Download Cardiorespiratory Response to Exercise Transposition of the Great

Cardiorespiratory Response to Exercise
After Venous Switch Operation for
Transposition of the Great Arteries*
Douard, MD; Laurent Labbe, MD; Jean Louis Barat, MD;
Paul
Broustet, MD; Eugene Baudet, MD; and Alain Choussat, MD
Jean
Herve
Study objective:
This
study reports
on
the
cardiorespiratory response
to
graded
exercise in
patients after venous switch operation for transposition of the great arteries.
Design: Several small studies have documented a diminished exercise tolerance after Mustard
repair for transposition of the great arteries; little information exists, however, about long-term
cardiorespiratory exercise performance in patients who have had the Senning procedure.
Patients: This prospective study reports on the serial long-term (mean, 11 ±2.8 years) cardiopul¬
monary exercise performance of 43 patients (age, 12±3.1 years) who underwent a Senning
procedure, with no significant postoperative abnormalities. Forty-three matched healthy chil¬
dren were also studied as a control group.
Measurements and results: All underwent exercise testing (Bruce protocol) with metabolic gas
exchange to determine parameters at 3 min, anaerobic threshold, similar heart rate (150
beats/min), and peak exercise. Time of exercise was 10.5±1.9 min in patients and 13.4±2 min in
control subjects (p=0.0001). Overall, patients reached 73% of peak oxygen uptake achieved by
control subjects (32.6±5.6 vs 44.7±6 mL/kg/min). Chronotropic response (188±15.7 vs
166.5±19.6 beats/min [p=0.0001]) and oxygen pulse (7.4±2.9 vs 10.7±4.2 mL/beat [p=0.0002])
were lower in patients at peak exercise. Patients had a greater respiratory response to exercise:
both respiratory rate and ventilatory equivalent for carbon dioxide were significantly higher at all
stages of exercise. Exercise capacity assessed by peak oxygen uptake was correlated with time
elapsed since surgical repair (r=0.48; p=0.001).
Conclusions: It is concluded that even in asymptomatic patients, exercise endurance and
respiratory response are generally altered as much as 11 ±2.8 years after venous switch
operation, although early surgical repair is predictive of a better long-term functional result.
(CHEST 1997; 111:23-29)
Key words: exercise testing; Senning; transposition of great vessels
Abbreviations: ASO=atrial switch operation; AT=anaerobic (ventilatory) threshold; RR=respiratory rate;
TGA=transposition of great arteries; Vco2=carbon dioxide output; Ve minute ventilation; Vo2=oxygen uptake;
=
Vt=tidal volume
A
¦**-
lthough the arterial switch operation is now
frequently the procedure of choice for correct¬
ing transposition of the great arteries (TGA), most
adolescents and young adults born with TGA owe
their survival to the atrial switch operation
(ASO).12 Mustard and Senning procedures result
in low early morbidity and mortality, but longterm results have shown an increased incidence of
arrhythmia,3-6 sudden deaths, and a decrease in
Hopital Cardiologique
1996; revision accepted July 29.
Manuscript received February 14, Service
des Epreuves d'Ejfort,
Reprint requests: Dr. Douard,
Hopital Cardiologique, 33604 Pessac, France.
*From the Cardiology Department of
Haut Leveque, Pessac, France.
functional capacity,718 probably because the mor¬
phologic
right ventricle may be unable to function
as successfully as a morphologic left ventricle in
the systemic position for long periods of time.19-23
Previous investigators have described a limited
cardiorespiratory response to exercise in patients
who have had ASO.6-91416 However, these series
were limited in number, did not always analyze gas
and included patients especially oper¬
exchange,with
ated on
the Mustard technique. Therefore,
the present study was undertaken to evaluate
exercise tolerance in a larger series of 43 patients
who had undergone a Senning procedure, with
special attention to cardiopulmonary response.
