Surgery for transposition of great arteries: A historical perspective

Abstract

The history of surgery for transposition of great arteries (TGA) has paralleled the history of cardiac surgery. In fact, it began before the birth of open heart surgery when the palliative Blalock-Hanlon septectomy was first performed in 1948. The atrial switch, which was an attempt to correct the physiology of transposition, had significant shortcomings. The arterial switch sought to address them. This has emerged as an anatomically as well as physiologically appropriate solution. Today we continue to pursue technical refinements as well as try to expand the indications of the arterial switch. This review traces the various milestones in this perpetual journey.

Keywords: Arterial switch; atrial switch; congenital heart disease; history of open-heart surgery; transposition of great arteries.

Figure 1

Pioneers of transposition of great arteries (TGA) surgery. (a) Alfred Blalock (b) C Rollins Hanlon ((A and B) Reproduced with permission from: Konstantinov IE, Alexi-Meskishvili VV, Williams WG, Freedom RM, Van Praagh R. Atrial switch operation: Past, present, and future. Ann Thorac Surg. 2004 Jun;77(6):2250-8.) (c) Vivien Thomas (Reproduced with permission from: Cheng TO. Hamilton Naki and Christiaan Barnard versus Vivien Thomas and Alfred Blalock: Similarities and dissimilarities. Am J Cardiol. 2006 Feb 1;97(3):435-6.) (d) Thomas Baffes (right) with his mentor Willis Potts (left) (Reproduced with permission from: Mavroudis C, Backer CL, Siegel A, Gevitz M. Revisiting the Baffes operation: Its role in transposition of the great arteries. Ann Thorac Surg. 2014 Jan;97(1):373-7.) (e) Ake Senning (Reproduced with permission from: Tutarel O, Westhoff-Bleck M. Ake Senning. Clin Cardiol. 2009 Aug;32(8):E66-7.) (f) William T Mustard (Reproduced with permission from: Stoney WS. Evolution of cardiopulmonary bypass. Circulation. 2009 Jun 2;119(21):2844-53.) (g) Adib Dominos Jatene (Reproduced with permission from: Jacobs ML, Tchervenkov CI. Tribute to a patriarch: Adib Domingos Jatene,1929-2014. World J Pediatr Congenit Heart Surg. 2015 Jan;6(1):7-8.)

Figure 2

Blalock- Hanlon operation. (a) Right pulmonary artery and superior pulmonary vein dissected free from surrounding tissue. (b) After applying a special clamp, parallel incisions made on right atrium and pulmonary veins, area to be excised shown. (c) B in cross-section. (d) After excising septum, incision closed with sutures. (e) D in cross-section. L. auricle = Left auricle, R. auricle = Right auricle, R. pulm. a. and v.= Right pulmonary artery and vein, R. sup. pulm. v. = Right superior pulmonary vein (Reproduced with permission from: Blalock A, et al., Surg Gynecol Obstet; 1950;90:1-15.)

Figure 3

Baffes operation. Right pulmonary veins directed to right atrium. Inferior vena cava baffled to left atrium using a graft. L. Pulm. Veins = Left pulmonary veins, L. vent. = Left ventricle, Pulm. art. = Pulmonary artery, R. ventricle = Right ventricle. (Reproduced with permission from: Baffes TG, Surg Gynecol Obstet; 1956;102:227-33.)

Figure 4

Albert operation. Right atrial view. Creation of bilobed flaps of interatrial septum (a) Each lobe used to cover the orifices of the vena cava. Remaining sides of the flaps sutured to the posterior wall of left atrium (b). View from right (c) and left (d) atrium. Use of graft instead of septum (e) (Reproduced with permission from: Albert HM, Surg Forum; 1955;5:74-7.)

Figure 5

Senning operation. Preoperative (1), surgery (2), and b c postoperative (3); X and XX represent edges to be sutured. Arrows represent direction of blood flow. Art. pulm. = Pulmonary artery, LA = Left atrium, V. cava = Vena cava, V. pulm. = Pulmonary vein (Reproduced with permission from: Senning A, Surgery; 1959;45:966-80.)

Figure 6

Mustard operation. Pericardial baffles are used to direct vena caval blood to mitral valve and pulmonary venous blood to tricuspid valve. (a) Atrial anatomy. (b) Suturing of pericardial baffle. (c) Completed procedure (Reproduced with permission from: Mustard WT, Surgery; 1964;55:469-72.)

Figure 7

Jatene operation. Original sketch (Reproduced with permission from Jatene AD, Fontes VF, Paulista PP, Souza LC, Neger F, Galantier M et al. Anatomic correction of transposition of the great vessels. J Thorac CardiovascSurg. 1976 Sep;72(3):364-70.)