Arterial switch operation (ASO) or arterial switch, is an
open heart surgical
Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...
procedure used to correct
dextro-transposition of the great arteries
dextro-Transposition of the great arteries (d-Transposition of the great arteries, dextro-TGA, or d-TGA) is a potentially life-threatening birth defect in the large arteries of the heart. The primary arteries (the aorta and the pulmonary artery) ...
(d-TGA).
Its development was
pioneer
Pioneer commonly refers to a settler who migrates to previously uninhabited or sparsely inhabited land.
In the United States pioneer commonly refers to an American pioneer, a person in American history who migrated west to join in settling and de ...
ed by
Canadian
Canadians (french: Canadiens) are people identified with the country of Canada. This connection may be residential, legal, historical or cultural. For most Canadians, many (or all) of these connections exist and are collectively the source of ...
cardiac
The heart is a muscular organ in most animals. This organ pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste such as carbon dioxide to t ...
surgeon
William Mustard and it was named for
Brazil
Brazil ( pt, Brasil; ), officially the Federative Republic of Brazil (Portuguese: ), is the largest country in both South America and Latin America. At and with over 217 million people, Brazil is the world's fifth-largest country by area ...
ian cardiac surgeon
Adib Jatene, who was the first to use it successfully. It was the first method of d-TGA repair to be attempted, but the last to be put into regular use because of
technological
Technology is the application of knowledge to reach practical goals in a specifiable and reproducible way. The word ''technology'' may also mean the product of such an endeavor. The use of technology is widely prevalent in medicine, science, ...
limitations at the time of its
concept
Concepts are defined as abstract ideas. They are understood to be the fundamental building blocks of the concept behind principles, thoughts and beliefs.
They play an important role in all aspects of cognition. As such, concepts are studied by s ...
ion.
Use of the arterial switch is
historical
History (derived ) is the systematic study and the documentation of the human activity. The time period of event before the invention of writing systems is considered prehistory. "History" is an umbrella term comprising past events as well ...
ly preceded by two
atrial switch
Atrial switch is a cardiac surgery, heart operation performed to treat dextro-Transposition of the great arteries. It involves the construction of an atrial baffle which redirects the blood coming into the atria to restore the connection between sy ...
methods: the
Senning and
Mustard procedure
The Mustard procedure was developed in 1963 by Dr. William Mustard at the Hospital for Sick Children in Toronto, Ontario, Canada.
Dr. Mustard, with support from the Heart and Stroke Foundation of Canada, developed an alternative and simplified t ...
s.
The atrial switch, which was an attempt to correct the physiology of transposition, had significant shortcomings. The arterial switch sought to address them. This has emerged as an anatomically as well as physiologically appropriate solution.
[Marathe SP, Talwar S. Surgery for transposition of great arteries: A historical perspective. Ann Pediatr Cardiol. 2015 May-Aug;8(2):122–8.]
Timing
The Jatene procedure is ideally performed during the second week of life, before the
left ventricle
A ventricle is one of two large chambers toward the bottom of the heart that collect and expel blood towards the peripheral beds within the body and lungs. The blood pumped by a ventricle is supplied by an atrium, an adjacent chamber in the upper ...
adjusts to the lower
pulmonary
The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of th ...
pressure
Pressure (symbol: ''p'' or ''P'') is the force applied perpendicular to the surface of an object per unit area over which that force is distributed. Gauge pressure (also spelled ''gage'' pressure)The preferred spelling varies by country and e ...
and is therefore unable to support the
systemic circulation
The blood circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human or other vertebrate. It includes the cardiovascular system, or vascular system, tha ...
. In the event of
sepsis
Sepsis, formerly known as septicemia (septicaemia in British English) or blood poisoning, is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is follo ...
or delayed
diagnosis
Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine " cause and effect". In systems engin ...
, a combination of
pulmonary artery banding (PAB) and
shunt construction may be used to increase the left ventricular mass sufficiently to make an arterial switch possible later in
infancy
An infant or baby is the very young offspring of human beings. ''Infant'' (from the Latin word ''infans'', meaning 'unable to speak' or 'speechless') is a formal or specialised synonym for the common term ''baby''. The terms may also be used to ...
.
Prognosis
The success of ASO procedure is largely dependent on the facilities available, the skill and experience of the surgeon, and the general health of the
patient
A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health c ...
. Under preferable conditions, the
intra-operative and
post-operative success rate is 90% or more, with a comparable survival rate after 5 years.
Approximately 10% of arterial switch recipients develop residual pulmonary
stenosis
A stenosis (from Ancient Greek στενός, "narrow") is an abnormal narrowing in a blood vessel or other tubular organ or structure such as foramina and canals. It is also sometimes called a stricture (as in urethral stricture).
''Stricture'' ...
post-operatively, which can lead to
right heart
The heart is a muscular Organ (biology), organ in most animals. This organ pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste such as ca ...
failure
Failure is the state or condition of not meeting a desirable or intended objective (goal), objective, and may be viewed as the opposite of Success (concept), success. The criteria for failure depends on context, and may be relative to a parti ...
if left untreated;
treatment usually involves
endovascular stenting and/or
xenograft
Xenotransplantation (''xenos-'' from the Greek meaning "foreign" or strange), or heterologous transplant, is the transplantation of living cells, tissues or organs from one species to another. Such cells, tissues or organs are called xenograft ...
patching.
