The arterial switch operation : going back to the roots Lalezari, S.

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The arterial switch operation : going back to the roots

Lalezari, S.

Citation

Lalezari, S. (2011, December 21). The arterial switch operation : going back to the roots.

Retrieved from https://hdl.handle.net/1887/18266

Version: Corrected Publisher’s Version

License: Licence agreement concerning inclusion of doctoral thesis in the Institutional Repository of the University of Leiden

Downloaded from: https://hdl.handle.net/1887/18266

Note: To cite this publication please use the final published version (if applicable).

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Reproduced from: Neo‐coarctation after the arterial switch operationʺ , Shirin Lalezari, Adriana C Gittenberger‐de Groot, Nico A Blom and Mark G Hazekamp (published in Interactive CardioVascular and Thoracic Surgery 2011;13:339‐340, doi:

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Neo-Coarctation after the Arterial Switch Operation

S. Lalezari¹, A.C. Gittenberger-de Groot², N.A. Blom³, M.G. Hazekamp¹

Departments of Cardiothoracic Surgery¹, Cardiology² and Pediatric Cardiology³, Leiden University Medical Center, Leiden, The Netherlands

Interactive Cardiovascular and Thoracic Surgery 2011;13(3):339-340

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Abstract

Neo-coarctation following arterial switch operation for transposition of the great arteries is a complication that is not regularly described, but may occur. We describe 5 patients who developed a neo-coarctation after operation. They were diagnosed with transposition of the great arteries, either with or without ventricular septal defect without signs or symptoms of a coarctation. Except for one patient, all patients were reoperated for a neo-coarctation within a year after the arterial switch operation. Several explanations are discussed as a possible cause for this phenomenon.

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Neo-Coarctation after the Arterial Switch Operation

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Introduction

The arterial switch operation (ASO) for patients with transposition of the great arteries (TGA) is being carried out for more than thirty years. Coarctation of the aorta following ASO in patients with TGA, who were not diagnosed with coarctation preoperatively, is an uncommon late complication rarely described in literature.¹

We describe five patients who developed a neo-coarctation of the aorta after ASO.

Patients, Methods and Results

Between 1977 and 2007, 332 patients have undergone ASO for TGA in our center of which five developed a neo-coarctation. Median age at ASO was 11 days (range 4 to 42 days) and median weight was 3.3 kilograms (range 1.7 to 3.5 kg). Other patient characteristics concerning the primary surgery are described in Table 1.

Table 1. Patient characteristics – initial surgery Patient Diagnosis Coronary

Anatomy PDA Prostaglandin

Therapy Weight (kg) Age (days)

1 TGA + VSD 1LCx-2R no no 3.0 13

2 TGA 1LCx-2R yes yes 1.7 11

3 TGA + VSD 1LCx-2R yes yes 3.3 4

4 TB-TGA 1R-2L yes yes 3.4 42

5 TGA 1LCx-2R yes Yes 3.5 8

Abbreviations:

TGA: Transposition of the Great Arteries; VSD: Ventricular Septal Defect; TB: Taussig-Bing; PDA:

Persistent Ductus Arteriosus

Four patients were reoperated for neo-coarctation within a year after ASO and one patient was reoperated almost 5 years after the initial ASO. None of the patients had any clinically detectable aortic arch abnormalities prior to the initial surgery. None of these cases were clustered in any way. Median time between the ASO and the reoperation for coarctation was 4 months (range 0.5 to 53.7 months).

The diagnosis was made whenever an important stenosis in the distal arch was found that needed surgical therapy. The coarctation in these patients was always juxta-ductal. There was no evidence of isthmic hypoplasia. Coarctation repair was performed through a limited

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left posterolateral thoracotomy using an end-to-end anastomosis in all patients. The excised specimens were not sent for histopathological research. There was no early or late mortality.

Median follow-up was 5 years (range 1 month to 8 years). In 2 patients, a mild gradient was present in the aortic arch during echocardiographic follow-up, however, no reoperation or transcatheter intervention has been necessary.

Comment

One of the most common reoperations after ASO concerns the right ventricular outflow tract.

