30 Years of Surgical Repair of Complex D-Transposition of the Great Arteries: How to Avoid Outflow Tract Obstructions?

Objectives: Several techniques have been introduced to manage patients with complex d-transposition of the great arteries (dTGA) with ventricular septal defect (VSD) and left ventricular outflow obstruction (LVOTO). Outflow tract obstructions, both left and right (RVOTO) remain challenging.

Methods: A retrospective review of all complex dTGA patients undergoing different repair techniques (modified Nikaidoh = group Nikaidoh, half-turned truncal switch = group half-turned, Rastelli = group Rastelli, arterial switch operation + LVOTO resection + VSD closure = group ASO) between 05/1990 and 05/2020 was performed. Preoperative baseline characteristics, procedural data, as well as early/mid-term outcome measures were analyzed. Patients were followed up echocardiographically from baseline to last visit. All four groups were analyzed using Kruskal–Wallis test with post hoc pairwise comparison. Freedom from death and reoperations/reinterventions were observed using Kaplan–Meier time-to-event models.

Result: A total of 77 patients (19 Nikaidoh, 14 half-turned, 32 Rastelli, 12 ASO) were included. Median age was 0.9 years (0.5–2.1), 62.3% were males and median weight at surgery was 9.4 kg (6.5–11.6) in the entire cohort. Groups did not differ in baseline characteristics except for age and weight, which were both significantly higher in the Rastelli group: 1.8 years (0.6–6.1), p < 0.01 and 10.5 kg (7.9–17.5), p < 0.01.

Total operating time and median bypass duration did not differ between groups; however, cross-clamp time was significantly shorter in the Rastelli group compared with the other groups: 110 minutes [81–138] versus 138 minutes [110–164], p = 0.01. Thirty-day mortality was 7.8% in the entire cohort and did not differ between the groups, also the frequency of postoperative complications was not different. Median follow-up in the entire cohort was 3.8 years (0.2–8.5). Overall 5- and 10-year survival rates were 82.8% (95% CI: 71–90.2) with no significant difference between the groups (p = 0.5). Five-year freedom from RVOTO reoperation, RVOTO catheter reintervention, and LVOTO reoperation also did not differ between groups: 75.5% (95% CI: 58.8–85.8%), 69.5% (95% CI: 53–81), p = 0.2, 98.3 (95% CI: 88.7–99.7%), p = 0.2.

Conclusion: Surgical repair of complex dTGA can be performed with excellent early and good mid-term outcome. RVOTO reinterventions and reoperations are frequent, regardless of the employed surgical technique. Longer follow-up durations are needed to draw definite conclusions.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
19 February 2021