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      Morphologic Substrates for First-Branch Pulmonary Arterial Hypoplasia in Transposition of the Great Arteries


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          Background: Distal right-sided outflow obstruction remains a problem after arterial switch operation. We studied the anatomical features of the pulmonary trunk (PT) and its branches that are susceptible to right and left pulmonary arterial (RPA and LPA) hypoplasia in transposition of the great arteries (TGA). Methods: One hundred and one angiograms of TGA performed between 1981 and 1996 were viewed, and Polaroid photos were taken at end-systole. The diameters of RPA, LPA, PT, duct, ascending aorta, and angles between PA and PT were measured, and the ductal flow direction was recorded. Results: Forty-eight cases (47.5%) had a PA/PT diameter ratio (both PAs had same size) below 0.49. A smaller PA/PT was significantly related to posterior inclination of the proximal PT [narrower right (r = 0.50, p < 0.00001) and left (r = 0.48, p < 0.00001) PA-PT angle in lateral view] and a larger duct (r = 0.37, p < 0.0001). Eighteen patients had a follow-up angiogram after a mean period of 8.5 months. Those with a closed duct had evident PA growth (n = 12, 0.51 ± 0.09 to 0.74 ± 0.17, p < 0.0001), but four patients with an attenuated duct had no significant change (0.58 ± 0.06 to 0.68 ± 0.08, p = NS), and one with a persistent large duct had even regression of PA/PT (0.36–0.19). The direction of ductal flow was toward the aorta during early systole on cineangiogram. Conclusions: First-branch PA hypoplasia, which is frequently seen in TGA, was related to the right-to-left shunt through a duct resulting in hemodynamic starvation, and to posterior inclination of the proximal PT in this setting. Natural regression of the duct facilitated PA growth.

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          Most cited references 17

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          Results of the arterial switch operation in neonates with transposed great arteries.

          The arterial switch operation is judged the best palliative operation for neonates with transposed great arteries. We aimed to assess the value of analysing a large series of unselected cases by this technically demanding operation and formulate a realistic prognosis. We reviewed all 432 neonates (mean age at operation 7 days, mean weight 3.25 kg) who underwent an arterial switch operation between 1987 and 1999. Follow-up (mean time: 4.9 years) was complete in 412 patients. Survival probability and freedom from reoperation was 94% and 78% at 10 years, respectively. 26 patients died, 16 because of myocardial ischaemia. Risk factors for death included early experience, low weight, associated cardiovascular malformations (especially hypoplasia of the right ventricle or aortic arch), and difficult patterns of coronary arteries. The risk of the coronary artery pattern was greatly reduced in those who had recent operations. At last follow-up, 90% of patients had normal life without treatment, and 94% a normal heart function on echocardiography. The arterial switch operation in neonates achieves excellent results mid-term. Obstruction of the translocated coronary arteries is responsible for most deaths and a substantial number of reoperations. Although confirmation is needed, these results allow anticipation of a favourable long-term prognosis.
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            Modified arterial switch operation by spiral reconstruction of the great arteries in transposition

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              Outflow obstruction after the arterial switch operation: A multiinstitutional study


                Author and article information

                S. Karger AG
                May 2007
                02 February 2007
                : 107
                : 4
                : 362-369
                Departments of aPediatrics and cSurgery, Mackay Memorial Hospital, Mackay Medicine, bNursing and Management College, Departments of dSurgery and ePediatrics, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
                99052 Cardiology 2007;107:362–369
                © 2007 S. Karger AG, Basel

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                Figures: 3, Tables: 3, References: 30, Pages: 8
                Original Research


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