Timing of Arterial Switch Operation in Dextro-Transposition of Great Arteries with Intact Septum: Factors Associated with Delay, Practice Variation, and Associated Outcomes.

We examined the current practice, factors associated with delay, and impact of timing of arterial switch operation (ASO) on outcomes of d-transposition of great arteries (d-TGA) with intact ventricular septum (IVS). Neonates with d-TGA + IVS undergoing ASO were identified from the Pediatric Health Informational System database. Factors associated with delayed repair, practice trends, and outcomes related to surgical timing were analyzed. A cut-point analysis was performed to determine if an age threshold predicted in-hospital death or post-op ECMO. A total of 3523 patients were included. The distribution by age was: 0-3 d: 24%, 4-7 d: 51%, 8-14 d: 20%, 15-30 d: 6%; median: 5 d(IQR 4-8). A cut-off age of 7 days was identified for the composite outcome (death/ECMO), with an odds ratio of 1.79 (95%CI: 1.13-2.82), p = 0.013, after adjusting for prematurity and other confounders. Predictors of delay beyond seven days included [OR(95% CI)] non-birth admissions:6.31(4.37-9.12), < 2 kg-birthweight: 3.21(1.69-6.09), pre-operative-stroke: 2.86(1.73-4.74), and balloon atrial septostomy: 2.25(1.81-2.79). Increasing center case volume was associated with earlier repair: 0.82(0.78-0.85), all p < 0.05. A trend was observed in decreasing age at ASO in the latest study years: 2018-2024 median age (IQR): 5 days (3-7) vs 2004-2017: 6 days (4-8), p < 0.001. In this large multicenter cohort comprised exclusively of d-TGA + IVS neonates; we found that ASO performed after the age of seven days resulted in worse in-hospital outcomes. Factors associated with surgical delay included non-birth admission, low-birthweight, pre-operative stroke, and balloon atrial septostomy. A trend toward very early repair within the first five days of life has emerged in the past decade.