Lacour-Gayet F, Piot D, Zoghbi J, Serraf A, Gruber P, Macé L, Touchot A, Planché C
Marie Lannelongue Hospital, Paris-Sud University, 133 Avenue de la Résistance, 92350 Le Plessis Robinson, Paris, France.
Eur J Cardiothorac Surg. 2001 Oct;20(4):824-9. doi: 10.1016/s1010-7940(01)00897-1.
Arterial switch is the operation of reference for the surgical treatment of transposition of the great arteries. In cases of late referral, perinatal complications or early left ventricular (LV) dysfunction, the one stage arterial switch is contra indicated. Anatomical repair remains possible in these patients following a LV retraining.
From January 1992 to January 2000, a LV retraining was attempted in 22 patients with transposition of the great arteries with intact ventricular septum (TGA IVS), whereas 470 direct arterial switch and 2 Senning were performed. Indication for LV retraining was based on a combination of factors including: an age older than 3 weeks, a "banana shape" aspect of the inter-ventricular septum and mainly a LV mass <35G/m(2).
The mean age at LV retraining was 3.2 months ranging from 9 days to 8 months. Usually conducted by sterntomy, it associated a loose PA banding with a LV/RV at 65% with a systemico-pulmonary shunt. The first stage was associated with frequent LV dysfunction and the LV retraining was discontinued in two patients in favor of one Senning and one early switch followed by ECMO. One patient died at first stage from a mediastinitis. Nineteen patients underwent a second stage arterial switch that was performed when the LV mass had reached 50 G/m(2) after a mean delay of 10 days, ranging from 5 days to 6 weeks. After a mean follow up of 25 months, there was one non-cardiac late death. The 17 patients followed and leaving with an arterial switch are in NYHA class I, with a mean LV shortening fraction of 39%.
Arterial switch following LV retraining in TGA IVS is a satisfactory option. The inferior limit of 35 G/m(2) adopted, to indicate LV retraining, seems a safe landmark. The quality of the myocardium generated and the respective roles played by the LV afterload, LV wall shear stress, LV inflow and outflow to induce the LV remodeling remain under debate.
动脉调转术是大动脉转位外科治疗的参考术式。对于转诊延迟、围产期并发症或早期左心室（LV）功能障碍的病例，一期动脉调转术为禁忌。在这些患者中，经过左心室重塑后仍可进行解剖修复。
1992年1月至2000年1月，对22例室间隔完整的大动脉转位（TGA IVS）患者尝试进行左心室重塑，同期进行了470例直接动脉调转术和2例森宁手术。左心室重塑的指征基于多种因素的综合判断，包括：年龄大于3周、室间隔呈“香蕉形”，主要是左心室质量<35G/m²。
左心室重塑的平均年龄为3.2个月，范围从9天至8个月。通常通过胸骨切开术进行，联合宽松的肺动脉环扎术，左心室/右心室比例为65%，并伴有体肺分流。第一阶段常伴有频繁的左心室功能障碍，两名患者停止左心室重塑，转而进行一例森宁手术和一例早期动脉调转术并辅以体外膜肺氧合（ECMO）。一名患者在第一阶段死于纵隔炎。19例患者在左心室质量达到50 G/m²后平均延迟10天（范围为5天至6周）进行了第二阶段动脉调转术。平均随访25个月后，有一例非心脏性晚期死亡。接受随访并采用动脉调转术的17例患者心功能分级为纽约心脏协会（NYHA）I级，左心室平均缩短分数为39%。
TGA IVS患者经左心室重塑后进行动脉调转术是一种令人满意的选择。用于指示左心室重塑的35 G/m²下限似乎是一个安全的指标。左心室后负荷、左心室壁剪切应力、左心室流入和流出在诱导左心室重塑中所起的作用以及所产生的心肌质量仍存在争议。
