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J Thorac Cardiovasc Surg 2004;127:975-981
© 2004 The American Association for Thoracic Surgery
Surgery for congenital heart disease |
a Ste-Justine Hospital, Montreal, Quebec, Canada
b Royal Children's Hospital, Melbourne, Australia
c Cleveland Clinic Foundation, Cleveland, Ohio, USA
Read at the Eighty-third Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass, May 4-7, 2003.
Received for publication May 13, 2002; revisions received October 2, 2003; accepted for publication October 6, 2003.
* Address for reprints: Roger B. B. Mee, MB, ChB, FRACS, Center for Pediatric and Congenital Heart Disease, Cleveland Clinic Foundation, 9500 Euclid Ave, Unit M41, Cleveland, OH 44195, USA
meer{at}ccf.org
OBJECTIVES: Systemic right ventricular failure after atrial switch procedures for transposition of the great arteries has been addressed at Melbourne's Royal Children's Hospital (1981-1993) and the Cleveland Clinic Foundation (1993-2001) with reconditioning of the morphologically left ventricle by means of pulmonary artery banding followed by an arterial switch operation and an atrial reseptation.
METHODS: Thirty-nine patients (Royal Children's Hospital, 19; Cleveland Clinic Foundation, 20) with a median age of 10.8 years (range, 13 months–24 years) entered this protocol a median of 10.3 years (range, 0.5-24 years) after an atrial switch procedure.
RESULTS: The median duration of pulmonary artery banding was 13 months (range, 0.5-5.4 years). Ten (28%) patients responded unfavorably to morphologically left ventricular reconditioning (5 mortalities: 4 transplantations and 1 PAB still in place). Twenty-four (83%) of the 29 patients who underwent an atrial switch operation and atrial reseptation survived. During a median follow-up period of 8.2 years (range, 1-16 years), 3 patients had cardiac-related deaths. All 18 long-term survivors are asymptomatic. At last echocardiographic evaluation, the morphologically left ventricular function was normal or mildly decreased in 16 (89%) patients, and all had normal or mildly decreased systemic right ventricular function with no or mild tricuspid regurgitation. Age greater than 12 years was associated with a greater probability of morphologically left ventricular failure and not completing the protocol (P = .02) and a higher operative mortality at anatomic correction (P = .02).
CONCLUSIONS: Morphologically left ventricular reconditioning and an anatomic correction protocol should be integrated into a cardiac transplantation program when treating patients with morphologically right ventricular failure after Mustard and Senning procedures. It is an alternative to cardiac transplantation in selected patients, with good long-term results. The response to morphologically left ventricular reconditioning past adolescence is inconsistent.
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