CLINICAL STUDIES
Evolution of risk factors influencing early mortality of the arterial switch operation
Elizabeth D. Blume, MD*  ,
Karen Altmann, MD*  ,
John E. Mayer, MD, FACC ,
Steven D. Colan, MD, FACC* ,
Kimberlee Gauvreau, ScD* and
Tal Geva, MD, AFACC*
* Department of Cardiology, Children’s Hospital, Boston, Massachusetts, USA
Department of Cardiac Surgery, Children’s Hospital, Boston, Massachusetts, USA
Department of Pediatrics and Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
Current affiliation: Columbia Presbyterian Medical Center, New York, New York, USA
Reprint requests and correspondence: Dr. Tal Geva, Department of Cardiology, Children’s Hospital, 300 Longwood Avenue, Boston, Massachusetts 02115
geva_t{at}a1.tch.harvard.edu
OBJECTIVES
The present study was undertaken to determine the independent risk factors for early mortality in the current era after arterial switch operation (ASO).
BACKGROUND
Prior reports on factors affecting outcome of the ASO demonstrated that abnormal coronary arterial patterns were associated with increased risk of early mortality. As diagnostic, surgical and perioperative management techniques continue to evolve, the risk factors for the ASO may have changed.
METHODS
All patients who underwent the ASO at Children’s Hospital, Boston between January 1, 1992 and December 31, 1996 were included. Hospital charts, echocardiographic and cardiac catheterization data and operative reports of all patients were reviewed. Demographics and preoperative, intraoperative and postoperative variables were recorded.
RESULTS
Of the 223 patients included in the study (median age at ASO = 6 days and median weight = 3.5 kg), 26 patients had aortic arch obstruction or interruption, 12 had Taussig-Bing anomaly, 12 had multiple ventricular septal defects, 8 had right ventricular hypoplasia and 6 were premature. There were 16 early deaths (7%), with 3 deaths in the 109 patients considered "low risk" (2.7%). Coronary artery pattern was not associated with an increased risk of death. Compared with usual coronary anatomy pattern, however, inverted coronary patterns and single right coronary patterns were associated with increased incidence of delayed sternal closure (p = 0.003) and longer duration of mechanical ventilation (p = 0.008). In a multivariate logistic regression model using only preoperative variables, aortic arch repair at a separate procedure before ASO and smaller birth weight were independent predictors of early mortality. In a second model that included both pre- and intraoperative variables, circulatory arrest time and right ventricular hypoplasia were independent predictors of early death.
CONCLUSIONS
The ASO can be performed in the current era without excess early mortality related to uncommon coronary artery patterns. Aortic arch repair before ASO, right ventricular hypoplasia, lower birth weight and longer intraoperative support continue to be independent risk factors for early mortality after the ASO.
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Abbreviations and Acronyms
| | ASO | = arterial switch operation | | CPB | = cardiopulmonary bypass | | DORV | = double outlet right ventricle | | d-TGA | = dextrotransposition of the great arteries | | ICU | = intensive care unit | | PA | = pulmonary artery | | TGA | = transposition of the great arteries | | VSD | = ventricular septal defect |
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