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Background and Objectives: With the growing population of arterial switch operation survivors, the rate of late complications associated with the operation is growing as well. The aim of this publication is to share our experience and encourage collaboration between congenital cardiac surgeons and interventional cardiologists in treating late complications after arterial switch operation. Materials and Methods: A retrospective analysis of Vilnius University Santaros Clinics Cardiothoracic Surgery Centre arterial switch operation survivors who underwent additional treatment for late neo-pulmonary artery stenosis and aortic arch obstruction between 1989 and 2019 was conducted. Results: Out of 95 arterial switch operation survivors 14 (15%) underwent 36 reinterventions. The majority were treated for neo-pulmonary stenosis. The median time from arterial switch operation to the first reintervention was 1.4 years (interquartile range, 2 months to 2.4 years). 1, 3, 5, and 10 years intervention-free survival in patients treated for neo-pulmonary stenosis and aortic arch obstruction was 98, 94, 94, and 93% vs. 95, 94, 94, and 93%, respectively. There were no complications associated with redo surgical procedures, while eight patients who underwent catheter-based interventional treatment had treatment-related complications, including one death. Conclusions: Both neo-pulmonary stenosis and aortic arch obstruction (new aortic coarctations or aortic recoarctations) tend to develop in the first decade after an arterial switch operation. Surgical and catheter-based interventional treatment with good results is possible even in a small volume center. Close collaboration of the congenital heart team (congenital cardiac surgeons and interventional cardiologists) in choosing the best treatment option for an individual patient helps to minimize the risk of potential complications.

The aims of this study were to evaluate the 16-year experience with  arterial switch operation at Beijing Children's Hospital and to determine early and late mortality and late morbidity, to explore risk factors for late complications and reintervention, and finally to evaluate whether the neoaortic sinotubular junction reconstruction technique reduces late complications of arterial switch operation. The clinical data of 185 patients with transposition of the great arteries who underwent arterial switch operation in Beijing Children's Hospital from January 2006 to January 2022 and 30 patients who underwent modified arterial switch operation with neoaortic sinotubular junction reconstruction technique in Fuwai Hospital during the same period were retrospectively analysed. Propensity score matching was also used to match the neoaortic sinotubular junction reconstruction patients in Fuwai Hospital with 30 non-neoaortic sinotubular junction reconstruction patients in Beijing Children's Hospital. There were 13 early deaths (7.03%) and five late deaths (3.01%). Nineteen patients (11.45%) developed new aortic valve regurgitation and 28 patients (16.87%) developed aortic root dilation. Late right ventricular outflow tract obstruction occurred in 33 patients (19.88%). Late reintervention occurred in 18 cases (10.84%). Multivariate analysis showed that aorto-pulmonary diameter mismatch, previous pulmonary artery banding, and mild moderate or above new aortic valve regurgitation at discharge were independent risk factors for late new aortic valve regurgitation and aortic root dilation. Low surgical weight was an independent risk factor specific to new aortic valve regurgitation, and bicuspid native pulmonary valve was an independent risk factor specific to aortic root dilation. Older surgical age and aortic root dilation were independent risk factors for late right ventricular outflow tract obstruction. Older surgical age, operation before 2014, late right ventricular outflow tract obstruction, and late aortic root dilation were independent risk factors for late intervention. Propensity score matching showed that new aortic valve regurgitation and aortic root dilation were not followed up in the neoaortic sinotubular junction reconstruction group, while seven cases of aortic root dilation and five cases of new aortic valve regurgitation occurred in the non-neoaortic sinotubular junction reconstruction group, respectively, and the differences were statistically significant (P = 0.003; P = 0.015). The increased incidence of new aortic valve regurgitation, aortic root dilation, and right ventricular outflow tract obstruction as children age is a major concern outcome in the future and may mean more late reintervention. neoaortic sinotubular junction reconstruction technique may reduce the incidence of new aortic valve regurgitation and aortic root dilation, and improve the late prognosis of arterial switch operation. Careful follow-up of neo-aortic valve and root function is imperative, especially in patients with aorto-pulmonary diameter mismatch, previous pulmonary artery banding, mild new aortic valve regurgitation at discharge, low surgical weight, and bicuspid native pulmonary valve structures.

