Should we address the neopulmonic valve? Significance of right-sided obstruction after surgery for transposition of the great arteries and coarctation.

BACKGROUND

The combination of transposition of the great arteries and coarctation of the aorta (TGA/CoA) presents a surgical challenge. We have adopted a concurrent aortic arch repair and arterial switch operation with excellent results. These patients tend to have a small aortic (ie, neopulmonary) annulus. This study evaluates the significance of right-sided obstruction after single-stage repair of TGA/CoA.

METHODS

Between May 1991 and May 2006, 53 patients with TGA/CoA or Taussig-Bing/CoA (n = 20; 38%) underwent a complete single-stage repair. Surgical technique involved the arterial switch operation and ventricular septal defect closure when present in 51 patients (96%). The aortic arch was enlarged in 36 patients (75%) with patch augmentation. Two patients (4%) underwent the augmentation of the right ventricular outflow tract (RVOT) at the first operation.

RESULTS

There was one hospital death (operative mortality, 1.9%) and one late death. The difference between the preoperative aortic and pulmonary annulus was significant (6.7 vs 10.4 mm, p < 0.001). The peak pressure gradient across the proximal RVOT at discharge was 16 +/- 16 mm Hg (range, 0 to 62 mm Hg). There have been six reoperations (11%) and four catheter interventions (7.5%) for right-sided obstruction. Freedom from reintervention/reoperation for right-sided obstruction at 1, 5, and 10 years is 95%, 87%, and 80%, respectively.

CONCLUSIONS

Neonatal single-stage repair for TGA/CoA achieves excellent survival without transannular patch repair at the first operation. Although some of the patients have pressure gradient across the RVOT, these lesions were amenable to reintervention with minimal morbidity.