CHEST 7111/1/ JANUARY, 1997
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23
Materials
and
ent temperature, barometric pressure, and water vapor.
Methods
Peak Vo2
defined as the maximal value of Vo2 obtained during the last
30 s of exercise. Oxygen pulse was calculated as the ratio of Vo2
was
Subjects
The forty-three patients (11 girls, 32 boys) underwent ASO at
our cardiologic hospital department between 1977 and 1988;
after operation, they had yearly clinical, ECG, and echocardio¬
graphic examinations. All patients had at least one postoperative
catheterization. Twenty-six patients had simple transposition,
defined as TGA with an otherwise normal heart, whereas the
remainder had additional associated defects, including ventricu¬
lar septal defect (seven patients) or ventricular outflow obstruc¬
tion (ten patients). At the time of the study, 11 patients had mild
obstruction,
pulmonary stenosis (<40 mm Hg), 5 had atrial baffle
and 1 had important tricuspid regurgitation. Two patients had
permanent pacemakers. All considered themselves asymptomatic
and most of them took part in gym at school. Mean age at surgical
repair was 9.6±5.6 months, and the postoperative interval ranged
from 6.5 to 18.3 years (mean, 11 ±2.8 years). Two patients were
taking cardiac medications at the time of their exercise study;
these were diuretics (one patient) and beta-blockers (one pa¬
tient). As a control group, 43 healthy voluntarily enrolled children
from local schools were also studied; none had a sport activity
elsewhere. They were matched for age, sex, height, and weight to
TGA patients
Exercise
(Table 1).
out exercise
by an exercise ECG system (Marquette Case 15;
Electronics Inc; Milwaukee). A 15-lead ECG was
obtained with the patient at rest, and at 1-min intervals for 5 min
after exercise testing. BP was measured at each workload with a
mercury sphygmomanometer.
Gas was measured directly through open-circuit spirometry
Marquette
(Medical Graphic Corporation CPX System, St. Paul, Minn) by a
first-responding oxygen analyzer and an infrared carbon dioxide
analyzer. Minute ventilation (Ve), oxygen uptake (Vo2), carbon
dioxide output (Vco2), and derived variables were measured for
each breath. Before each exercise study, the system was cali¬
brated with known volumes of airflow and precise gas mixtures.
Gas exchange and flow measurements were corrected for ambi-
1.Comparison ofAnthropometric and Exercise
Subjects
Variables in Patients and Control
Control
Patients
(n=43)
Age,
Statistical Methods
analyses were performed using software (Mac Statview
are reported as mean values ±SD. Differences
between mean values were calculated by analysis of variance with
repeated measurements. Differences were considered statisti¬
cally significant at the p<0.05 level. Linear regression analysis
was used to study the correlation between exercise time or age of
surgery and the different indexes of cardiopulmonary tolerance.
The
512).
Data
Testing
This study was undertaken with the approval of the local ethics
committee, and written informed consent from each subject's
parents was obtained. Treadmill exercise testing was performed
using a Bruce protocol. All children were encouraged by an
nurse to exercise to exhaustion.
experienced
Heart rate and rhythm were monitored continuously through¬
Table
the concomitant heart rate. Anaerobic threshold was deter¬
mined mainly by the V slope method, in addition to the following
conventional criteria: an increase, after a period of stability or
reduction in ventilatory equivalent for oxygen (Ve/Vo2) and a
steeper increase in the gas exchange ratio. Vo2 at anaerobic
threshold was also expressed in percent of the maximal oxygen
consumption. The relationship between both respiratory rate
(RR) and ventilation (Ve) against carbon dioxide production
(Vco2) was calculated as indexes of the ventilation response.
All parameters were examined at four reference time points, ie,
the third minute of the test, anaerobic threshold, 150 beats/min
if reached, and peak exercise.
to
yr
Weight, kg
cm
Height,
BSA*
m2
Rest heart rate, beats/min
Rest systolic BP, mm Hg
Peak heart rate, beats/min
Peak systolic BP, mm Hg
Endurance time, min
*BSA=body surface area.
