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Comparative Study
. 2018 Dec;106(6):1827-1833.
doi: 10.1016/j.athoracsur.2018.06.084. Epub 2018 Aug 31.

Long-Term Survival After Arterial Versus Atrial Switch in d-Transposition of the Great Arteries

Alexander Kiener  1 , Michael Kelleman  2 , Courtney McCracken  2 , Lazaros Kochilas  3 , James D St Louis  4 , Matthew E Oster  5
Affiliations
Comparative Study

Long-Term Survival After Arterial Versus Atrial Switch in d-Transposition of the Great Arteries

Alexander Kiener et al. Ann Thorac Surg. 2018 Dec.

Abstract

Background: The arterial switch operation (ASO) became the procedure of choice for dextro-transposition of the great arteries (d-TGA) nearly 30 years ago, but the long-term results of this operation are unknown. We aimed to compare the long-term transplant-free survival of patients with d-TGA who underwent ASO versus atrial switch in the Pediatric Cardiac Care Consortium.

Methods: We performed a retrospective cohort study of d-TGA patients undergoing ASO or atrial switch in the United States between 1982 and 1991. Long-term transplant-free survival was obtained by linking Pediatric Cardiac Care Consortium data with the National Death Index and the Organ Procurement and Transplant Network. Kaplan-Meier survival plots were constructed, and multivariable regression was used to compare long-term transplant-free survival.

Results: Of 554 d-TGA patients who underwent ASO (n = 259) or atrial switch (n = 295), the 20-year overall transplant-free survival was 82.1% for those undergoing ASO and 76.3% for those who had atrial switch procedure. Adjusted overall transplant-free survival beyond 10 years after operation was superior for ASO compared with atrial switch (hazard ratio 0.07, 95% confidence interval: 0.01 to 0.52, p = 0.009). During this period, the ASO had higher in-hospital mortality than the atrial switch (21.6% versus 12.9%, p = 0.007). After excluding patients with in-hospital mortality, the transplant-free survival 20 years after repair was 97.7% for the ASO patients versus 86.3% for the atrial switch patients.

Conclusions: Despite initial higher in-hospital mortality for ASO during the study period, there is a significant long-term transplant-free survival advantage for ASO as compared with atrial switch for d-TGA surgery. Ongoing monitoring is required to assess late risk of cardiovascular disease.

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Figures

Figure 1.
Figure 1.
Patient inclusion diagram. NDI = National Death Index, ASO = arterial switch operation.
Figure 2.
Figure 2.
Operations for dextro-transposition of the great arteries in the Pediatric Cardiac Care Consortium, expressed as percent of total d-TGA operations in the bar graph as well as raw number of each operation. d-TGA = dextro-transposition of the great arteries.
Figure 3.
Figure 3.
Kaplan-Meier curves for overall transplant-free survival of patients with detro-transposition of the great arteries are shown by operation group. For the time period after 10 years, mortality HR for ASO vs. atrial switch is displayed, adjusted for sex, transposition complexity, and surgical center. ASO = arterial switch operation, HR = hazard ratio, CI = confidence interval.
Figure 4.
Figure 4.
Kaplan-Meier survival curves for transplant-free survival of patients with d-transposition of the great arteries shown by operation group, conditional on survival to hospital discharge following initial operation. For the time period after 10 years, mortality HR of ASO vs. atrial switch is displayed, adjusted for sex, transposition complexity, and surgical center. ASO = arterial switch operation, HR = hazard ratio, CI = confidence interval.
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