A clinical comparison of arterial and atrial repairs for transposition of the great arteries: early and midterm survival and functional results.

BACKGROUND

The early experience in correction of simple transposition of the great arteries (TGA) involved redirection of atrial inflow to re-establish systemic and pulmonary blood flow, the basis of the Senning and Mustard operations. Since 1984, however, the arterial switch operation (Jatene) has been increasingly used. It appears that with experience the peri-operative mortality rate for arterial repair is comparable to that for atrial repairs, while the late morbidity rates have generally favoured arterial repair, with sequelae such as obstruction of venous inflow, dysrhythmias, systemic atrioventricular valve dysfunction and impaired systemic ventricle function being more common following atrial repairs.

METHODS

A retrospective review of patients surgically treated for TGA at the Prince Charles Hospital.

RESULTS

Between April 1973 and July 1994, 103 patients with simple TGA underwent surgical correction using one of three standard approaches currently advocated (arterial switch/Jatene, Senning or Mustard operations). Fifty-one Jatene, 31 Senning and 21 Mustard operations were performed. Associated procedures included closure of ventricular septal defect, right and left ventricular outflow tract resection and pulmonary artery band removal. The coronary artery anatomy was found to be suitable in all except two patients when the Jatene operation was planned; both these patients had a Senning procedure without mortality. There were nine peri-operative deaths (4 Jatene, 2 Senning, 3 Mustard), and five late deaths (1 Jatene, 1 Senning, 3 Mustard). Follow-up was maintained to a mean time of 60.5 months (range, 9 days to 203 months). In the Jatene group there were five anastomotic stenoses (all involving the neo-pulmonary artery), three cases of arrhythmias (two postoperative supraventricular tachycardia and one nodal rhythm) and two pulmonary valve stenoses. In the Senning group there were four anastomotic stenoses (three involving pulmonary vein and one causing superior vena cava (SVC) inlet obstruction) and four cases of arrhythmias (with one requiring permanent pacemaker insertion). In the Mustard group there were two cases of SVC obstruction and two permanent pacemaker insertions for bradycardia.

CONCLUSIONS

These early and midterm results suggest that the arterial switch operation has comparable overall mortality to, and less morbidity than, the atrial repairs for TGA with the retention of left ventricle to systemic arterial connection, which may provide improved long-term results.