Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Management of acute coronary syndrome wikipedia , lookup
Heart failure wikipedia , lookup
Electrocardiography wikipedia , lookup
Cardiac contractility modulation wikipedia , lookup
Arrhythmogenic right ventricular dysplasia wikipedia , lookup
Mitral insufficiency wikipedia , lookup
Cardiac surgery wikipedia , lookup
Lutembacher's syndrome wikipedia , lookup
Quantium Medical Cardiac Output wikipedia , lookup
Atrial septal defect wikipedia , lookup
Atrial fibrillation wikipedia , lookup
Dextro-Transposition of the great arteries wikipedia , lookup
LONG-TERM RESULTS OF ATRIAL SWITCH IN TGA MARKO TURINA UNIVERSITY HOSPITAL ZURICH, SWITZERLAND Åke Senning, 1915-2000 First description of atrial correction of TGA Senning, Opuscula Medica (!) 1958 Correction of TGA at the University Hospital Zurich, 1962-2000 (493 pts.) Atrial vs. arterial repair 35 No. Patients 30 25 20 15 10 5 0 Atrial repair Arterial repair Correction of TGA at the University Hospital Zurich Age at the time of correction 140 months 120 100 80 60 40 20 0 1962 1966 1970 1974 1978 1982 1986 1990 1994 Genoni et al., 1999 TGA: 32 years of atrial repair Actuarial survival in hospital survivors (follow-up 95.3 % complete) % 100 80 60 40 20 0 0 5 overall 10 15 before 1978 after 1978 20 years Genoni et al., 1999 TGA: 32 years of atrial repair Actuarial survival in hospital survivors % survival 100 80 60 40 20 0 0 5 10 15 20 25 years overall simple complex Genoni et al., 1999 ATRIAL CORRECTION OF TGA Cause of late death University Hospital Zürich, 1962 - 1987 (33/239 patients) Malignancy 3.1% Pulmonary embolism 3,1% Accident 6,3% Heart failue 62,5% Unknown 3,1% Sudden 21,9% FAILING RIGHT VENTRICLE AFTER ATRIAL CORRECTION OF TGA • Does this disease truly exists? • Is it inevitable in majority of atrial repair survivors? • Which are predictors of RV failure? • Possible causes? • Treatment options? • Magnitude of the problem? FAILING RIGHT VENTRICLE AFTER ATRIAL CORRECTION OF TGA Time of onset (after 1st operation) 5 7.7 % of all corrections Patients 4 3 2 1 0 2 4 6 8 10 12 14 16 18 Years after 1st operation 20 0 Zurich University Hospital, 17/220 patients operated 1964-1985, follow-up 95.3 % complete RV failure after atrial correction for TGA as function of age at correction hazard function 5 Differences are not significant! % / YEAR 4 3 2 1 0 2 1 2 1 3 1 2 0 1 2 1 2 4 0 2 4 1 3 6 0 T I M E ( M O N T H S ) FAILING RIGHT VENTRICLE AFTER ATRIAL CORRECTION OF TGA Surgical options • Correction of all residual anomalies. • Restoration of AV synchrony (DDDR or biventricular pacing). • Repair of systemic AV valve. • Banding + arterial switch (Mee’s technique) • Damus-Stansel-Kaye procedure (PA-Aorta anastomosis, RV- PA homograft) • Heart transplantation FAILING RIGHT VENTRICLE AFTER ATRIAL CORRECTION OF TGA Boston experience: Chang et al, Circulation 1992;86:II-140-9 • 10 patients after Mustard or Senning repair • Anatomic correction in 5 pts. (Arterial switch in 3 and Damus-Stansel-Kaye in 2) • Heart transplantation in 5 pts. • Results: 1 early death (switch), 90% survival @ 27 months • Complications: 3 AI in switch group with 1 AVR; 1 lymphoma in TX group SWITCH CONVERSION LATE AFTER ATRIAL REPAIR FOR TGA Cochrane et al, Ann Thor Surg 1993;56:854-62 • 24 patients after Mustard or Senning repair • Direct conversion in 4 pts. with 1 early death • PA banding in 20 pts. : 3 deaths, 2 unsuitable for correction, 15 suitable. • Staged switch in 12 with 2 deaths • Late survival of switch conversion 80 % @ 1 year, majority with improved LV function Roger Mee’s results in patients with previous atrial correction of TGA Poirier N. C. et al.; J Thorac Cardiovasc Surg 2004;127:975-981 FAILING RIGHT VENTRICLE AFTER ATRIAL CORRECTION OF TGA Possible causes • Inherent inability of RV to support systemic circulation for the whole life span • Damage to the RV due to long-standing cyanosis and volume overload (“late corrections”) • Perioperative damage to the right ventricle (deficient myocardial protection) • Atrial dysrhythmias • Tricuspid valve incompetence PROBLEM AREAS OF ATRIAL SWITCH FOR TGA Related to