Primary arterial switch operation in children presenting late with d-transposition of great arteries and intact ventricular septum. When is it too late for a primary arterial switch operation?

OBJECTIVE The surgical management of infants older than 2 weeks with d-transposition of great arteries and intact ventricular septum (IVS) is a matter of debate. Some studies have presented good results of primary arterial switch operation (ASO) in these children. The aim of this study was to assess the surgical outcome of the primary ASO in children with d-transposition of great arteries and IVS presenting beyond 6 weeks of age. METHODS The clinical records of the children (more than 6 weeks age) with d-transposition of great arteries and IVS, who underwent primary ASO at our institute between January 2003 and June 2009 were reviewed. Left ventricular geometry and interventricular septal motion on the transthoracic cross-sectional echocardiogram were taken to assess the left ventricle preparedness. RESULTS Fifty-five children (age ranging from 42 days to 9 years) with d-transposition of great arteries and IVS underwent primary ASO. The mean cardiopulmonary bypass time was 94.7±21.3 min, while mean aortic cross-clamp time was 53.2±8.1 min. Seven (13%) of these children died during their hospital stay. The children who had severely regressed left ventricle (banana-shaped left ventricular geometry) were operated with integrated extra corporeal membrane oxygenation-cardiopulmonary bypass (ECMO-CPB) circuit for left ventricular re-training. The children with regressed left ventricle required longer ventilatory time and inotropic support. Recovery of left ventricular geometry has taken 1-6 months depending on age at surgery. CONCLUSIONS The children older than 6 weeks with d-transposition of great arteries and IVS can benefit from primary ASO with acceptable results. However, the need for mechanical support in some of the older patients may limit the widespread adoption of such a strategy.