Predictors of neo-aortic valve regurgitation in the long term after arterial switch operation

Introduction: Neo-aortic root dilation (ARD) is common after arterial switch operation (ASO) for D-loop transposition of the great arteries (TGA). We sought to compare short and long-term outcomes for bicuspid native pulmonary valve (BNPV) patients to those with normal trileaflet variants (TNPV). Methods: A retrospective cohort of TGA patients undergoing ASO at Boston Children’s Hospital from 1989-2018 was analyzed, matching BNPV patients 1:3 with TNPV patients by year of ASO; those with >mild subpulmonary stenosis or complex TGA were excluded. Categorical and continuous variables were compared using Fisher’s exact and Wilcoxon rank sum tests, respectively. Kaplan-Meier analyses with log-rank test compared groups for time to first reoperation on the neo-aortic valve, first occurrence of ≥moderate neo-aortic regurgitation (AR), and ARD defined as root z-score ≥4. Hazard ratios were estimated based on the Cox proportional hazards model. Results: A total of 83 BNPV patients were matched with 217 TNPV. BNPV patients were more likely to have a VSD (75% vs 44%, p <0.001). Early surgical outcomes including hospital LOS (11 vs 10 days) and 30-day mortality (3.6% vs 2.8%) were similar. During median 10 years follow-up, neo-aortic valve reoperation occurred in 4 BNPV (6%) vs 6 TNPV (3%) patients, with no statistically significant difference in time to reoperation. More BNPV patients had AR at discharge (4.9% vs 0%, p=0.014) and during follow-up (13.4% vs 4.3%, HR 3.9, p=0.004), with shorter time to first occurrence of AR (Figure 1A); this remained significant after adjusting for presence of VSD. Similarly, ARD was more common in BNPV (45% vs 37%, HR 1.64, p=0.02) with shorter time to first occurrence (Figure 1B). Conclusions: While patients with BNPV have similar short-term ASO outcomes, AR and ARD occur more frequently and earlier compared with TNPV patients. Further long-term studies are needed to determine whether this results in greater need for neo-aortic valve reoperation.

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Long-term fate of the aortic valve after an arterial switch operation

Journal of Thoracic and Cardiovascular Surgery ◽

10.1016/j.jtcvs.2014.11.075 ◽

2015 ◽

Vol 149 (4) ◽

pp. 1089-1094 ◽

Cited By ~ 24

Author(s):

Mauro Lo Rito ◽

Mario Fittipaldi ◽

Randula Haththotuwa ◽

Timothy J. Jones ◽

Natasha Khan ◽

...

Keyword(s):

Aortic Valve ◽

Arterial Switch Operation ◽

Arterial Switch ◽

Switch Operation

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Impact of pulmonary artery reduction during arterial switch operation: 14 years follow-up

Interactive Cardiovascular and Thoracic Surgery ◽

10.1093/icvts/ivaa034 ◽

2020 ◽

Vol 30 (6) ◽

pp. 917-924

Author(s):

Fernanda Lübe Antunes Pereira ◽

Cristiane Nunes Martins ◽

Roberto Max Lopes ◽

Matheus Ferber Drummond ◽

Fernando Antonio Fantini ◽

...

Keyword(s):