surgical technique: • SVC or IVC stenosis • Pulmonary vein stenosis • Atrial dysrhythmias Related to the method: • Tricuspid valve incompetence • Failure of systemic (right) ventricle Prevention of pulmonary vein stenosis after atrial correction: Augmentation of pulmonary venous atrium with autologous in-situ pericardium Systemic AV valve SVC IVC Pulmonary atrium opened Prevention of pulmonary vein stenosis in atrial correction: Augmentation of pulmonary venous atrium with autologous in-situ pericardium SVC Autologous in-situ pericardium attached to its blood supply IVC LATE RESULTS IN ADULT SURVIVORS OF ATRIAL TGA CORRECTION Puley et al, Am J Card 1999;83:1080-4 • 86 patients >18 years old • Late deaths: 8 pts. (9 %) • Late heart failure in 9 pts. (10 %) • Atrial arrhythmia's in 73 % of survivors • Pacemaker implants in 22 % Authors’ conclusion: these patients remain at risk for premature death, supraventricular tachycardia, and congestive heart failure (a) Freedom from severe systemic ventricular dysfunction after surgical repair of TGA. (b) Freedom from severe AV-valve insufficiency after surgical repair of TGA. TGA, transposition of the great arteries. Görler H et al. Interact CardioVasc Thorac Surg 2011;12:569-574 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. ATRIAL CORRECTION OF TGA University Hospital Zürich, 1962 - 1997 231 patients, average follow-up 13.4 years, (158 patients @10, 22 @ 20 years) NYHA III/IV 5% NYHA II 29% NYHA I 66% Genoni et al., 1999 ATRIAL CORRECTION OF TGA: INTELLECTUAL DEVELOPMENT University Hospital Zürich, 1962 - 1997 205 patients, average follow-up 10.1 years SPECIAL CLASSES 13% RETARDED 2% NORMAL SCHOOL 85% Genoni et al., 1999 ATRIAL CORRECTION OF TGA: Present occupation University Hospital Zürich, 1962 - 1997 (82 adults) Clerical work 44% University graduates 13% No profession 1% Manual labor 41% Marital status and births: comparison of women who had undergone atrial repair with a control group consisting of 26 year old women living in Switzerland in 1993. 10 live births in TGA survivors, all free of heart malformations Genoni M et al. Heart 1999;81:276-277 Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved. ATRIAL CORRECTION OF TGA: INCIDENCE OF PACEMAKER IMPLANTS University Hospital Zurich, 1962 1987 (239 Patients) Incidence of implants 12 10 8 6 4 2 0 0 1 2 3 4 5 6 7 8 9 Years postop. 10 11 12 13 14 15 (a) Freedom from loss of sinus rhythm after surgical repair of TGA. (b) Freedom from pacemaker implantation after surgical repair of TGA. (c) Freedom from right bundle branch block after surgical repair of TGA. TGA, transposition of the great arteries. Görler H et al. Interact CardioVasc Thorac Surg 2011;12:569-574 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Conduction system in Senning’s correction of TGA Avoid sutures in the vicinity of AV and SA node TRANSPOSITION OF THE GREAT ARTERIES Why has arterial correction replaced the atrial method for total correction of TGA? • Total correction can be performed at neonatal stage • No “interval mortality” after Rashkind • Lower operative mortality and smoother postoperative course • Technically less demanding • Left ventricle in systemic circulation “Double switch” in corrected TGA: Senning atrial correction and arterial switch, to restore appropriate ventricles to systemic and pulmonary circulation. ARGUMENTS FOR A (LIMITED) UTILIZATION OF ATRIAL CORRECTION • Senning’s atrial correction has accumulated > 30 years experience; long-term outlook for arterial switch is less well known (neoaorta, coronaries, reoperations). • Technical problems of atrial correction (stenosis SVC or pulmonary veins) are avoidable. • Failure of systemic ventricle is not obligatory. • Atrial correction was performed in older children with long-standing cyanosis which might have caused late heart failure. • Dysrhythmias remain a problem in atrial correction Present Limited Role Of Atrial TGA Correction • TGA presenting later in life with normal PA pressure. Long-term advantages of banding + AP shunt followed by arterial switch are unproven. • Double switch in some patients with corrected transposition (VSD or PS).