Abstract Objectıves The arterial switch operation (ASO) is the standard treatment for transposition of the great arteries (TGA), requiring robust myocardial protection due to the neonatal myocardium’s vulnerability to ischaemia. This study compares the myocardial protective efficacy of Custodiol, Del Nido, and cold intermittent blood cardioplegia in neonates undergoing ASO. Methods We retrospectively analysed 133 neonates with TGA undergoing ASO (2013-2024) at 4 Turkish centres, grouped by cardioplegia: cold blood (n = 47), Custodiol (n = 44), or Del Nido (n = 42). Outcomes included aortic cross-clamp and cardiopulmonary bypass times, troponin I, CK-MB, inotropic support, and ventilation duration. Results Custodiol and Del Nido had shorter cross-clamp (70.4 (8.5) vs 68.7 (7.9) vs 78.2 (9.1) minutes, P < .001) and bypass times (P = .004), lower troponin I (4.2 (1.3) vs 4.0 (1.5) vs 6.8 (1.9) ng/mL, P < .001), reduced inotropic needs (P < .001), and shorter ventilation/intensive care unit stays (P ≤ .010). Mortality was similar (P = .47). Conclusıons Custodiol and Del Nido cardioplegia strategies provided favourable outcomes compared to cold blood cardioplegia in neonates undergoing ASO, with implications for optimizing myocardial protection protocols in this population. Transposition of the great arteries (TGA) is a critical congenital heart defect requiring arterial switch operation (ASO). Graphical Abstract

In selected patients with transposition of the great arteries (TGA), ventricular septal defect (VSD) and left ventricular outflow tract obstruction (LVOTO), the arterial switch operation (ASO) may be the procedure of choice. This study reviews the clinical outcomes of TGA-VSD-LVOTO patients after ASO and compares mechanisms of LVOTO in this patient group to a historical series of cardiac specimens. This retrospective analysis included all cases with TGA-VSD-LVOTO who underwent ASO between January 1977 and December 2023. Additionally, a series of non-operated cardiac specimens with TGA-VSD-LVOTO was selected and examined for morphological comparison. Eleven patients with TGA-VSD-LVOTO underwent ASO. Eight of them had TGA-VSD, and three had Taussig-Bing anomaly. LVOTO mechanisms were multifactorial, including posteriorly deviated infundibular septum and fibrous tissue masses. Median age at ASO was 0.4 (0.07-1.8) years. Ten patients underwent primary LVOTO relief during ASO; no in-hospital mortality occurred. Two patients died >30 days post-ASO at 3.1 months and 6.0 years. Median follow-up was 19.0 (11.1-26.8) years, all survivors in NYHA class I. The patient without initial LVOTO relief did require reoperation during follow-up for progressive LVOTO at 3.5 months post-ASO. Two patients had moderate residual LVOTO at latest follow-up (gradient 30-50 mmHg). No significant neoaortic valve regurgitation was observed. From the anatomical specimen series, 10 of 33 TGA-VSD-LVOTO specimen were deemed eligible for ASO, revealing similar LVOTO mechanisms as the clinical cases. ASO is feasible in selected patients with TGA-VSD-LVOTO showing good long-term outcomes with preserved neoaortic valve function and no reoperations for LVOTO after initial relief.