Overview
*
General anaesthesia
General anaesthesia (UK) or general anesthesia (US) is a medically induced loss of consciousness that renders the patient unarousable even with painful stimuli. This effect is achieved by administering either intravenous or inhalational general ...
and
cardiopulmonary bypass
Cardiopulmonary bypass (CPB) is a technique in which a machine temporarily takes over the function of the heart and lungs during surgery, maintaining the circulation of blood and oxygen to the body. The CPB pump itself is often referred to as a he ...
are used.
* The
aorta
The aorta ( ) is the main and largest artery in the human body, originating from the left ventricle of the heart and extending down to the abdomen, where it splits into two smaller arteries (the common iliac arteries). The aorta distributes ...
and
pulmonary artery
A pulmonary artery is an artery in the pulmonary circulation that carries deoxygenated blood from the right side of the heart to the lungs. The largest pulmonary artery is the ''main pulmonary artery'' or ''pulmonary trunk'' from the heart, and t ...
are detached from their
native
Native may refer to:
People
* Jus soli, citizenship by right of birth
* Indigenous peoples, peoples with a set of specific rights based on their historical ties to a particular territory
** Native Americans (disambiguation)
In arts and entert ...
root
In vascular plants, the roots are the organs of a plant that are modified to provide anchorage for the plant and take in water and nutrients into the plant body, which allows plants to grow taller and faster. They are most often below the sur ...
s and reattached to the opposite root; thus, the pulmonary root becomes the
neo-aorta, and the aortic root becomes the neo-pulmonary artery.
* The
coronary arteries
The coronary arteries are the arterial blood vessels of coronary circulation, which transport oxygenated blood to the heart muscle. The heart requires a continuous supply of oxygen to function and survive, much like any other tissue or organ of ...
are
transplanted from the aorta/neo-pulmonary artery to the pulmonary artery/neo-aorta.
* Length of procedure, from initiation of anaesthesia to post-operative cease thereof, is approximately 6–8 hours.
Preparatory
If the procedure is anticipated far enough in advance (with
prenatal
Prenatal development () includes the development of the embryo and of the fetus during a viviparous animal's gestation. Prenatal development starts with fertilization, in the germinal stage of embryonic development, and continues in fetal devel ...
diagnosis, for example), and the individual's
blood
Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the c ...
type is known, a family member with a compatible
blood type
A blood type (also known as a blood group) is a classification of blood, based on the presence and absence of antibodies and inherited antigenic substances on the surface of red blood cells (RBCs). These antigens may be proteins, carbohydrate ...
may
donate
A donation is a gift for charity, humanitarian aid, or to benefit a cause. A donation may take various forms, including money, alms, services, or goods such as clothing, toys, food, or vehicles. A donation may satisfy medical needs such as blo ...
some or all of the blood needed for
transfusion during the use of a
heart-lung machine
Cardiopulmonary bypass (CPB) is a technique in which a machine temporarily takes over the function of the heart and lungs during surgery, maintaining the circulation of blood and oxygen to the body. The CPB pump itself is often referred to as a he ...
(HLM). The patient's
mother
]
A mother is the female parent of a child. A woman may be considered a mother by virtue of having given childbirth, birth, by raising a child who may or may not be her biological offspring, or by supplying her ovum for fertilisation in the cas ...
is normally unable to donate blood for the transfusion, as she will not be able to donate blood during
pregnancy
Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins.
Pregnancy usually occurs by sexual intercourse, but ca ...
(due to the needs of the
fetus
A fetus or foetus (; plural fetuses, feti, foetuses, or foeti) is the unborn offspring that develops from an animal embryo. Following embryonic development the fetal stage of development takes place. In human prenatal development, fetal deve ...
) or for a few weeks after giving
birth
Birth is the act or process of bearing or bringing forth offspring, also referred to in technical contexts as parturition. In mammals, the process is initiated by hormones which cause the muscular walls of the uterus to contract, expelling the f ...
(due to
blood loss
Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...
), and the process of collecting a sufficient amount of blood may take several weeks to a few months. However, in cases where the individual has been diagnosed but surgery must be delayed, maternal (or even
autologous
Autotransplantation is the transplantation of organs, tissues, or even particular proteins from one part of the body to another in the same person ('' auto-'' meaning "self" in Greek).
The autologous tissue (also called autogenous, autogene ...
, in certain cases) blood donation may be possible, as long as the mother has a compatible blood type. In most cases, though, the patient receives a donation from a
blood bank
A blood bank is a center where blood gathered as a result of blood donation is stored and preserved for later use in blood transfusion. The term "blood bank" typically refers to a department of a hospital usually within a Clinical Pathology laborat ...
. A blood transfusion is necessary for the arterial switch because the HLM needs its "circulation" filled with blood and an infant does not have enough blood on their own to do this (in most cases, an adult would not require blood transfusion).
The patient will require a number of
imaging
Imaging is the representation or reproduction of an object's form; especially a visual representation (i.e., the formation of an image).
