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!