This study evaluates the morbidity, mortality, and cost differences between patients who underwent either a simple or a complex arterial switch operation. A retrospective study of patients undergoing an arterial switch operation at a single institution was performed. Simple cases were defined as patients with d-transposition of the great arteries with usual coronary anatomy or circumflex artery originating from the right with either intact ventricular septum or ventricular septal defect. Complex cases included all other forms of coronary anatomy, aortic coarctation or arch hypoplasia, and Taussig-Bing anomalies. Costs were acquired using an institutional activity-based accounting system. A total of 98 patients were identified, 68 patients in the simple group and 30 in the complex group. The mortality rate was 2% for the simple and 7% for the complex group, p=0.23. Major morbidities including cardiac arrest, extracorporeal membrane oxygenation, a major coronary event, surgical or catheter-based re-intervention, stroke, or permanent pacemaker placement, non-cardiac surgical procedures, mediastinitis, and sepsis did not differ between the simple and complex groups (16 versus 27%, p=0.16). The complex group had increased bleeding requiring re-exploration (0 versus 10%, p=0.04). Hospital and ICU length of stay did not differ. Complex patients had higher overall hospital costs (simple $80,749 versus complex $97,387, p=0.01) and higher postoperative costs (simple $60,192 versus complex $70,132, p=0.02). The operating room and supplies accounted for the majority of the cost difference. Complex arterial switches can be safely performed with low rates of morbidity and mortality but at an increased cost.

Background The aim of this study was to determine if there was a difference between coronary reimplantation after neoaortic reconstruction and open coronary reimplantation technique in arterial switch operation (ASO). Methods A total of 236 patients who underwent ASO from March 1994 to August 2018 were enrolled in this study. Multivariate analysis was performed for postoperative early mortality. Patients were divided into the open coronary reimplantation and coronary reimplantation after neoaortic reconstruction groups. The 30-day mortality, intraoperative and postoperative coronary artery (CA) revisions, CA–related late morbidity and mortality, and early and late neoaortic valve regurgitations after ASO were compared between the two groups. Results Overall postoperative early mortality was 7.2% (17/236). Patients who underwent open coronary reimplantation had higher early mortality as compared with those who underwent coronary reimplantation after neoaortic reconstruction. Risk factors for postoperative early mortality from multivariate analysis were cardiopulmonary bypass time and open coronary reimplantation. There was a higher incidence of CA–related late mortality or morbidity in the open coronary reimplantation group. The open coronary reimplantation group had a higher incidence of intraoperative or postoperative CA revision. There were no differences in the incidence of mild or more neoaortic valve regurgitation at discharge or in the 5-year freedom from mild or more neoaortic valve regurgitation. Conclusions CA reimplantation after neoaortic reconstruction yields better results in mortality and intraoperative or postoperative CA–related problems in ASO without increasing postoperative neoaortic valve regurgitation.

BackgroundTo date, clinical trials have been underpowered to demonstrate a benefit from ACE inhibitors (ACEis) or angiotensin II receptor blockers (ARBs) in preventing systemic right ventricle (sRV) failure and disease progression in patients with transposition of the great arteries (TGA). This observational study aimed to estimate the effect of ACEi and ARB on heart failure (HF) incidence and mortality in a large population of patients with an sRV.MethodsData on all patients with an sRV under active follow-up at two tertiary centres between January 2007 and September 2018 were studied. The effect of ACEi and ARB on the incidence of HF and mortality was estimated using a propensity score weighting approach to control confounding.ResultsAmong the 359 patients with an sRV (32.2 (IQR 26.4–38.3) years, 59.3% male, 66% complete TGA with atrial switch repair and 34% congenitally corrected TGA), 79 (22%) had a moderate to severe sRV dysfunction and 138 (38%) were treated with ACEi or ARB. Fourteen (3.6%) patients died, 8 (2.1%) underwent heart transplantation and 46 (11.8%) had a new HF event over a median follow-up of 7.1 (IQR 4.0–9.4) years. On multivariate Cox analysis with adjustment using propensity score weighting approaches, ACEi or ARBs treatment was not significantly associated with a lower HF incidence or mortality in patients with an sRV.ConclusionsDespite significant neurohormonal activation described in patients with an sRV, there is still no evidence of a beneficial effect of ACEi or ARB on morbidity and mortality in this population.