Imaging technology is the application of materials and methods to create, preserve, or duplicate images.
...
procedures in order to determine the individual
anatomy
Anatomy () is the branch of biology concerned with the study of the structure of organisms and their parts. Anatomy is a branch of natural science that deals with the structural organization of living things. It is an old science, having its ...
of the great arteries and, most importantly, the
coronary arteries
The coronary arteries are the arterial blood vessels of coronary circulation, which transport oxygenated blood to the heart muscle. The heart requires a continuous supply of oxygen to function and survive, much like any other tissue or organ of ...
. These may include
angiography
Angiography or arteriography is a medical imaging technique used to visualize the inside, or lumen, of blood vessels and organs of the body, with particular interest in the arteries, veins, and the heart chambers. Modern angiography is performe ...
,
magnetic resonance imaging
Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio wave ...
(MRI), and/or
computed tomography (CT scan). The coronary arteries are carefully mapped out in order to avoid unexpected intra-operative complications in transferring them from the native aorta to the neo-aorta.
Pre-operative
As with any procedure requiring general anaesthesia, arterial switch recipients will need to
fast for several hours prior to the surgery to avoid the risk of aspiration of vomitus during the induction of anesthesia.
As the patient is anesthetized, they may receive the following
drugs
A drug is any chemical substance that causes a change in an organism's physiology or psychology when consumed. Drugs are typically distinguished from food and substances that provide nutritional support. Consumption of drugs can be via inhalat ...
, which continue as necessary throughout the procedure:
*
Inhalational anaesthetic
*
muscle relaxant
A muscle relaxant is a drug that affects skeletal muscle function and decreases the muscle tone. It may be used to alleviate symptoms such as muscle spasms, pain, and hyperreflexia. The term "muscle relaxant" is used to refer to two major therapeu ...
, to induce temporary
paralysis
Paralysis (also known as plegia) is a loss of motor function in one or more muscles. Paralysis can also be accompanied by a loss of feeling (sensory loss) in the affected area if there is sensory damage. In the United States, roughly 1 in 50 ...
*
opioid
Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioid us ...
analgesic
An analgesic drug, also called simply an analgesic (American English), analgaesic (British English), pain reliever, or painkiller, is any member of the group of drugs used to achieve relief from pain (that is, analgesia or pain management). It ...
, to manage pain, cause
sedation
Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure. Examples of drugs which can be used for sedation include isoflurane, diethyl ether, ...
and induce
serenity
*
Aprotinin
The drug aprotinin (Trasylol, previously Bayer and now Nordic Group pharmaceuticals), is a small protein bovine pancreatic trypsin inhibitor (BPTI), or basic trypsin inhibitor of bovine pancreas, which is an antifibrinolytic molecule that inhibits ...
, or other antifibrinolytic, to prevent excessive
bleeding
Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...
*
Methylprednisolone
Methylprednisolone (Depo-Medrol, Medrol, Solu-Medrol) is a synthetic glucocorticoid, primarily prescribed for its anti-inflammatory and immunosuppressive effects. It is either used at low doses for chronic illnesses or used concomitantly at high ...
, to reduce
swelling and
inflammation
Inflammation (from la, wikt:en:inflammatio#Latin, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or Irritation, irritants, and is a protective response involving im ...
*
Prophylactic
Preventive healthcare, or prophylaxis, consists of measures taken for the purposes of disease prevention.Hugh R. Leavell and E. Gurney Clark as "the science and art of preventing disease, prolonging life, and promoting physical and mental hea ...
antibiotics
An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention o ...
, to prevent
infection
An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...
Intra-operative
![Blausen 0047 ArterialSwitchOperation 02](https://upload.wikimedia.org/wikipedia/commons/c/cd/Blausen_0047_ArterialSwitchOperation_02.png)
The heart is accessed via
median sternotomy
Median sternotomy is a type of surgical procedure in which a vertical inline incision is made along the sternum, after which the sternum itself is divided using a sternal saw. This procedure provides access to the heart and lungs for surgical pro ...
, and the patient is given
heparin
Heparin, also known as unfractionated heparin (UFH), is a medication and naturally occurring glycosaminoglycan. Since heparins depend on the activity of antithrombin, they are considered anticoagulants. Specifically it is also used in the treatm ...
to prevent the blood from
clot
A thrombus (plural thrombi), colloquially called a blood clot, is the final product of the blood coagulation step in hemostasis. There are two components to a thrombus: aggregated platelets and red blood cells that form a plug, and a mesh of c ...
ting. A generous section of
pericardium
The pericardium, also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong connective tissue (fibrous pericardium), and an inner layer made of ...
is
harvested, then
disinfect
A disinfectant is a chemical substance or compound used to inactivate or destroy microorganisms on inert surfaces. Disinfection does not necessarily kill all microorganisms, especially resistant bacterial spores; it is less effective than ste ...
ed and
sterilized with a weak solution of
glutaraldehyde
Glutaraldehyde is an organic compound with the formula . The molecule consists of a five carbon chain doubly terminated with formyl (CHO) groups. It is usually used as a solution in water, and such solutions exists as a collection of hydrates, c ...
