Emergency arterial switch: Rescue therapy for life-threatening hypoxemia in infants with transposition of great arteries with intact intraventricular septum

Published:November 21, 2022DOI:



      A small percentage of infants with d-loop transposition of the great arteries with intact intraventricular septum have life-threatening refractory hypoxemia often due to coexistent persistent pulmonary hypertension of the newborn. In this case series we describe the outcomes of a “rescue” emergency arterial switch operation (ASO).


      We undertook a retrospective medical record analysis of infants with d-loop transposition of the great arteries with intact intraventricular septum who underwent an ASO in New Zealand from January 1, 1996, to April 30, 2017. Data were compared for those who received an emergency ASO and those with a nonemergency ASO for descriptive purposes. An emergency ASO was defined as one that was undertaken for life-threatening refractory hypoxemia when the only alternative stabilization strategy was preoperative extracorporeal life support. 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.


      Two hundred seventy-two infants underwent an ASO with 25 (9%) who received an emergency ASO. No infants received preoperative extracorporeal life support. The emergency group had greater 30-day postoperative mortality (8.0% vs 0.4%; P = .01) with no difference in abnormal neurodevelopmental outcome among the survivors (17.4% vs 13.8%; P = .35). The emergency group had more therapies for low cardiac output syndrome, more postoperative seizures, and a longer length of stay.


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

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      ASO (arterial switch operation), BAS (balloon atrial septostomy), CPB (cardiopulmonary bypass), ECLS (extracorporeal life support), LCOS (low cardiac output syndrome), maxVIS (maximum vasoactive-inotropic score), PGE1 (prostaglandin E1), PPHN (persistent pulmonary hypertension of the newborn), TGA/IVS (d-loop transposition of the great arteries with intact intraventricular septum)
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      • Commentary: Emergent arterial switch for critically ill babies with transposition
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          Among the most important advances over the past 2 decades in the field of congenital heart surgery has been the development and refinement of emergency extracorporeal membrane oxygenation (ECMO). Whether dealing with cardiac arrest after surgery or arrival in the middle of the night of an undiagnosed neonate, generic arteriovenous ECMO smoothly instituted by a coordinated experienced team has become the hallmark of every high quality, busy congenital program. ECMO allows for stabilization, thoughtful and accurate diagnosis, and time to develop a longer-term plan.
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