Arterial Switch Operation ◽

Z Score ◽

Valve Regurgitation ◽

Arterial Switch ◽

Switch Operation ◽

Long Term Follow Up ◽

Z Scores ◽

The Mean

Abstract OBJECTIVES Pulmonary artery/aorta (PA/Ao) size discrepancy plays an important role in the development of neoaortic root growth and valve regurgitation. Since 2004, we started using PA reduction to manage severe great vessels root mismatch at the time of arterial switch operation. The purpose of this study is to evaluate the impact of this technique in the mid- and long-term follow-up. METHODS Patients considered to have severe PA/Ao mismatch (>2:1 ratio) underwent resection of a 3- to 4-mm flap of the posterior PA wall. Patients submitted to this technique were followed up with clinical and image examinations. Echocardiographic findings were reviewed, and Z-scores were recorded to evaluate the incidence and progression of neoaortic root dilatation and valve regurgitation. RESULTS The median (Q1–Q3) follow-up time was 8 years (3–11). Before arterial switch operation, the median (Q1–Q3) Z-score of the PA annulus was 2.90 (2.75–3.75). At the latest follow-up, the median Z-score of the neoaortic annulus was 1.34 (0.95–1.66). The mean difference between the Z-scores of PA annulus and neoaortic annulus was 1.56 (P < 0.0001). The mean value of the sinus of Valsalva was +0.29 ± 1, that of sinotubular junction was +0.71 ± 0.6 and that of ascending Ao was +1.09 ± 0.7. There was no severe dilatation of the neoaortic annulus, neoaortic root or ascending Ao during follow-up. Neoaortic valve regurgitation was none or mild in 93% of patients. CONCLUSIONS PA reduction proved to be a feasible and low-risk procedure to approach PA/Ao mismatch in arterial switch operation. Mid- and long-term follow-up showed a tendency towards stabilization of the neoaortic root dilatation and satisfactory valve performance after the procedure. Further investigation is required with a larger population and longer-term follow-up.

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Arterial Switch Operation, Aortic Root Dilation, and Long-Term Aortic Valve Competence

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2008.06.044 ◽

2008 ◽

Vol 86 (6) ◽

pp. 2025-2026 ◽

Cited By ~ 5

Author(s):

Tomaso Bottio ◽

Gaetano Thiene ◽

Vincenzo Tarzia ◽

Giulio Rizzoli ◽

Gino Gerosa

Keyword(s):

Aortic Valve ◽

Aortic Root ◽

Arterial Switch Operation ◽

Arterial Switch ◽

Switch Operation

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Progression of aortic root dilatation and aortic valve regurgitation after the arterial switch operation

Heart ◽

10.1136/heartjnl-2019-315157 ◽

2019 ◽

Vol 105 (22) ◽

pp. 1732-1740 ◽

Cited By ~ 8

Author(s):

Roel L F van der Palen ◽

Teun van der Bom ◽

Annika Dekker ◽

Roula Tsonaka ◽

Nan van Geloven ◽

...

Keyword(s):

Risk Factors ◽

Aortic Valve ◽

Aortic Root ◽

Arterial Switch Operation ◽

Valve Regurgitation ◽

Aortic Valve Regurgitation ◽

Sinotubular Junction ◽

Switch Operation ◽

Over Time ◽

Aortic Dimensions

ObjectiveTo study neo-aortic growth and the evolution of neo-aortic valve regurgitation (AR) in patients with transposition of the great arteries (TGA) after arterial switch operation (ASO) from newborn to adulthood and to identify patients at risk.MethodsNeo-aortic dimensions (annulus/root/sinotubular junction) and neo-aortic valve regurgitation were assessed serially in 345 patients with TGA who underwent ASO between 1977 and 2015. Linear mixed-effect models were used to assess increase of neo-aortic dimensions over time and to identify risk factors for dilatation. Risk factor analysis for AR by using time-dependent Cox regression models.ResultsAfter a rapid increase in the first year after ASO and proportional growth in childhood, neo-aortic dimensions continue to increase in adulthood without stabilisation. Annual diameter increase in adulthood was 0.39±0.06, 0.63±0.09 and 0.54±0.11 mm for, respectively, neo-aortic annulus, root and sinotubular junction, all significantly exceeding normal growth. AR continues to develop over time: freedom from AR ≥moderate during the first 25 years post-ASO was 69%. Risk factors for root dilatation were complex TGA anatomy (TGA-ventricular septal defect (VSD), double outlet right ventricle with subpulmonary VSD) and male gender. Risk factors for AR ≥moderate were: complex TGA anatomy and neo-aortic growth. Per millimetre increase in aortic root dimension, there was a 9% increase in the hazard of AR ≥moderate. Bicuspid pulmonary valve did not relate to the presence of root dilatation or AR.ConclusionAfter ASO, neo-aortic dilatation proceeds beyond childhood and is associated with an increase in AR incidence over time. Careful follow-up of the neo-aortic valve and root function is mandatory, especially in males and in patients with complex TGA anatomy.

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