; and the coronary and great artery anatomy are examined. The
ductus arteriosus
The ''ductus arteriosus'', also called the ''ductus Botalli'', named after the Italian physiologist Leonardo Botallo, is a blood vessel in the developing fetus connecting the trunk of the pulmonary artery to the proximal descending aorta. It allo ...
and
right pulmonary branch, up to and including the first branches in the
hilum of the right
lung
The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...
, are separated from the surrounding supportive
tissue to allow mobility of the
vessels.
Silk
Silk is a natural protein fiber, some forms of which can be woven into textiles. The protein fiber of silk is composed mainly of fibroin and is produced by certain insect larvae to form cocoons. The best-known silk is obtained from the coc ...
marking
sutures may be placed in the pulmonary trunk at this time, to indicate the
commissure
A commissure () is the location at which two objects abut or are joined. The term is used especially in the fields of anatomy and biology.
* The most common usage of the term refers to the brain's commissures, of which there are five. Such a commi ...
of the aorta to the
neo-aorta; alternatively, this may be done later in the procedure.
The cardiopulmonary bypass is then initiated by inserting a
cannula
A cannula (; Latin meaning 'little reed'; plural or ) is a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of samples. In simple terms, a cannula can surround the inner or outer surfaces ...
into the
ascending aorta
The ascending aorta (AAo) is a portion of the aorta commencing at the upper part of the base of the left ventricle, on a level with the lower border of the third costal cartilage behind the left half of the sternum.
Structure
It passes obliqu ...
as
distally
Standard anatomical terms of location are used to unambiguously describe the anatomy of animals, including humans. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position pro ...
from the aortic root as possible while still supplying all
arterial
An artery (plural arteries) () is a blood vessel in humans and most animals that takes blood away from the heart to one or more parts of the body (tissues, lungs, brain etc.). Most arteries carry oxygenated blood; the two exceptions are the pul ...
branches, another cannula is inserted into the
right atrium
The atrium ( la, ātrium, , entry hall) is one of two upper chambers in the heart that receives blood from the circulatory system. The blood in the atria is pumped into the heart ventricles through the atrioventricular valves.
There are two atr ...
, and a vent is created for the
left ventricle
A ventricle is one of two large chambers toward the bottom of the heart that collect and expel blood towards the peripheral beds within the body and lungs. The blood pumped by a ventricle is supplied by an atrium, an adjacent chamber in the upper ...
via
catheterization
In medicine, a catheter (/ˈkæθətər/) is a thin tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure. Cath ...
of the
right superior pulmonary vein. The HLM is started at a low-
flow and the patient's
body
Body may refer to:
In science
* Physical body, an object in physics that represents a large amount, has mass or takes up space
* Body (biology), the physical material of an organism
* Body plan, the physical features shared by a group of anima ...
is
cooled to a
rectal
The rectum is the final straight portion of the large intestine in humans and some other mammals, and the gut in others. The adult human rectum is about long, and begins at the rectosigmoid junction (the end of the sigmoid colon) at the le ...
temperature
Temperature is a physical quantity that expresses quantitatively the perceptions of hotness and coldness. Temperature is measured with a thermometer.
Thermometers are calibrated in various temperature scales that historically have relied o ...
of 20
° C (68 °
F), which prevents the
brain damage
Neurotrauma, brain damage or brain injury (BI) is the destruction or degeneration of brain cells. Brain injuries occur due to a wide range of internal and external factors. In general, brain damage refers to significant, undiscriminating t ...
otherwise associated with the temporary
circulatory arrest necessary during the procedure; the patient must be cooled for a minimum of 20 minutes prior to beginning the repair.
While the patient is cooling, the ductus arteriosus is
ligated at both the aortic and pulmonary
ostia, then
transect
A transect is a path along which one counts and records occurrences of the objects of study (e.g. plants).
There are several types of transect. Some are more effective than others.
It requires an observer to move along a fixed path and to count ...
ed at its center; the
left pulmonary branch, including the first branches in the hilum of the left lung, is separated from the supportive tissue; and the aorta is marked at the site it will be transected, which is just below the
pulmonary bifurcation
The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...
, proximal to where the pulmonary artery will be transected.
When the patient is fully cooled, the ascending aorta is clamped as close as possible below the HLM cannula, and
cardioplegia
Cardioplegia is intentional and temporary cessation of cardiac activity, primarily for cardiac surgery.
Overview
The word ''cardioplegia'' combines the Greek ''cardio'' meaning the "heart", and ''plegia'' "paralysis". Technically, this means a ...
is achieved by delivering cold blood to the heart via the ascending aorta (below the
cross clamp). The aorta is then transected at the marked spot, and the pulmonary artery is transected a few millimetres below the bifurcation. The vessels are again examined, and the pulmonary root is inspected for
left ventricular outflow tract obstruction (LVOTO). If a
ventricular septal defect
A ventricular septal defect (VSD) is a defect in the ventricular septum, the wall dividing the left and right ventricles of the heart. The extent of the opening may vary from pin size to complete absence of the ventricular septum, creating one ...
