Congenital: Pulmonary Artery
Branch pulmonary artery stenosis after arterial switch operation: The effect of preoperative anatomic factors on reintervention

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Abstract

Background

We hypothesized that preoperative patient characteristics and branch pulmonary artery (PA) size might influence the rate of postoperative branch PA reintervention in patients with transposition of the great arteries who undergo the arterial switch operation (ASO).

Methods

The retrospective single-center study included 262 consecutive (2008-2017) newborns who underwent the ASO. Demographic characteristics, echocardiography, and clinical outcomes were reviewed. Competing risk analysis modeled incidence of branch PA reintervention and cause-specific hazard regression for predictors analyses.

Results

Median age and weight were 7 (range, 5-11) days and 3.4 (range, 3.1-3.8) kg, respectively. Various types of early branch PA reinterventions (concomitant revision or reintervention during the intensive care unit stay) were required in 28 (10.7%) patients. These patients had prolonged ventilation (P < .001), intensive care unit duration (P < .001), worse right ventricular function (P = .043), and high in-hospital mortality (P = .010). Branch PA dimensions significantly decreased immediately after ASO compared with baseline measurements. The median follow-up duration was 20.8 (range, 0.9-44.7) months. Branch PA reintervention was common among survivors without early reinterventions (9.4%), and even more frequent among those with early reinterventions (25%). Subsequent reintervention (all catheter-based) was necessary for more than one-third of patients after initial branch PA reintervention. The multivariable analysis showed preoperative dimension of the left PA (hazard ratio, 0.527 [95% CI, 0.337-0.823]; P = .005), and right PA (hazard ratio, 0.503 [95% CI, 0.318-0.796]; P = .003) were independently associated with late branch PA reinterventions.

Conclusions

Branch PA reintervention was common and often required surgical or catheter-based reinterventions after ASO. PA branch diameters became significantly smaller after ASO. Smaller preoperative branch PA predicted late branch PA reintervention, indicating a smaller margin of geometrical tolerance to this effect.

Section snippets

Methods

The Research Ethics Board at The Hospital for Sick Children approved the study (1000060700, April 12, 2018) and waived the requirement for patient consent. We retrospectively reviewed records of all patients who underwent ASO between January 2008 and December 2017. Patients with ventricular septal defect (VSD) and/or aortic arch obstruction were included. Patients with Taussig-Bing anomaly and left ventricular outflow tract obstruction were excluded. A total of 262 consecutive patients were

Early Reintervention

As shown in Figure E2, branch PA revision was the most common intraoperative revision procedure (n = 20; 41.6%), followed by coronary artery revision (n = 12; 25.5%), residual VSD closure (n = 3; 6.4%), tricuspid valve repair (n = 3; 6.4%), and MPA revision (2.1%). Among 20 patients who had branch PA revisions (LPA = 18, RPA = 6), more than two-thirds (n = 14; 70.0%) underwent LPA revision, one-fifth (n = 4; 20.0%) had bilateral branch PA revision, and only 2 patients (10.0%) required RPA

Discussion

This study was undertaken to characterize the incidence, type, location, and predictors of branch PA reintervention in patients with TGA who underwent the ASO. Various types of early branch PA reintervention were required in approximately 10% of patients. These patients were associated with prolonged ventilation duration and ICU stay, worse RV function at discharge, and a high risk of in-hospital death. Branch PA dimensions immediately decreased after ASO compared with preoperative

Conclusions

Branch PA reintervention was common in TGA patients who underwent the ASO. Early reintervention was associated with adverse in-hospital outcomes. The stretching effect after the LeCompte maneuver is likely responsible for the reduction of PA branch dimensions immediately after ASO. Smaller preoperative branch PAs predicted late branch PA reintervention, indicating a smaller margin of geometrical tolerance to this effect.

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