 |
|
| Surgical treatment for patients with late systemic right ventricular failure following Mustard/Senning procedures for d-TGA |
|
Stephan Thelitz, Sunil P. Malhotra, Edwin Petrossian, Nicole Tselentis, Frandics P. Chan, Norman Silverman, Vadiyala M. Reddy, Frank L. Hanley; Stanford University School of Medicine, Stanford, CA Objective: Late RV failure occurs in 10-15% of Senning/Mustard pts. Atrial baffle takedown and arterial switch operation (ASO) is an important management option for these pts. From 1993-2007 22 atrial switch pts,mean age 16.7±7.5(SD)yrs, were diagnosed with severe RV failure and/or severe tricuspid regurgitation. We initiated a treatment program aimed at conversion to ASO. Methods: Staged retraining of the LV by PAB was performed in 19 pts; 3 pts with intrinsic LVOTO underwent primary ASO. PAB was performed at an interval of 11.9±5.2(SD)yrs following atrial switch procedure. Adequacy of PAB and LV status was evaluated by echo, cardiac cath, and more recently MRI.Criteria for judging an adequate LV response has evolved. Readjustment of PAB was necessary in 12 pts. Results: Fourteen (14/19) PAB pts. were judged to have positive LV retraining response. To date, seven have had ASO. Two (2/7) died perioperatively of acute LV failure. The other seven positive responders are awaiting ASO with PABs in place for 0.2 to 11 yrs. Five (5/19) PAB pts had poor LV retraining response, necessitating cessation of PAB tightening or even PAB loosening in 3; the other 2 died at 156 and 259 days following PAB of biventricular failure. The ASO was performed primarily in the 3 pts with LVOTO, with one early death. At 8.2±.6 yrs following conversion to ASO, all 7 living ASO pts are in NYHA class I-II. All 10 living PAB pts are in NYHA class I-II. Overall, 5/22 pts died (3 ASO pts early, and 2 PAB pts late). All 5 deaths occurred in the first half of the experience. Age, PAB-ASO interval, and an inadequately pressurized LV were not implicated in any deaths. Further observations include: 1)LV mass may be more important that LV pressure in predicting success, 2) the PAB itself may provide palliation by relieving tricuspid regurgitation; 3)individual response to LV retraining is unpredictable 4)an important learning curve exists for patient selection and subsequent management. Conclusion: Conversion remains an option for pts. with failing systemic RV; however, careful pt selection is critical. Selection for PAB requires a systemic RV that can continue to perform during the prolonged training period, and selection for the ASO in PAB pts requires fully trained LVs that have been functioning adequately at systemic workloads for at least a year and have a normal mass. Even when these criteria are met, substantial risks remain related to the uncertain performance of the LV when placed in the systemic circulation. Back to 88th Annual Meeting Back to Program Outline |
We Model Excellence |
|
Copyright © American Association for Thoracic Surgery. All rights reserved.
Read the Privacy Policy.
IMPORTANT REMINDER: The preceding information is intended only to provide
general guidance and not as a definitive basis for diagnosis or treatment in any particular case.
It is very important that you consult a doctor about any specific medical problem or question.
Read the Privacy Policy.
IMPORTANT REMINDER: The preceding information is intended only to provide
general guidance and not as a definitive basis for diagnosis or treatment in any particular case.
It is very important that you consult a doctor about any specific medical problem or question.