Transcript Double Switch Operation for Failing Systemic Ventricle

Double Switch Operation for
Failing Systemic Ventricle
Yong Jin Kim, M.D.
Department of Thoracic & Cardiovascular Surgery
Seoul National University Hospital
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Introduction
• Conventional managements of AV discordant heart
( Atrial switch operation in TGA) place the morphologic
right ventricle & tricuspid valve in the systemic position
• The morphologic RV shows significant incidence of
progressive ventricular dysfunction & TV regurgitation
• Double switch operation (Conversion switch operation)
as an alternative in selected patients
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Congenitally Corrected Transposition
of Great Arteries
1. Incidence
0.5% of CHD, slightly male predominating
2. Heart block
1) Complete heart block
5-10% at birth, 10-15% in adolescence, 30% in adult
2) 1st or 2nd degree A-V block ; 40 - 50% at birth
3) 40% retain normal PR interval & QRS through their lives
3. Ventricular function
Not truly normal, but sufficiently good in most
Tendency to deteriorate after 2nd –3rd decade of life.
4. Coexisting cardiac anomalies
VSD, PS, left A-V valve incompetence ( tricuspid )
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Characteristics of Both Ventricles
1. Ventricle shape
Cylindric vs. crescent-shaped cavity
2. Contraction pattern
Concentric vs. bellow-like contraction
3. Pumping action
Pressure pump vs. low pressure-volume pump
4. Coronary artery supply
Two system vs. one system
5. Embryology
Primitive ventricle vs. bulbus cordis
6. Papillary muscles
Two papillary vs. small & numerous (septophylic)
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Congenitally Corrected TGA
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CC-TGA
Morphologic
left ventricle
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CC-TGA
Morphologic
right ventricle
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Classic Operative Indications of
CC-TGA
The presence of corrected TGA is not an indication
for a reparative operation
1. Ventricular septal defect
· same as normal heart
2. VSD & Important PS
· same as TOF
3. Left-sided tricuspid incompetence
· same as mitral incompetence
4. Complete heart block
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Classic Operation of CC-TGA
1. Repair of ventricular septal defect
2. Repair of coexisting VSD & PS
· Extracardiac conduit
· Without extracardiac conduit
3. Correction of incompetent tricuspid valve
· Repair ( annuloplasty )
· Replacement
4. Fontan-type repair
Straddling, A-V canal , hypoplastic ventricle
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“ Classic” Repair of Congenitally Corrected
TGA and VSD
(Termignon JL, et al. Ann Thorac Surg 1996)
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From 1974 to 1994, 52 CC-TGA patients
CC-TGA & VSD + LVOTO (Group I)
CC-TGA & Isolated VSD (Group II)
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: 37
: 15
Tricuspid plasty or replacement
1 (3%) in group I, 8 (53%) in group II
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Overall operative mortality : 15% (8/52)
Incidence of postop. AV block 27% (14/52)
Redo tricuspid valve plasty or replacement in 12
The operative mortality , the incidences of TVR
& AV block are high
Secondary heart failure is frequent
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Tricuspid Regurgitation & RV Dysfunction
in CC-TGA
• High risk of TR development by the 3rd decade
of life (20 to 50%)
• Most important risk factor for death after classic
repairs
• Measurable deterioration of RV within 3 years of
classic repairs
• RV dysfunction appears to be almost secondary
to long-standing TR ( Prieto, et al. Circulation.1998 )
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Major Problems after Atrial Switch
Operation in TGA
• Right ventricular failure
7-10% per 10 years , high with VSD closure
• Tricuspid regurgitation
• Rhythm disturbance
1/3 of patients lost sinus rhythm after 10 years
& atrial flutter is risk factor for late death
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Morphologic RV after Atrial Switch
Operation
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Nature of right ventricle
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One coronary ventricle
One conduction radiation
Without well-balanced papillary muscle
Not suitable to systemic ventricular function
Tricuspid regurgitation
1.
Stretching of originally noncircular tricuspid ring
Poorly supported tricuspid annulus –
RV dysfunction may induce important TR
2. Damage of TV valve as a result of VSD patching
3. Failure of systolic leaflet coaptation
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Surgical Management for Failing
Systemic RV
• Double switch operation
Correction of AV and VA discordance simultaneously
– Senning(Mustard) + ASO
– Senning(Mustard) + Rastelli
– Senning(Mustard) + REV
• Conversion switch operation
– Previous atrial switch take-down & ASO
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Surgical Considerations
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Left ventricular outflow tract
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Status of atrioventricular valves
Ventricular size & its function
Heart block & arrhythmias
Patterns of coronary arteries
Status of atrial switch operation
Technical problems for ASO
LV training & timing of operation
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Proposed Patient Selection Criteria
1.