(VSD) is present, it may be repaired, at this point via either the
aortic or
pulmonary valve
The pulmonary valve (sometimes referred to as the pulmonic valve) is a valve of the heart that lies between the right ventricle and the pulmonary artery and has three cusps. It is one of the four valves of the heart and one of the two semilunar va ...
; it may alternatively be repaired later in the procedure.
The great arteries are usually arranged using the
LeCompte maneuver
The LeCompte maneuver is a technique used in open heart surgery, primarily on infants and children. The maneuver entails cutting the main pulmonary artery and moving it anterior to the aorta before reattaching the pulmonary artery during the fol ...
, with the aortic cross clamp positioned to hold the pulmonary artery
anterior
Standard anatomical terms of location are used to unambiguously describe the anatomy of animals, including humans. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position prov ...
to the ascending aorta; though with some congenital arrangements of the great arteries, such as side-by-side, this is not possible and the arteries will be transplanted in the non-anatomic 'anterior aorta' arrangement. If the aortic commissure has not yet been marked, it may be done at this point, using the same method as would be used prior to bypass; however, there is a third opportunity for this still later in the procedure.
Coronary arteries are examined closely, and the ostia and proximal arterial course are identified, as are any
infundibular An infundibulum (Latin for ''funnel''; plural, ''infundibula'') is a funnel-shaped cavity or organ.
Anatomy
* Brain: the pituitary stalk, also known as the ''infundibulum'' and ''infundibular stalk'', is the connection between the hypothalamus and ...
branches, if they exist. The coronary ostia and a large "button" of surrounding aortic wall are then
excise
file:Lincoln Beer Stamp 1871.JPG, upright=1.2, 1871 U.S. Revenue stamp for 1/6 barrel of beer. Brewers would receive the stamp sheets, cut them into individual stamps, cancel them, and paste them over the Bunghole, bung of the beer barrel so when ...
d from the aorta, well into the
sinus of Valsalva
An aortic sinus, also known as a sinus of Valsalva, is one of the anatomic dilations of the ascending aorta, which occurs just above the aortic valve. These widenings are between the wall of the aorta and each of the three cusps of the aortic valv ...
; and the proximal sections of the coronary arteries are separated from the surface of the heart, which prevents
tension
Tension may refer to:
Science
* Psychological stress
* Tension (physics), a force related to the stretching of an object (the opposite of compression)
* Tension (geology), a stress which stretches rocks in two opposite directions
* Voltage or el ...
or
distortion
In signal processing, distortion is the alteration of the original shape (or other characteristic) of a signal. In communications and electronics it means the alteration of the waveform of an information-bearing signal, such as an audio signal ...
after
anastomosis
An anastomosis (, plural anastomoses) is a connection or opening between two things (especially cavities or passages) that are normally diverging or branching, such as between blood vessels, leaf#Veins, leaf veins, or streams. Such a connection m ...
to the neo-aorta. Infundibular branches are sometimes unable to be spared, but this is a very rare occurrence. If the aortic commissure has not previously been marked, the excised coronary arteries will be used to determine the
implantation position of the aorta.
The aorta is then transplanted onto the pulmonary root, using either absorbable or permanent continuous
suture. The aortic clamp is temporarily removed while small sections of the neo-aorta are cut away to accommodate the coronary ostia, and a continuous absorbable suture is then used to anastomose each coronary "button" into the prepared space. In most cases, the coronary implantation sites will be at left and right anterior positions at the base of the neo-aorta; however, if the
circumflex coronary artery
The circumflex branch of left coronary artery, or left circumflex artery or circumflex artery, is a branch of the left coronary artery.
Description
The left circumflex artery follows the left part of the coronary sulcus, running first to the l ...
branches from the
right coronary artery
In the blood supply of the heart, the right coronary artery (RCA) is an artery originating above the right cusp of the aortic valve, at the right aortic sinus in the heart. It travels down the right coronary sulcus, towards the crux of the hear ...
, the circumflex coronary artery will be distorted if the pair are not implanted higher than normal on the neo-aorta, and in some cases they may need to be implanted above the aortic commissure, on the native aorta itself. The circumflex coronary artery may originate from the same coronary sinus as, rather than directly from, the right coronary artery, in which case they may still be excised on the same "button" and transplanted similarly to if they had a shared ostium, unless one or both have
intramural
Intramural sports are recreational sports organized within a particular institution, usually an educational institution, or a set geographic region. The term, which is chiefly North American, derives from the Latin words ''intra muros'' meaning " ...
communication with another coronary vessel. Sometimes, one or more coronary ostia are located very close to the
valvular opening and a small portion of the native aortic valve must be removed when the coronary artery is excised, which causes a generally mild, and usually well-tolerated, neo-pulmonary
valve regurgitation.
The HLM is turned off and the aortic and atrial cannula are removed, then an
incision is made in the right atrium, through which the
congenital
A birth defect, also known as a congenital disorder, is an abnormal condition that is present at birth regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. The disabilities can ...
or
palliative
Palliative care (derived from the Latin root , or 'to cloak') is an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and often terminal illnesses. Wit ...
atrial septal defect
Atrial septal defect (ASD) is a congenital heart defect in which blood flows between the atria (upper chambers) of the heart. Some flow is a normal condition both pre-birth and immediately post-birth via the foramen ovale; however, when this d ...
