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Complete transposition
echocardiography: pre-operative
Xavier Iriart
Department of congenital heart disease
Francis Fontan surgical centre for congenital heart disease
Bordeaux, France
Anatomic forms
! "Simple TGA: ! 50%
Unusal coronary anatomy
! Complex TGA
! Ventricular septal defect
! " Obstruction to left ventricular outflow
! " RVOT obstruction & coarctation
Goals of preoperative echocardiography
! Diagnosis
! Hemodynamics: mixing
!   Segmental analysis: associated malformations
! Coronary artery pattern
Situs solitus with D-loop TGA
LPA
RPA
PA
Ao
RPA
RPA
LPA
LPA
RV
Ao
Ao
LV
PA
PA
Determinants of systemic arterial
oxygenation and mixing
foramen ovale
+ compliance of the
atriums and ventricles
ductus arteriosus
+resistances of the systemic and
pulmonary vascular beds
Atrial level assessment
! " Evaluation of interatrial septum
! " rare true ASD secundum (5%)
! Almost always PFO
! " Size of the shunt
! " Flow direction and velocity
! Mean transseptal flow gradient
!"
Determine necessity of BAS
Echographic guidance for BAS
! " Place the catheter in the LA
! " Rule out inflation in the PV or across the MV
! " Echo guidance is repeated for further inflations
mitral valve
left atrial appendage
pulmonary veins
Echocardiography of the PDA
! " Important for mixing
! Bidirectionnal shunt depending on PVR and SVR
Segmental analysis
!  Atrial level: left juxtaposition of RAA
! Ventricular level: VSD
! Outflow tract and conal anatomy
!  Great vessels
! Coronary anatomy
Associated anomalies
! "Juxtaposition of the atrial appendages
! " Rare 2%
! " Association with complex TGA (dextrocardia, tricuspid atresia)
! Left juxtaposition more frequent
! Leftward RAA associated with change in interatrial septal
orientation
Juxtaposition of LAA: change in
septal orientation
-Posterior IAS: oriented normally
-Anterior IAS: oriented transversally
From Rice MJ et at. JACC 1983
Ventricular septal defect
! Present in 40-45% of TGA
! " Location
! " 33% Perimembranous
! " 30% malaligned defects
! " 25% muscular VSD
! " 5% inlet or outlet septal defects
VSD in TGA
! "Perimembranous VSD: 33%
VSD in TGA
! "Malaligned outlet defects: 30%
! "can cause LVOTO or RVOTO
VSD in TGA
! Inlet VSD: 5%
! " potentially associated with AVV anomalies
! "Attachement to the crest of the VSD
Straddling, overriding
! Straddling
Outflow tract obtruction
! "Right ventricular outflow tract obstruction
! " Rare, associated with anterior malaligned VSD
! Mutiple levels of obstruction+++
! subaortic stenosis, Ao valve and arch hypoplasia, CoA, IAA
Outflow tract obtruction
! Left ventricular outflow tract obstruction
! Occurs in !25% of TGA
! "20% of patients with IVS
! only 5% significant obstruction
! Potentially resected during ASO
! "30% of patients with VSD
! Consider alternative surgery in complex/severe obstrctuion
Echocardiography
! Conal anatomy
! Usually well developed subaortic conus and pulmonary mitral
continuity in 88%
! Unusual 12% (bilat conus 7%, absent subAo, present subpulm
3%, bilat abs 2%)
Pulm-mitral
Subaortic conus
continuity
Normal
subaortic conus
Pulmonary-mitral
continuity
Relationship of great arteries
Aorta anterior and right/ PA
post and left: usual
AO
Aorta directly anterior to PA
AO
Commisural malalignment
AO
Aorta side by side
to PA
AO
Aorta anterior and left to PA
Coronary artery anatomy: Leiden convention
!   Facing sinuses supporting the coronary arteries
!   Common terminology: aortic sinuses located to the right (sinus 1) and left
hand (sinus 2) of the observer
Coronary anatomy in TGA
! Critical importance before ASO
! " Imaging of coronary arteries; high parasternal SAX with
complementary information in A4Ch and LAX views
! " Extensive anatomic variations in origin and course: 8 major
anatomic patterns
! Unusual coronary artery patterns more common in patients with
! side-by-side great arteries or posterior aorta
! ventricular septal defect.
Coronary anatomy
65%
14%
1
2
7.5%
3%
1.7%
2.4%
4.2%
3
Wernovsky G et al. Corono Artery Dis 1993
Clockwise rotation
transducer mark 3 o’clock
High parasternal SAX
Parasternal LAX
counterclockwise rotation
transducer mark 1 o’clock
Bicuspid PV
LJAA
Posterior LCX
LCA
RCA
Intramural coronary artery
3%
! Origin: opposite sinus
! Parallel course within the Ao wall
! " Single or separate ostia
RCA
Intramural LCA
TGA echography: conclusion
! Diagnosis
! Pathophysiologic assessment
!   BAS monitoring
! Sequential segmental: associated malformations
! Coronary artery pattern