12±3.1
38.2±15.9
145±17
1.12±0.31
85.7±15
100±10
166±20
122±16
10.5±1.9
Subjects
(n=43)
p Value
NS
12.8±3.4
44.6±15
NS
154±19NS
1.39±0.32
NS
99±15
0.0001
109±13
0.002
188±16
0.0001
140±23
0.0001
13.4±2
0.0001
Results
Characteristics of the patients and control groups
summarized in Table 1. No significant differ¬
found between patients and control
with
subjectssurface area.
respect to age, sex, weight, height, and
body
Compliance with the study exer¬
cise was excellent for all children. Fatigue or breathlessness were the only reasons to stop exercise.
Mean heart rates at rest on ECG were 87±15.1
beats/min in patients and 99.2± 14.9 beats/min in the
normal group (p=0.0001). All normal subjects and
36 of 43 patients were in sinus rhythm at rest; 5
patients had intermittent junctional rhythm; 2 pa¬
tients were paced because of sinus node dysfunction.
All patients but one developed sinus tachycardia with
exercise; 6 patients had significant atrial (n=3) or
ventricular (n=3) arrhythmias during exercise. At
control subjects achieved a signifi¬
peak exercise,heart
rate (187.8±16.1 vs 166.5±19.6
cantly higher
are
ences were
beats/min; p=0.0001). Twenty-one patients
were
unable to reach 80% of their theoretical maximal
heart rate, and 6 patients did not achieve 150
beats/min at the end of exercise; the relation¬
ship between chronotropic response and Vo2 was
y=3.1 x+47.2 in control subjects and y=4.2 x+31.3
in patients, where y=heart rate (beats/min) and
x=Vo2 in mL/min/kg (Fig 1). Maximal exercise heart
rate showed no correlation with either age at the
time of operation or age at the time of exercise
testing. However, maximal heart rate was weakly
correlated with peak Vo2 in patients (r=0.29,
p=0.05). Systolic BP was also different at rest (pa-
24
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21742/ on 05/06/2017
Clinical
Investigations
-55
O Controls
. Patients
a
45
O
./
"E 35
'5.
W
o
cr
25
1000
VC02
2000
(ml/min)
1600
§,
O Controls
. Patients
1400
0
E 1200
o
>
1000CO
800
600
25
35
Respiratory
45
rate
55
(/min)
RR=Vco2 relationships in patients and control
Top: exercise.
Data are expressed as mean±SEM, at
subjects
during
the third minute of exercise, AT, 150 beats/min, and peak
exercise. Bottom: average Vt-RR relationships in patients and
control subjects during exercise. Two asterisks indicate p<0.001;
three asterisks, p<0.0001.
Figure 5.
absent in normal subjects. However, peak Vo2
decrease (.27%) is only partially explained by chronotropic alteration ( 12%) after atrial repair. This
chronotropic limitation may not be specific to atrial
repair but might be a common denominator to all
intracardiac repair, as the cardiopulmonary bypass
has been associated with surgical fibroprocedure
elastosis that could directly or indirectly disrupt the
integrity of the sinus mode.14
The other cause suggested for limited capacity
after venous switch operation is an inadaptation of
the right ventricle in the systemic position. Several
and especially isoechocardiographic,
angiographic,
exercise
studies
have
shown
ventricular hypotopic
kinesia and a decrease in stroke volume.1923
Although right ventricle dilatation may be a compen¬
satory mechanism for chronotropic insufficiency,6
C02 rebreathing and isotopic measurements of car¬
diac flow showed a decrease in stroke volume during
exercise testing under constant maximal load.9 In our
was
study, oxygen pulse, an indirect indicator of the
stroke volume, was decreased at the end of testing
(7.4±2.9 vs 10.7±4.2 mL/beat; p<0.001) and at
submaximal loads.