(ASD) is repaired; where a
Rashkind balloon atrial septostomy was used, the ASD should be able to be closed with sutures, but cases involving large congenital ASDs or
Blalock-Hanlon atrial septectomy, a pericardial,
xenograft
Xenotransplantation (''xenos-'' from the Greek meaning "foreign" or strange), or heterologous transplant, is the transplantation of living cells, tissues or organs from one species to another. Such cells, tissues or organs are called xenograft ...
, or
Dacron
Polyethylene terephthalate (or poly(ethylene terephthalate), PET, PETE, or the obsolete PETP or PET-P), is the most common thermoplastic polymer resin of the polyester family and is used in fibres for clothing, containers for liquids and foods ...
patch may be necessary. If there is a VSD which has not yet been repaired, this is performed via the atrial incision and
tricuspid valve
The tricuspid valve, or right atrioventricular valve, is on the right dorsal side of the mammalian heart, at the superior portion of the right ventricle. The function of the valve is to allow blood to flow from the right atrium to the right vent ...
, using sutures for a small defect or a patch for a large defect.
When the septal defects have been repaired and the atrial incision is closed, the previously removed cannula are replaced and the HLM is restarted. The left ventricle is then vented and the cross clamp removed from the aorta, enabling full-flow to be re-established and rewarming to begin; at this point the patient will receive an additional dose of Regitine to keep
blood pressure
Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" r ...
under control. The previously harvested pericardium is then used to patch the coronary
explantation sites, and to extend - and widen, if necessary - the neo-pulmonary root, which allows the pulmonary artery to be anastamosed without
residual tension; the pulmonary artery is then transplanted to the neo-pulmonary root.
Final stages
The patient is fitted with
chest tube
A chest tube (also chest drain, thoracic catheter, tube thoracostomy or intercostal drain) is a surgical drain that is inserted through the chest wall and into the pleural space or the mediastinum in order to remove clinically undesired substanc ...
s, temporary
pacemaker
An artificial cardiac pacemaker (or artificial pacemaker, so as not to be confused with the natural cardiac pacemaker) or pacemaker is a medical device that generates electrical impulses delivered by electrodes to the chambers of the heart eith ...
leads, and
ventilated before
wean
Weaning is the process of gradually introducing an infant human or another mammal to what will be its adult diet while withdrawing the supply of its mother's milk.
The process takes place only in mammals, as only mammals produce milk. The infan ...
ing from the HLM is begun.
*
inotrope
An inotrope is an agent that alters the force or energy of muscular contractions. Negatively inotropic agents weaken the force of muscular contractions. Positively inotropic agents increase the strength of muscular contraction.
The term ''inotro ...
, to assist the heart in
contracting adequately
The
rib cage
The rib cage, as an enclosure that comprises the ribs, vertebral column and sternum in the thorax of most vertebrates, protects vital organs such as the heart, lungs and great vessels.
The sternum, together known as the thoracic cage, is a semi- ...
is relaxed and the external surgical
wound
A wound is a rapid onset of injury that involves laceration, lacerated or puncture wound, punctured skin (an ''open'' wound), or a bruise, contusion (a ''closed'' wound) from blunt force physical trauma, trauma or compression. In pathology, a '' ...
is bandaged, but the
sternum
The sternum or breastbone is a long flat bone located in the central part of the chest. It connects to the ribs via cartilage and forms the front of the rib cage, thus helping to protect the heart, lungs, and major blood vessels from injury. Sh ...
and chest incision are left open to provide extra room in the
pleural cavity
The pleural cavity, pleural space, or interpleural space is the potential space between the pleurae of the pleural sac that surrounds each lung. A small amount of serous pleural fluid is maintained in the pleural cavity to enable lubrication bet ...
, allowing the heart room to swell and preventing pressure caused by
pleural effusion
A pleural effusion is accumulation of excessive fluid in the pleural space, the potential space that surrounds each lung.
Under normal conditions, pleural fluid is secreted by the parietal pleural capillaries at a rate of 0.6 millilitre per kilog ...
.
Post-operative
The sternum and chest can usually be closed within a few days; however, the chest tubes, pacemaker, ventilator, and drugs may still be required after this time. The patient will continue to fast for up to a few days, and
breastmilk
Breast milk (sometimes spelled as breastmilk) or mother's milk is milk produced by mammary glands located in the breast of a human female. Breast milk is the primary source of nutrition for newborns, containing fat, protein, carbohydrates (lactos ...
or
infant formula
Infant formula, baby formula, or simply formula (American English); or baby milk, infant milk or first milk (British English), is a manufactured food designed and marketed for feeding to babies and infants under 12 months of age, usually prepar ...
can then be gradually introduced via
nasogastric tube
Nasogastric intubation is a medical process involving the insertion of a plastic tube (nasogastric tube or NG tube) through the nose, down the oesophagus, and down into the stomach. Orogastric intubation is a similar process involving the inserti ...
