Late Outcomes after Arterial Switch Operation for Taussig

Late Outcomes after Arterial Switch Operation for Taussig‐Bing Anomaly:
Can we afford Biventricular Repair?
M Vergnat, A Baruteau, L Houyel, M Ly, R Roussin, V Lambert, E Belli
Centre Chirurgical Marie Lannelongue / M3C
Paris-South University, France
NO DISCLOSURE
ASO for TBA
Background
•DORV
•Subpulmonary Malalignment VSD
•Aorta D-malposed ≈ Side by side
•Associated anomalies: AAO
•Procedure of choice: ASO
Taussig HB, Bing RJ. Am Heart J 1949;37(4):551‐9
ASO for TBA
Rationale
• Surgical Challenge
•
•
•
•
Neonatal procedure
Intracardiac baffling
Coronary anatomy
Associated Aortic Arch repair
• Anatomic repair of Taussig‐Bing hearts. Serraf A et al. Circulation 1991 ;84:III200‐5.
• Risk Factors influencing outcome
ASO for TBA
Methods
Inclusion criteria
Van Praagh:
 “real” DORV
 Sub-pulmonary VSD
 Bilateral Coni
Mitro-pulmonary discontinuity
 GA out of RV (> 50% rule)
 No pulmonary stenosis
ASO for TBA
Patients
• 1997-2010
• 69 patients: ASO
60 primary / 9 staged
• Median age at repair: 24 (range: 4-618) days
≤1 month: n=38 (55%)
ASO for TBA
Patients
Anatomy
Great Vessels
Side by side
D-malposition
PA-Aorte ratio
Coronary pattern
C or E
A or D
Commissural malalignment
Aortic Arch Obstruction
Outflow Tract Obstruction
Right (sub-aortic)
Left (sub-pulmonary)
47 (68%)
22 (32%)
1.5 (1-2.5)
38 (55%)
31 (45%)
6 (9%)
26 (38%)
10 (14%)
15 (22%)
ASO for TBA
Results
Operative data
Timing (min)
bypass
184±64
X-clamp
114±33
DHCA (n=10) 30±9
LV to PA Tunnel
PA
57 (83%)
RV
RA
7 (10%)
5 (7%)
Dacron
pericardium
Goretex
56 (83%)
12 (17%)
1 (2%)
ASO for TBA
Results
Operative data
Associated procedures
Aortic Arch repair
homograft / direct
26 (38%)
21 / 5
RVOTO relief (subAortic)
12 (17%)
LVOTO relief (subPulmonary)
4 (6%)
Pulmonary bifurcation translation
VSD closure
PAB
4 (6%)
2 (3%)
1 (2%)
ASO for TBA
Results
Mortality
• Early Mortality: n=4 (5.8%, 95%CI 1.6-14.2)
- Coronary anatomy: 3 type E, 1 type C
- Delay: perop., H+6, D3 and D11 (1 ECMO)
- Cause: myocardial ischemia
ASO for TBA
Results
Overall outcome
« Late » mortality: n=5 (7.7%) (<1year)
(3 Sudden Deaths, 2 Biventricular failures)
All patients
53
53
49
40
32
Years
Survival
ASO for TBA
Results
Overall outcome
Type A & D
All patients
Type C & E
Log-Rank Test
Type C & E vs. A & D p=0.04
Years
Survival
ASO for TBA
Results
Overall outcome
Median Follow-up 11.2 years (0.1-16.2)
All patients
85±4% at one and 10 years
53
53
49
40
32
Years
Survival
ASO for TBA
Results
Surg. and Cath. Reinterventions
All patients
58±7% at 10 years
45
41
36
23
17
Years
Freedom from Reintervention
ASO for TBA
Results
Surg. and Cath. Reinterventions
RVOT+PA
LVOT+Aorta
All patients
Years
Freedom from Reintervention
ASO for TBA
Results
Reinterventions (n=38 in 21 pts,40%)
9 (17%)
Catheter
Aortic Arch
PA
8
5
balloon or stent
balloon or stent
Surgery
LVOTO
Aortic Valve: remplacement/repair
Reccurent Arch obstruction
13
19 (36%)
25
8
5/3
3
Pulmonary arterioplasty
RVOTO
11
5
VSD
Coronary
4
3
ASO for TBA
Results
Surg. and Cath. Reinterventions
All patients
45
41
36
23
17
Years
Freedom from Reintervention
ASO for TBA
Results
Surg. and Cath. Reinterventions
Risk factor
Normal Arch
All patients
Obstructed
Arch
Log-Rank Test
Normal Arch vs. Obstructed Arch p=0.006
Years
Freedom from Reintervention
ASO for TBA
Results
Surg. and Cath. Reinterventions
Risk factor
Crafoord
p=0.002
AAO Reint.
AAO
p=0.02
postOp AR≥2
p=0.02
p=0.03
PA/Ao >2
p=0.04
RVOTO Reint.
ARegurg Reint.
ASO for TBA
Results
Follow-Up
• Median Follow-up 11.2 years (0.1-16.2)
• 60 survivors:
- 96% NYHA1
- 98% sinus and normal BiV function
- 1 Heart Transplant
- 74% « normal » echocardiography:
• 9% AVR, 4% grade3 AR, 17% grade 2
• 13% mild (L/R) VOTO
• 7% medical AAO
ASO for TBA
Conclusions
•
Complex anomaly/procedure
•
Early outcome (mortality)
•

1st year, coronary-related

Early identification of lesions at risk
Long-term outcome: > 10 y (reinterventions)


Sustained functional outcome, no mortality
Reinterventions ↔ Ao. Arch Obstruction

Neo-Aortic root preservation:
(patch augmentation, VSD closure technique)
preventive management of RVOT at risk for obstruction