In normal children and adolescents, oxygen pulse
correlates better than peak Vo2 with morphometric
parameters, particularly body surface.25 In our pa¬
tients and control subjects, these correlations were
excellent but with different coefficients.
Although our study unfortunately confirms that
children treated with the Senning technique have a
functional limitation close to that in chil¬
long-term
dren operated on a few years earlier with the
Mustard operation, it does show for the first time an
inverse relationship between time since intervention
and ulterior aerobic capacity (r=0.48; p=0.001),
while there is no significant correlation between the
age of patients (or control subjects) and peak Vo2.
We observed no significant relationship between age
at surgery and maximal heart rate or 02 pulse at peak
effort. Unlike previous series in which no association
was noted between time since intervention and
exercise capacity, it seems that the earlier the chil¬
dren are operated on with the Senning technique,
the better their ultimate effort capacity.
Our patients were all operated on by the same
surgeon, and were operated on as quickly as possible
when functional tolerance was poor (persistent cya¬
nosis despite an efficient atrioseptostomy of Rashkind-Miller). It may be that submitting the right
ventricle early to conditions of systemic load leads to
better long-term tolerance, with exercise capacities
similar to those in patients operated on with an
arterial switch technique.26
The ventilatory adaptation of our patients during
exercise testing was also quite different from that of
normal patients and is reminiscent of the modifica¬
tions described in cardiac insufficiency.27'28 There is,
in fact, an excess ventilatory response as measured by
the respiratory frequency (or overall ventilation)
to the production of C02.29 Such anoma¬
compared
lies have also been described more recently after
Fontan procedures and repair of tetralogy of
Fallot.30
However, we found no correlation between respi¬
ratory equivalents for C02 measured at the end of
exercise and peak Vo2 in patients or control subjects,
previous report.24 The relationship
is all the more disturbed as the
limitation of effort capacity increases, was also ab¬
normal in our patients. This disturbance is associated
contrary
to
a
Vt-RR, which
with a decrease in Vt at the end of effort than
acceleration in respiratory frequency. How¬
ever, the mechanisms involved in this abnormal
ventilatory response are not well understood. Unfor¬
tunately our patients did not have additional respimore
with
an
CHEST / 111 / 1 / JANUARY, 1997
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21742/ on 05/06/2017
27
12
o> 60 r
\
|
55
50
v.
45
E
40
35
a;
3
Controls
Patients
30
10
Lil
(/)
-J
D
a.
CM
o 10
O
150 b/min
Figure 2. Box plots of the values of Vo2 during exercise in
control subjects and patients at the third minute of the test, AT,
150 beats/min, and peak exercise. The central dot is the sample
mean. The bottom and top edges of the box are the sample 25th
and 75th percentiles.
pulse at the end of exercise was strongly correlated
with body surface area in the patient group (r=0.89;
but with a lower slope relationship (con¬
p=0.0001)
trol subjects, y=11.2 x-4.78; patients, y=8.3 x.2.8,
where y=oxygen pulse and x=body surface area).
During exercise, the patient group had a Ve lower
than control subjects (46±18.7 vs 69.3±30.1 L/min;
of exercise. However, the
p<0.0001) at the end
was
very different between the
ventilatory pattern
two groups: the increase of tidal volume (Vt) was
lower during exercise in patients. Patients had a
greater respiratory response to exercise with RR/
Vco2 and Ve/Vco2 showing significant increases at
all stages of exercise. Figure 5 shows the Vt-RR
for each group. We found no significant
relationshipbetween
correlation
Ve/Vco2 and Vo2 at the end of
exercise.
All these differences in cardiopulmonary parame¬
also present for the Senning subgroup with
or without additional defects.
ters were
Discussion
Comparisons of cardiopulmonary function in pa¬
0
c
O Controls
. Patients
.Q
% 25
£ 20
2"
tients
S
11
having undergone
2.5
10
venous
5
7.5
Age
at surgery (months)
12.5
Figure 3. Relation between
15
17.5
switch
20
operation
22.5
.
peak Vo2 (mL/min/kg)
(months) at surgery in patients.