(NG tube); the primary
goal
A goal is an idea of the future or desired result that a person or a group of people envision, plan and commit to achieve. People endeavour to reach goals within a finite time by setting deadlines.
A goal is roughly similar to a purpose or ai ...
after a successful arterial switch, and before
hospital
A hospital is a health care institution providing patient treatment with specialized health science and auxiliary healthcare staff and medical equipment. The best-known type of hospital is the general hospital, which typically has an emerge ...
discharge, is for the
infant
An infant or baby is the very young offspring of human beings. ''Infant'' (from the Latin word ''infans'', meaning 'unable to speak' or 'speechless') is a formal or specialised synonym for the common term ''baby''. The terms may also be used to ...
to gain back the weight they have lost and continue to gain weight at a normal or near-normal rate.
History
Scottish pathologist
Pathology is the study of the causal, causes and effects of disease or injury. The word ''pathology'' also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when us ...
Matthew Baillie
Matthew Baillie FRS (27 October 1761 – 23 September 1823) was a British physician and pathologist, credited with first identifying transposition of the great vessels (TGV) and situs inversus.
Early life and education
He was born in the mans ...
first described
TGA in 1797, presumably as a
posthumous
Posthumous may refer to:
* Posthumous award - an award, prize or medal granted after the recipient's death
* Posthumous publication – material published after the author's death
* Posthumous (album), ''Posthumous'' (album), by Warne Marsh, 1987
* ...
diagnosis. Without surgical correction, preoperative mortality in the neonate is approximately 30% within the first week of life and up to 90% within the first year;
the survivors would have been those with one or more
concomitant
Concomitance is the condition of accompanying or coexisting. A concomitant is something that accompanies something else.
Concomitant or concomitance may refer to:
* Concomitance (doctrine), a Christian doctrine
* Concomitant (classical algebraic ...
intracardiac
Intracardiac injections are injections that are given directly into the heart muscles or ventricles. They can be used in emergencies, although they are rarely used in modern practice.
History
The practice of intracardiac injection originated in ...
shunts (ASD,
patent ductus arteriosus
''Patent ductus arteriosus'' (PDA) is a medical condition in which the ''ductus arteriosus'' fails to close after birth: this allows a portion of oxygenated blood from the left heart to flow back to the lungs by flowing from the aorta, which has ...
(PDA),
patent foramen ovale
Atrial septal defect (ASD) is a congenital heart defect in which blood flows between the atria (upper chambers) of the heart. Some flow is a normal condition both pre-birth and immediately post-birth via the foramen ovale; however, when this d ...
(PFO), and/or VSD), and are unlikely to have survived past
adolescence
Adolescence () is a transitional stage of physical and psychological development that generally occurs during the period from puberty to adulthood (typically corresponding to the age of majority). Adolescence is usually associated with the t ...
.
In 1950,
American
American(s) may refer to:
* American, something of, from, or related to the United States of America, commonly known as the "United States" or "America"
** Americans, citizens and nationals of the United States of America
** American ancestry, pe ...
surgeons
Alfred Blalock
Alfred Blalock (April 5, 1899 – September 15, 1964) was an American surgeon most noted for his work on the medical condition of shock as well as Tetralogy of Fallot— commonly known as Blue baby syndrome. He created, with assistance from h ...
and
C. Rollins Hanlon introduced the ''Blalock-Hanlon atrial septectomy'', which was then routinely used to palliate patients. This would have effectively reduced early mortality rates, particularly in cases with no concomitant shunts, but is unlikely to have reduced late mortality rates.
Mustard first conceived of, and attempted, the anatomical repair (arterial switch) for d-TGA in the early 1950s. His few attempts were unsuccessful due to technical difficulties posed by the
translocation of the coronary arteries, and the idea was abandoned.
Swedish cardiac surgeon
Åke Senning
Åke Senning (* 14 December 1915 in Rättvik, Sweden; † 21 July 2000 in Zurich, Switzerland) was a Swedish cardiac surgeon who worked at Zurich University Hospital from 1961 until his retirement in 1985.
Biography
Åke Senning was born ...
described the first corrective surgery for d-TGA (the ''Senning procedure'') in 1959, which involved using the
atrial septum
The interatrial septum is the wall of tissue that separates the right and left atria of the heart.
Structure
The interatrial septum is a that lies between the left atrium and right atrium of the human heart. The interatrial septum lies at angl ...
to create an
intratrial baffle that redirected
bloodflow at the
atrial
The atrium ( la, ātrium, , entry hall) is one of two upper chambers in the heart that receives blood from the circulatory system. The blood in the atria is pumped into the heart ventricles through the atrioventricular valves.
There are two atr ...
level; Senning yielded a high success rate using this procedure, significantly lowering both early and late mortality rates.
Due to the technical complexity of the Senning procedure, others could not duplicate his success rate; in response, Mustard developed a simpler alternative method (the ''Mustard procedure'') in 1964, which involved constructing a baffle from
autologous
Autotransplantation is the transplantation of organs, tissues, or even particular proteins from one part of the body to another in the same person ('' auto-'' meaning "self" in Greek).
