARTERIES

Although most children after an arterial switch operation for transpos ition of the great arteries have normal development and cardiac functi on, a few require reoperation. During the last 10 years, 68 of 753 pat ients who underwent arterial switch operations (9.3%) underwent 75 reo perations. Thirty underwent early reoperation (<30 days or during the same hospital stay) and 38 underwent late reoperation, Causes for reop eration included pacemaker insertion (n = 5), left diaphragm plication (n = 4), revision for hemostasis (n = 1), mediastinitis (n = 2), supe rior vena cava thrombosis (n = 9), subvalvular pulmonic stenosis (n = 5), supravalvular pulmonic stenosis (n = 16), residual atrial (n = 2) or ventricular (n = 8) septal defects, isolated mitral valve insuffici ency (n = 2), aortic valve insufficiency (either isolated [n = 1] or i n association with mitral incompetence [n = 1] or stenosis (n = 11), l eft coronary artery ostial stenosis (n = 1), and recurrent aortic (n = 6) or neoaortic (n = 4) aortic coarctation. In all but 27 patients, t he residual defects were already present immediately after the complet ion of the arterial switch operation; however, only patients with crit ical lesions were reoperated on early. Interventional catheterization procedures were performed when indicated; however, they only postponed inevitable reoperation. Successful relief of superior vena cava throm bosis was achieved by atriojugular bypass grafting in two patients, by early open thrombectomy in six patients, and by direct patch angiopla sty of the superior vena cava once. Patch plasty for subvalvular or su pravalvular pulmonic stenosis was carried out in 21 patients, septal d efect closure was carried out in nine patients, and pulmonary artery b anding was performed in one patient with criss-cross atrioventricular relationship and multiple ventricular septal defects. Valve repair was performed in all five patients,vith either isolated or combined aorti c and mitral valve dysfunction. One patient with left coronary ostial stenosis underwent a patch enlargement of this ostium. Recoarctation w as repaired by end-to-end anastomosis in eight patients and by a subcl avian flap and a patch angioplasty in one patient each. Seven patients underwent a second reoperation for supravalvular pulmonary stenosis ( n = 3), mitral valve replacement (n = 1), ventricular septal defect cl osure (n = 1), and recurrent coarctation (n = 2). There were six intra operative (8.8%) and two late deaths. All early deaths occurred after early reoperations. Risk factors for intraoperative death at reoperati on were early reoperation (p < 0.01) and multiple residual ventricular septal defect (p < 0.01). Among the entire group who underwent arteri al switch operation, there were no risk factors for the overall group of persons undergoing reoperation; however, univariate analysis reveal ed risk factors for reoperation for right ventricular outflow tract ob struction. These included nonneonatal repair (p < 0.01), long-standing pulmonary arterial banding (p < 0.01), associated defects (p < 0.001) , and the surgical technique used for pulmonary arterial reconstructio n (single versus two pericardial patches, direct anastomosis without p atch insertion; p < 0.05). Multivariate analysis revealed that only th e presence of a hypolastic native aortic anulus as opposed to the nati ve pulmonary anulus was a risk factor for postoperative pulmonary sten osis and reoperation, Mean follow-up of 70 +/- 19 months was achieved in all survivors, and they were all free of symptoms and need for medi cation, In conclusion, most lesions requiring a reoperation after an a rterial switch operation are detectable early, and intraoperative echo cardiography might consequently be useful, Most late reoperations can be prevented by primary neonatal repair of almost all forms of transpo sition of the great arteries.