Download Why I do it: Atrial Switch for d-TGA

Why I do it: Atrial Switch for d-TGA
Jeffrey C. Hellinger MD FACC
New York Cardiovascular Institute
Lenox Hill Radiology
Outline: Why I do d-TGA Atrial Switch
1. Define Disease (anatomy, physiology,clinical
presentation)
2. Management
3. Imaging
Communicating Circulations
 Situs
 Inversus
TGA: Parallel
Circulations
 Aorta arises
from RV
 PA arises
from LV
TGA: Classification: Discordance and Physiology
 VentriculoArterial
 AtrioVentricular and VentriculoArterial
Features of Disease
Associated Anomalies
 Cyanosis
 Congestive Heart Failure
 Elevated Hgb
 FTT
 Severity and manifestations
of disease depend upon
Associated Anomalies
 Necessary for Survival
 ASD
 VSD
 PDA
 LVOT Obstruction
 Coarctation
 PA Stenosis
Key Management Strategies


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Oxygenation / Perfusion
Control pulmonary overcirculation
Balloon Septostomy
Atrial Septectomy
Operative Repair
ATRIAL SWITCH: Indications
 Not candidate for Arterial Switch




Late diagnosis
Large VSD with pulmonary hypertension
Poor LV function
complex coronary anomalies
 Used as part of double switch for L-TGA
(Senning – Rastelli )
SENNING PROCEDURE
RA Incision
Atrial Septum
Resection
Creation of Flap
Quaegebeur, Thorax, 1977, 32, 517-524
SENNING PROCEDURE
LA Incision
Quaegebeur, Thorax, 1977, 32, 517-524
Suture Flap
across PV
SENNING PROCEDURE
RA Dorsal
Closure
RA Ventral
Closure
Quaegebeur, Thorax, 1977, 32, 517-524
MUSTARD PROCEDURE
Modified Senning: atrial resection with intraatrial pericardial baffle
Warnes, Circulation 2006;114:2699-2709
Post-Operative Complications
 Arrhythmias (sinoatrial node; AF, VF, trial, F, )







Sudden Death
Right heart dysfunction / RH Failure
Tricuspid insufficiency
Baffle leak / paradoxical embolism
Systemic venous stenosis - obstruction
Pulmonary venous stenosis - obstruction
Pulmonary hypertension
Agnetti, et al Clin. Cardiol. 27, 611–614 (2004)
Warnes, Circulation 2006;114:2699-2709
S/P ATRIAL SWITCH
Post-Operative Functional Status
 NYHA Class I
 NYHA Class II
 NYHA Class III
80%
17%
3%
Agnetti, et al Clin. Cardiol. 27, 611–614 (2004)
S/P ATRIAL SWITCH
IMAGING
 Radiography
 Echocardiography
 MRI / MRA
 CTA
S/P ATRIAL SWITCH
MRI-MRA / CTA: Morphology
 Systemic venous pathway
 Pulmonary venous pathway
 Cardiac chambers (e.g. right)
 Size
 Hypertrophy
 AV valve apparatus
 Exclude leak
 Aorta / PA (size, obstruction)
S/P ATRIAL SWITCH
MRI: Function
 Systemic venous flow




Pulmonary venous flow
Quantify leak
Aortic flow
Pulmonary arterial flow
13
14
Summary: Atrial Switch
 Redirects venous blood flow
 Complications: arrhythmias, venous
obstruction, Right heart failure, TV insufficiency,
baffle leaks, PHTN
 Diagnosis: ECHO, Xray
 Post-operative follow-up: ECHO, MRI, CT
 Imaging Pearls: look for associated anomalies,
physiology sequelae, post-operative complications
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