MAXV02
and age
4
6
8
Exercise time
10
12
14
(min)
Figure 4. Oxygen pulse (mL/beat) in normal subjects and
Data (mean±SEM) were obtained at the third minute
patients.
of exercise, AT, 150 beats/min, and peak exercise. Two asterisks
indicate p<0.001.
maxi¬
subjects have indicated different
to
exercise.7-8
and
performances adaptations
However, most studies have focussed on patients
who had the Mustard procedure. Reybrouck et al15
alone recently reported a small series of 20 patients
followed up 7.3 years after a Senning operation. The
is shorter sim¬
follow-up for the Senning recent.
procedure
Better long-term
ply because it is morecould
ex¬
theoretically be uses
capacity
performance
with
the
because
it
Senning
operation,
pected viable atrial tissue. We
report herein the
exclusively
TGA
of
on
series
operated
patients (n=43)
largest
the
operated on with
exclusively includingwithpatients
10
than
a
of
more
Senning procedure
follow-up
11
6.5
to
18.3; mean, ±2.8).
years (from
to matched control subjects, our pop¬
Compared
ulation had a reduced aerobic capacity with shorter
exercise time (-22%), peak Vo2 (-27%), or Vo2 at
aerobic threshold (.29%). Although our patients
were asymptomatic, the slope of Vo2 vs workload
with different
increase was reduced as in
with normal
mum
patients
stages of heart failure.24 The results from the present
study are in agreement with the previous report of
Reybrouck et al16 and with similar cardiopulmonary
alterations observed after Mustard operations.91415
Exercise performance limitation after atrial repair
has been attributed to an impaired chronotropic
group, had a
response.6 Our patients, as a combined
mean resting heart rate that was significantly less
than normal; on exercise stress testing, the rhythm
reverted to sinus in all patients but remained lower
at the end of exercise (166 ±20 vs 188±16 beats/min;
p=0.0001).
Twenty-one patients were unable to
reach 80% of their theoretical maximal heart rate.
We found a weak correlation between maximal heart
rate and peak Vo2 in patients (r^O.29; p=0.05) that
26
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21742/ on 05/06/2017
Clinical
Investigations
-55
O Controls
. Patients
a
45
O
./
"E 35
'5.
W
o
cr
25
1000
VC02
2000
(ml/min)
1600
§,
O Controls
. Patients
1400
0
E 1200
o
>
1000CO
800
600
25
35
Respiratory
45
rate
55
(/min)
RR=Vco2 relationships in patients and control
Top: exercise.
Data are expressed as mean±SEM, at
subjects
during
the third minute of exercise, AT, 150 beats/min, and peak
exercise. Bottom: average Vt-RR relationships in patients and
control subjects during exercise. Two asterisks indicate p<0.001;
three asterisks, p<0.0001.
Figure 5.
absent in normal subjects. However, peak Vo2
decrease (.27%) is only partially explained by chronotropic alteration ( 12%) after atrial repair. This
chronotropic limitation may not be specific to atrial
repair but might be a common denominator to all
intracardiac repair, as the cardiopulmonary bypass
has been associated with surgical fibroprocedure
elastosis that could directly or indirectly disrupt the
integrity of the sinus mode.14
The other cause suggested for limited capacity
after venous switch operation is an inadaptation of
the right ventricle in the systemic position. Several
and especially isoechocardiographic,
angiographic,
exercise
studies
have
shown
ventricular hypotopic
kinesia and a decrease in stroke volume.1923
Although right ventricle dilatation may be a compen¬
satory mechanism for chronotropic insufficiency,6
C02 rebreathing and isotopic measurements of car¬
diac flow showed a decrease in stroke volume during
exercise testing under constant maximal load.9 In our
was
study, oxygen pulse, an indirect indicator of the
stroke volume, was decreased at the end of testing
(7.4±2.9 vs 10.7±4.2 mL/beat; p<0.001) and at
submaximal loads.
