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Emergency Arterial Switch: Rescue Therapy for Life-Threatening Hypoxaemia in Transposition of Great Arteries with Intact Intraventricular Septum

Published:November 21, 2022DOI:https://doi.org/10.1016/j.jtcvs.2022.11.014
Emergency Arterial Switch: Rescue Therapy for Life-Threatening Hypoxaemia in Transposition of Great Arteries with Intact Intraventricular Septum
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      Abstract

      Objective

      A minority of infants with d-loop transposition of the great arteries with intact intraventricular septum (TGA/IVS) have life-threatening refractory hypoxaemia often due to coexistent persistent pulmonary hypertension of the newborn (PPHN). This case series describes the outcomes of a ‘rescue’ emergency arterial switch operation (ASO).

      Methods

      Retrospective medical record analysis of infants with TGA/IVS who underwent an ASO in New Zealand from 1st January 1996 to 30th April 2017. Data were compared between those who received an emergency ASO and those with a non-emergency ASO for descriptive purposes. An emergency ASO was defined as one that was undertaken for life-threatening refractory hypoxemia where the only alternative stabilisation strategy was preoperative extracorporeal life support (ECLS). Primary outcome measures were 30-day postoperative mortality and abnormal neurodevelopmental outcome in the survivors. Secondary outcomes were low cardiac output, arrhythmia, renal dysfunction, postoperative seizures, and length of stay. Other known risk factors for morbidity and mortality were also assessed.

      Results

      272 infants underwent an ASO with 25 (9%) receiving an emergency ASO. No infants received preoperative ECLS. The Emergency Group had greater 30-day postoperative mortality (8.0% vs 0.4%; p = 0.01) with no difference in abnormal neurodevelopmental outcome amongst the survivors (17.4% vs 13.8%; p = 0.35). The Emergency Group had more therapies for low cardiac output syndrome (LCOS), more postoperative seizures, and a longer length of stay.

      Conclusions

      An emergency ASO is a definitive rescue therapy that can be undertaken with acceptable mortality and neurodevelopmental outcome given the preoperative clinical state.

      Graphical abstract

      Figure thumbnail fx1
      Graphical Abstract

      Keywords

      Abbreviations and Acronyms:

      ASO (arterial switch operation), BAS (balloon atrial septostomy), CPB (cardiopulmonary bypass), TGA/IVS (d-loop transposition of the great arteries with intact intraventricular septum), ECLS (extracorporeal life support), LOS (length of stay), LCOS (low cardiac output syndrome), PICU (paediatric intensive care unit), PGE1 (prostaglandin E1), PPHN (persistent pulmonary hypertension of the newborn), ECMO (extracorporeal membrane oxygenation), VIS (vasoactive-inotropic score)
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      Article Info

      Publication History

      Accepted: November 11, 2022
      Received in revised form: November 7, 2022
      Received: August 26, 2022

      Publication stage

      In Press Journal Pre-Proof

      Footnotes

      Conflict of interest statement: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

      Funding: None.

      IRB: The study protocol was approved by the Auckland District Health Board research review committee with a waiver of consent (Approval Number: A+8017; approval date: 3rd April 2018)

      Central Picture: Emergency ASO rather than preoperative ECLS for TGA/IVS and life-threatening hypoxaemia

      Central Message: An emergency ASO provides acceptable outcomes for infants with TGA/IVS and life-threatening refractory hypoxaemia likely due to coexistent pulmonary hypertension.

      Perspective: This is the largest case series describing the outcomes of an emergency ASO as treatment for TGA/IVS and severe intractable hypoxaemia. Although mortality is higher compared to those who received a non-emergency ASO, the 30-day mortality and neurodevelopmental outcome is acceptable. Use of an emergency ASO may avoid the risks associated with preoperative ECLS and thus encourage a change in practice.

      Identification

      DOI: https://doi.org/10.1016/j.jtcvs.2022.11.014

      Copyright

      © 2022 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery

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