The autologous tissue (also called autogenous, autogene ...
pericardium
The pericardium, also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong connective tissue (fibrous pericardium), and an inner layer made of ...
or
synthetic material, such as Dacron. This procedure yielded early and late mortality rates comparable to the Senning procedure; however, a
late morbidity rate was eventually discovered in relation to the use of synthetic graft material, which does not grow with the recipient and eventually causes
obstruction
Obstruction may refer to:
Places
* Obstruction Island, in Washington state
* Obstruction Islands, east of New Guinea
Medicine
* Obstructive jaundice
* Obstructive sleep apnea
* Airway obstruction, a respiratory problem
** Recurrent airway o ...
.
In 1966, American surgeons
William Rashkind and
William Miller transformed the palliation of d-TGA patients with the innovative ''Rashkind balloon atrial septostomy'', which, unlike the
thoracotomy
A thoracotomy is a surgical procedure to gain access into the pleural space of the chest. It is performed by surgeons (emergency physicians or paramedics under certain circumstances) to gain access to the thoracic organs, most commonly the hea ...
required by a septectomy, is performed through the
minimally invasive
Minimally invasive procedures (also known as minimally invasive surgeries) encompass surgical techniques that limit the size of incisions needed, thereby reducing wound healing time, associated pain, and risk of infection. Surgery by definition ...
surgical technique of
cardiac catheterization
Cardiac catheterization (heart cath) is the insertion of a catheter into a chamber or vessel of the heart. This is done both for diagnostic and interventional purposes.
A common example of cardiac catheterization is coronary catheterization that ...
.
The late morbidity rate is high in atrial switch, combined with advances in
microvascular surgery
Microsurgery is a general term for surgery requiring an operating microscope. The most obvious developments have been procedures developed to allow anastomosis of successively smaller blood vessels and nerves (typically 1 mm in diameter) which ...
, created a renewed interest in Mustard's original concept of an arterial switch procedure. The first successful arterial switch was performed on a forty-two-day-old d-TGA + VSD infant by Jatene in 1975. Egyptian cardiac surgeon
Magdi Yacoub
Sir Magdi Habib Yacoub ( ar, د/مجدى حبيب يعقوب ; born 16 November 1935), is an Egyptian retired professor of cardiothoracic surgery at Imperial College London, best known for his early work in repairing heart valves with surgeon ...
was subsequently successful in treating TGA with AN intact
interventricular septum
The interventricular septum (IVS, or ventricular septum, or during development septum inferius) is the stout wall separating the ventricles, the lower chambers of the heart, from one another.
The ventricular septum is directed obliquely backwar ...
when preceded by pulmonary artery banding and systemic-to-pulmonary shunt palliation.
[Yacoub MH, Radley-Smith R, Maclaurin R. Two-stage operation for anatomical correction of transposition of the great arteries with intact interventricular septum. Lancet. 1977;1:1275–8] Austrian surgeon
B. Eber was the first to recount a small series of successful arterial switch procedures, and the first large successful series was reported by
Guatemala
Guatemala ( ; ), officially the Republic of Guatemala ( es, República de Guatemala, links=no), is a country in Central America. It is bordered to the north and west by Mexico; to the northeast by Belize and the Caribbean; to the east by H ...
n surgeon
Aldo R. Casteneda. In the postoperative period, increased incidence and degree of supravalvular pulmonary stenosis. Eliminating the pericardial patch for pulmonary artery reconstruction and using a direct connection reduced the incidence of this complication.
[Kuroczyński W, Kampmann Ch, Peivandi AA, Hartert M, Knuf M, Heinemann MK, Vahl C-F: Mid-term results of a modified arterial switch operation using the direct reconstruction technique of the pulmonary artery. Cardiology Journal, 2010, Vol. 17, No. 6, pp. 574-579]
By 1991, the arterial switch had become the procedure of choice, and it remains the standard modern procedure for d-TGA repair.
[JP Breinholt, S John - Management of the Adult with Arterial Switch. Methodist DeBakey Cardiovascular Journal, 2019, 15(2):133-137]
As long-term results of arterial switch are being reported, newer sets of potential surgical problems are becoming evident. Progressive neo-aortic dilation (pulmonary valve at birth) has been observed. However, this dilation does not necessarily translate into aortic regurgitation (AR) and need for surgery in all patients. Older age at time of ASO, presence of ventricular septal defect, and previous PA banding have been found to be risk factors for AR.
supravalvular pulmonary stenosis was commonly observed in the postoperative period. A direct connection of the pulmonary artery reduced the incidence of this complication
The world's smallest infant to survive an arterial switch was Jerrick De Leon, born 13 weeks premature. At the time of the operation on February 6, 2005, he weighed just over 1.5 pounds (700 grams).
"''Pioneering surgery saves baby born 3 months early''"
- CNN.com
CNN (Cable News Network) is a multinational cable news channel headquartered in Atlanta, Georgia, U.S. Founded in 1980 by American media proprietor Ted Turner and Reese Schonfeld as a 24-hour cable news channel, and presently owned by ...
article dated February 17, 2005
References
External links
The cardiothoracic surgery network (CTSNet): Transposition of Great Vessels
Med-Lib: Transposition of the great arteries
{{Cardiac procedures
Cardiac surgery