In normal children and adolescents, oxygen pulse
correlates better than peak Vo2 with morphometric
parameters, particularly body surface.25 In our pa¬
tients and control subjects, these correlations were
excellent but with different coefficients.
Although our study unfortunately confirms that
children treated with the Senning technique have a
functional limitation close to that in chil¬
long-term
dren operated on a few years earlier with the
Mustard operation, it does show for the first time an
inverse relationship between time since intervention
and ulterior aerobic capacity (r=0.48; p=0.001),
while there is no significant correlation between the
age of patients (or control subjects) and peak Vo2.
We observed no significant relationship between age
at surgery and maximal heart rate or 02 pulse at peak
effort. Unlike previous series in which no association
was noted between time since intervention and
exercise capacity, it seems that the earlier the chil¬
dren are operated on with the Senning technique,
the better their ultimate effort capacity.
Our patients were all operated on by the same
surgeon, and were operated on as quickly as possible
when functional tolerance was poor (persistent cya¬
nosis despite an efficient atrioseptostomy of Rashkind-Miller). It may be that submitting the right
ventricle early to conditions of systemic load leads to
better long-term tolerance, with exercise capacities
similar to those in patients operated on with an
arterial switch technique.26
The ventilatory adaptation of our patients during
exercise testing was also quite different from that of
normal patients and is reminiscent of the modifica¬
tions described in cardiac insufficiency.27'28 There is,
in fact, an excess ventilatory response as measured by
the respiratory frequency (or overall ventilation)
to the production of C02.29 Such anoma¬
compared
lies have also been described more recently after
Fontan procedures and repair of tetralogy of
Fallot.30
However, we found no correlation between respi¬
ratory equivalents for C02 measured at the end of
exercise and peak Vo2 in patients or control subjects,
previous report.24 The relationship
is all the more disturbed as the
limitation of effort capacity increases, was also ab¬
normal in our patients. This disturbance is associated
contrary
to
a
Vt-RR, which
with a decrease in Vt at the end of effort than
acceleration in respiratory frequency. How¬
ever, the mechanisms involved in this abnormal
ventilatory response are not well understood. Unfor¬
tunately our patients did not have additional respimore
with
an
CHEST / 111 / 1 / JANUARY, 1997
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21742/ on 05/06/2017
27
ratory function tests (including vital capacity, pulmo¬
nary diffusing properties, lung distensibility, etc) and
our study cannot elucidate this discussion. But as in
patients with cardiac insufficiency, the relationship
between ventilation and C02 production was not
linear in our patients, so there is growing support for
another stimulus being involved, particularly a mus¬
cular ergoreflex.27 This could explain the benefits of
training observed in recent years in patients
physical
with cardiac insufficiency,31 and also in children
operation.32
operated on byinvenous switch
Our study
a large series of patients mainly
the Senning technique and with a
operated on withconfirms
that atrial repair is associ¬
follow-up
long
ated with a limitation in maximal aerobic capacity
with an early anaerobic AT. Although patients may
be asymptomatic, they have an inadapted ventilatory
response to exercise. Chronotropic insufficiency and
especially the already documented relative inadaptation of the right ventricle to exercise should make
clinicians vigilant about the long-term outcome of
these patients. However, it would seem that inter¬
ventions performed earlier with the Senning tech¬
nique lead to better long-term exercise capacity, thus
reopening the debate concerning the respective ad¬
vantages of the arterial2633 with venous switch oper¬
ation.
linguistic assistance.