Unobstructed LV-PA & RV-Ao connections
2.
Balanced ventricular & AV valve sizes
3.
Septatable heart, without AV valve straddling
4.
Translocatable coronary arteries
5.
Current LV/RV pressure ratio greater than 0.7
6.
Competent mitral valve with good LV function
(Karl TR, et al. ATS 1997)
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Preparation for Systemic Left
Ventricle
• Naturally occurring preparation
• Pulmonary artery banding
– Age
– Banding (LV retraining) duration
• Preoperative selection criteria
– Age
– Wall thickness
– LV/RV pressure ratio
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Senning Procedure
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Mustard Procedure
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Senning plus ASO
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Conversion Switch Operation
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Senning Plus Arterial Switch Operation for
Congenitally Corrected Transposition
(TR Karl, et al. Ann Thorac Surg 1997)
• From 1989 to 1996
• 14 Senning + ASO : age 0.5 to 120mo
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1 hospital mortality
Actuarial survival beyond 10 months : 81%
Median grade of TR : preop ¾ to ¼ postop
Normal RV function : 11/12 current survivors
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Results of the Double Switch Operation in
the Current Era (Imamura, et al. Ann Thorac Surg 2000)
• From 1993 to 1998
• 22 Double Switch Operations : 3mo to 55yrs
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Senning & ASO
: 10
Senning & Rastelli : 12
No early and late Mortality
Epicardial pacemaker insertion in 2
• Significantly improved degree of TR with normal
LV and RV function
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Systemic Right Ventricular Failure after Atrial
Switch Operation: Midterm Results of
Conversion into an Arterial Switch
(Daebritz SH, et al. Ann Thorac Surg 2001)
• 4 patients age 38 to 59 months of RV failure
underwent arterial switch operation
• Previous operation : Senning & VSD closure
• 1 late death(43.5 mo) due to LV dysfunction
• Survivors : improved FS, NYHA class I – II
• Alternative to cardiac transplantation in children
• Long-term morbidity caused by rhythm disturbance
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Experience in SNUCH
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From 1990 to 2001 ( 21 patients )
20 double switch operations
1 conversion switch operation
Age : ranged 1 month to 16 years (mean 46months)
M : F = 12 : 9
Dx : CC-TGA (with VSD, PS or PA) – 18
DORV(l–loop), PS, VSD – 2
d-TGA, VSD – 1 ( Conversion switch after Senning )
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Experience in SNUCH
• Preoperative procedures (13 )
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Pulmonary artery banding
LMBTS
RMBTS
LMBTS + RMBTS
VSD closure
Atral septostomy
PPM insertion
RV-PA conduit
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:2
:3
:1
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:1
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Experience in SNUCH
• Operative techniques in 21 patients
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Senning + ASO
:6
Senning + Rastelli : 9
Mustard + ASO
:1
Mustard + Rastelli : 1
Senning + REV
:2
Mustard + REV
:1
– * 1 conversion arterial switch operation
after Senning & PAB
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Experience in SNUCH
• Overall operative mortality : 6 / 21 (28.5%)
– Number of death according to period
– 1990 - 1993 : 5 / 10 (23.8%) in initial period
LCOS 4 , sepsis 1
* 3 early myocardial failure
– 1994 - 2001 : 1 / 11 ( 4.8%)
Sepsis 1
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Experience in SNUCH
• Complications
– AV block : permanent pacemaker in 3
– Chylothorax in 4
• Reoperation in 3
– Senning pathway reaugmentation
– Redo Rastelli op. d/t residual PS
– Conduit change with Homograft
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Experience in SNUCH
• Overall outcomes in survivors
- Postoperative TR
: all survivors in minimal or grade I
- Preserved ventricular function
: all in NYHA functional class I or II
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Operative Procedure
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Conclusion
• TR and the subsequent RV dysfunction represent the
major risk factor for CC-TGA patients.
• Double switch operation in selected patients in optimal
anatomic & physiologic subsets has encouraging early
outcomes with its theoretical advantages.
• Conversion switch operation can be performed with an
acceptable risk , and may provide long-term survival
if adequate patient preparation is warranted.
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