Also, reoperation for neo-aortic regurgitation has been described, as well as reoperation for recurrent arch abnormalities.^2,3 However, the incidence of a developing neo-coarctation, is not high. Still, it may occur after the ASO, as has been described by Mulder et al, who have reported two patients developing a neo-coarctation, with no previous signs of a preoperatively existing coarctation [1].

In our series, 5 out of 332 patients (1.5%) developed a neo-coarctation. None of the patients had any clinical evidence of arch hypoplasia or pre-existing coarctation pre-ASO. However, all but one were described to be dependent on their fairly large, prostaglandin mediated, patent ductus arteriosus. Even when an atrial balloon septostomy was performed and judged successful, prostaglandin therapy was continued. In patients with localised coarctation it has been shown that ductal tissue may encircle the aorta as a ductal sling which can aggravate the coarctation with closure of the patent ductus (PDA) after birth.⁴ Several case reports support this finding, describing relief of coarctation after prostaglandin admission in patients with critical coarctation and a closed ductus arteriosus.⁵ However, all these case reports involve patients without any previous cardiac surgery.

If a ductal “sling” would be present in our patient group, the patients would have been diagnosed with coarctation prior to the ASO. Elzenga et al,⁶ however, showed that in cases without coarctation ductal tissue can extend into the ascending aorta for up to 30 to 50%. If this finding is combined with the surgical approach an explanation for the neo-coarctation can be a rare iatrogenic event.

The ductus arteriosus is usually clipped during ASO. One might reason that if the clips are placed too close to the ascending aorta, the extending ductal tissue is damaged and, as a result proliferation of this tissue might form a neo-coarctation.

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Neo-Coarctation after the Arterial Switch Operation

81 Several groups have reported about recurrence rate in relation to surgical technique for coarctation of the aorta.⁷ The subclavian flap aortoplasty (SFA) is the favored technique nowadays for coarctation repair. However, recoarcation also occurs after SFA and the presence of intrinsic abnormalities of the periductal aortic wall might play a role in the occurrence of recoarctation after repair.

In our patient group, all patients were reoperated for a neo-coarctation. One of the patients did not have a PDA at the time of initial surgery, however, in this case we still speculate that the above-presented theory may have played a role in the occurrence of the neo- coarctation.

Conclusion

A neo-coarctation after the arterial switch operation is a rare finding and is not being described regularly in literature. Nevertheless, we emphasize that in patients with TGA and a large, prostaglandin-dependent PDA, a neo-coarctation can form some time after the ASO, even without clinical or echocardiographic signs of coarctation before or during initial surgery.

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References

1. Mulder HJ, Kaan GL, Nijveld A, van Oort A, Barentsz J, Lacquet KL. Coarctation developing after arterial switch operation for transposition of the great arteries. Ann Thorac Surg 1994;58:227-29

2. Dibardino DJ, Allison AE, Vaughn WK, McKenzie ED, Fraser CD. Current expectations for newborns undergoing the arterial switch operation. Ann Surg 2004;239:588-98

3. Angeli E, Raisky O, Bonnet D, Sidi D, Vouhé PR. Late reoperations after neonatal arterial switch operation for transposition of the great arteries. Eur J Cardiothor Surg 2008;34:32-6

4. Ho SY, Anderson RH. Coarctation, tubular hypoplasia and the ductus arteriosus. Histological study of 35 specimens. Br Heart J 1979;41:268-24

5. Liberman L. Gersony WM, Flynn PA, Lamberti JJ, Cooper RS, Starc TJ. Effectiveness of Prostaglandin E₁ in relieving obstruction in coarctation of the aorta without opening the ductus arteriosus. Pediatr Cardiol 2004;25:49-52

6. Elzenga NA, Gittenberger-de Groot. Localised coarctation of the aorta. An age dependent spectrum. Br Heart J 1983;49:317-23

7. Dehaki MG, Ghavidel AA, Givtaj N, Omrani G, Salehi S. Recurrence rate of different techniques for repair of coarctation of aorta: A 10 years experience. Ann Pediatr Cardiol 2010;3:123-26