Kobayashi Yasuyuki, Suryakumar Aditya, Beroukhim Rebecca, Staffa Steven J, Zurakowski David, Emani Sitaram M
Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
J Thorac Cardiovasc Surg. 2025 Jul 5. doi: 10.1016/j.jtcvs.2025.06.033.
To assess risk factors for neo-aortic insufficiency (AI) after the arterial switch operation (ASO) or double-switch operation (DSO) for transposition of the great arteries (TGA) beyond the neonatal period. We hypothesized that native left ventricular outflow tract obstruction (nLVOTO) without prior pulmonary artery banding (PAB) increases the risk of neo-AI-related reoperation.
This retrospective review included 157 patients (excluding neonates) with D- or L-TGA who underwent ASO (n = 47) or DSO (n = 110) between 2011 and 2024. The primary endpoint was neo-AI-related reoperation, and risk factors were assessed.
Fifteen patients required a neo-AI-related reoperation. Multivariable analysis identified nLVOTO without antecedent PAB as the sole risk factor for these reoperations. Freedom from neo-AI-related reoperation at 5 years was 59.1% in the nLVOTO group (n = 48) and 93.2% in the PAB group (n = 109) (P < .001). The change in neo-aortic root z-score (neoAoR-Z) following ASO was greater in the nLVOTO group compared to the PAB group (1.07 vs 0.16; P < .001). Among the 11 patients in the nLVOTO group requiring reoperation, 4 (36%) underwent the procedure before discharge. In patients with nLVOTO, freedom from neo-AI-related reoperation at 4 years was 79.5% for those with a prebypass neoAoR-Z ≤0, 72.7% in those with a prebypass neoAoR-Z >0 with root reduction, and 19.0% in those with a pre-bypass neoAoR-Z >0 without reduction (P = .008).
A rapid increase in the neoAoR-Z is associated with a higher incidence of neo-AI in the nLVOTO group compared to the PAB group. Simultaneous neo-aortic root reduction may mitigate this risk, warranting consideration of additional surgical strategies.
评估大动脉转位（TGA）患儿在新生儿期后接受动脉调转术（ASO）或双调转术（DSO）后发生新主动脉瓣关闭不全（AI）的危险因素。我们假设未经肺动脉环扎术（PAB）的先天性左心室流出道梗阻（nLVOTO）会增加与新AI相关再次手术的风险。
这项回顾性研究纳入了2011年至2024年间接受ASO（n = 47）或DSO（n = 110）的157例（不包括新生儿）D型或L型TGA患者。主要终点是与新AI相关的再次手术，并评估危险因素。
15例患者需要进行与新AI相关的再次手术。多变量分析确定，无前驱PAB的nLVOTO是这些再次手术的唯一危险因素。nLVOTO组（n = 48）5年时无新AI相关再次手术的比例为59.1%，PAB组（n = 109）为93.2%（P <.001）。与PAB组相比，nLVOTO组ASO后新主动脉根部z评分（neoAoR-Z）的变化更大（1.07对0.16；P <.001）。nLVOTO组中需要再次手术的11例患者中，4例（36%）在出院前接受了手术。在nLVOTO患者中，体外循环前neoAoR-Z≤0的患者4年时无新AI相关再次手术的比例为79.5%，体外循环前neoAoR-Z>0且进行根部缩小的患者为72.7%，体外循环前neoAoR-Z>0且未进行缩小的患者为19.0%（P =.008）。
与PAB组相比，nLVOTO组neoAoR-Z的快速增加与新AI的更高发生率相关。同时进行新主动脉根部缩小可能会降低这种风险，因此有必要考虑额外的手术策略。