Ray
Helbing
1987; 60:346-50
5 Gillette PC, Wampler DG, Shannon C, et al. Use of cardiac
pacing after the Mustard operation for transposition of the
great arteries. J Am Coll Cardiol 1986; 7:138-41
Paridon SM, Humes RA, Pinsky WW. The role of chrono¬
tropic impairment during exercise after the Mustard opera¬
tion. J Am Coll Cardiol 1991; 17:729-32
Darvell FJ, Rossi IR, Rossi MB, et al. Intermediate to late
term results of Mustard's procedure for complete transposi¬
tion of the great arteries with an intact ventricular septum. Br
J 1988; 59:468-73
Ensing GJ, Heise CT, Driscoll DJ. Cardiovascular response to
exercise after the Mustard operation for simple and complex
transposition of the great vessels. Am J Cardiol 1988; 62:
Heart
8
617-22
after the Mustard operation in transposition of the great
arteries. Am J Cardiol 1983; 51:1526-29
12 Musewe NN, Reisman J, Benson LN, et al. Cardiopulmonary
adaptation at rest and during exercise 10 years after Mustard
atrial repair for transposition of the great arteries. Circulation
1988; 77:1055-61
13
Myridakis DJ, Ehlers KH, Engle MA. Late follow-up after
venous switch operation (Mustard procedure) for simple and
complex transposition of the great arteries. Am J Cardiol
1994; 74:1030-36
14 Perrault H, Drblik SP,
Montigny M, et al. Comparison of
cardiovascular adjustments to exercise in adolescents 8 to 15
years of age after correction of tetralogy of Fallot, ventricular
septal defect or atrial septal defect. Am J Cardiol 1989;
64:213-17
15
16
Reybrouck T, Dumoulin M, Van der Hauwaert LG. Cardio¬
respiratory exercise testing after venous switch operation in
children with complete transposition of the great arteries.
Am J Cardiol 1988; 61:861-65
Reybrouck T, Gewillig M, Dumoulin M, et al. Cardiorespi¬
exercise performance after Senning operation for
ratory
transposition of the great arteries. Br Heart J 1993; 70:175-79
Transposition of the great arteries:
late results in adolescents and adults after the Mustard
18
WA, Hansen B, Ottenkamp J, et al. Long-term
results of atrial correction for transposition of the great
arteries: comparison of Mustard and Senning operations.
J Thorac Cardiovasc Surg 1994; 108:363-72
2 Turina M, Siebenmann R, Nussbaumer P, et al. Long-term
look after atrial correction of transposition of the great
arteries. J Thorac Cardiovasc Surg 1988; 95:828-35
3 Beerman LB, Neches WH, Flicker FJ, et al. Arrhythmias in
transposition of the great arteries after the Mustard opera¬
tion. Am J Cardiol 1983; 51:1530-34
4 Byrum CJ, Bove EL, Sondheimer HM, et al. Sinus node shift
after the Senning procedure compared with the Mustard
procedure for transposition of the great arteries. Am J Cardiol
7
478-82
11 Mathews RA, Flicker FJ, Beerman LB, et al. Exercise studies
Cooke for his
References
6
Oxygen uptake transient
kinetics during constant-load exercise in children after oper¬
ations of ventricular septal defect, tetralogy of Fallot, trans¬
position of the great arteries, or tricuspid valve atresia. Am J
Cardiol 1994; 74:166-69
10 Hochreiter C, Snyder MS, Borer JS, et al. Right and left
ventricular performance 10 years after Mustard repair of
transposition of the great arteries. Am J Cardiol 1994; 74:
17 Warnes CA, Somerville J.
ACKNOWLEDGMENT: We thank Dr.
1
9 Gildein P, Mocellin R, Kaufmehl K.
19
procedure. Br Heart J 1987; 58:148-55
Bowyer JJ, Busst CM, Till JA, et al. Exercise ability after
Mustard's operation. Arch Dis Child 1990; 65:865-70
Dihmis WC, Hutter JA, Joffe HS, et al. Medium-term clinical
results after the Senning procedure with haemodynamic and
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