This retrospective study aimed to determine the incidence, risk factors, and outcomes of acute kidney injury (AKI) in neonates following the arterial switch operation (ASO) for transposition of great arteries (TGA). Retrospective review of medical data of children who underwent ASO in 2019-2020 in the Ukrainian Children's Cardiac Center. 76 consecutive neonatal patients were included, 48 developed AKI after ASO (51.7%), and 24 - had severe AKI (25.8%). Severe AKI development was associated with longer cross-clamp time: 82 (61-127) versus 73.5 (53-136) in the non-severe AKI group (p = 0.02). 76 min of cross-clamp time were defined as a threshold value for increased severe AKI risk, OR 4.4 (95% CI: 1.5 - 13, p = 0.01). Higher lactate levels during cardiopulmonary bypass (CPB) increased severe AKI development risk, OR 1.5 (95% CI: 1.0 − 2.0, p = 0.03). Children with severe AKI had prolonged mechanical ventilation, longer time to negative fluid balance, and higher postoperative day 3 (POD3) Inotropic Score (IS). Only one patient required peritoneal dialysis. In our study, 51.7% of patients developed AKI after ASO, 25.8%-severe AKI. Prolonged cross-clamp time and higher lactate levels during cardiopulmonary bypass increased the risk for severe AKI development. The development of AKI was associated with prolonged mechanical ventilation, longer time to negative fluid balance, higher POD 3 Inotropic Score.

The arterial switch operation for d-transposition of the great arteries achieves anatomic repair but creates the potential for right ventricular outflow tract obstruction as a result of the LeCompte maneuver. The resultant right ventricular hypertension is generally well tolerated but a select group are referred for cardiac catheterization. The outcomes of these catheterizations have not been well described. The objective of this study was to describe the degree and nature of right ventricular outflow tract obstruction found during cardiac catheterization among patients following the arterial switch operation as well as determine the rate of intervention and assess the acute impact of any catheter intervention undertaken. We conducted a retrospective study of patients after arterial switch operation with the LeCompte maneuver and subsequent right heart catheterization. Descriptive statistics were reported, and paired sample t tests were used for analysis. 544 children had an arterial switch operation, of which 110 children (20%) had a cardiac catheterization procedure after surgery and 11% had a right heart catheterization. Of the right heart catheterizations, 90% had an intervention (balloon and/or stent). In the interventional group, the right ventricle to systemic pressure ratio decreased modestly, from 2/3 to half systemic, after balloon dilation and/or stent placement ( p  < 0.01). No serious complications were observed.

The optimal approach for supravalvar right ventricular outflow tract obstruction(RVOTO) after arterial switch operation(ASO) is unclear. The results of percutaneous balloon dilatation have been variable. We report the results of simultaneous double balloon dilation for RVOTO after ASO. Sixteen patients (1.3(0.7–3.8) years; 9.8(8.1–15.1) kgs underwent the procedure at 14(8–44.5) months after ASO. Salient technical features included placement of balloons over stiff guide-wires positioned in both branch pulmonary arteries to enable dilation of the distal-most main pulmonary artery (MPA) with high inflation pressures (~ 12–14 atmospheres) and short inflation-deflation cycles. Effective balloon size was based on the PA annulus or MPA distal to the narrowing. The final balloon: narrowest segment diameter ratio was 2.7. Following dilation, the right ventricle to systemic systolic pressure ratio decreased from 0.9 ± 0.18 to 0.52 ± 0.16 ( p   < 0.001) and mean RVOT gradient from 78 ± 18 to 34 ± 13.9 mmHg ( p  < 0.001). Narrowest diameter improved from 5.4 ± 2.2 to 9.2 ± 2.2 mm. There were no major complications. Two patients with inadequate relief (final RV-systemic ratios: 1.03 and 0.7) were referred for surgery. At median follow up of 9 months, IQR 7–22, range 5–73, others are free of re interventions with median RVOT gradient of 42, IQR 27–49, range 21–55 mmHg. The immediate and short-term follow up results of double balloon dilatation for supravalvar RVOTO is encouraging and may avoid the need for repeat surgery in the majority of patients. Further follow up is needed to determine the long-term durability of the results.