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. 2023 Jul 19;2(5):100407.
doi: 10.1016/j.jacadv.2023.100407. eCollection 2023 Jul.

Arterial Switch for Transposition of the Great Arteries: Treatment Timing, Late Outcomes, and Risk Factors

Dan-Mihai Dorobantu  1   2   3 , Ferran Espuny Pujol  4 , Martin Kostolny  5 , Katherine L Brown  5 , Rodney C Franklin  6 , Sonya Crowe  4 , Christina Pagel  4 , Serban C Stoica  3
Affiliations

Arterial Switch for Transposition of the Great Arteries: Treatment Timing, Late Outcomes, and Risk Factors

Dan-Mihai Dorobantu et al. JACC Adv. .

Abstract

Background: Reports of long-term mortality and reintervention after transposition of the great arteries with intact ventricular septum treatment, although favorable, are mostly limited to single-center studies. Even less is known about hospital resource utilization (days at hospital) and the impact of treatment choices and timing on outcomes.

Objectives: The purpose of this study was to describe survival, reintervention and hospital resource utilization after arterial switch operation (ASO) in a national dataset.

Methods: Follow-up and life status data for all patients undergoing ASO between 2000 and 2017 in England and Wales were collected and explored using multivariable regressions and matching.

Results: A total of 1,772 patients were identified, with median ASO age of 9.5 days (IQR: 6.5-14.5 days). Mortality and cardiac reintervention at 10 years after ASO were 3.2% (95% CI: 2.5%-4.2%) and 10.7% (95% CI: 9.1%-12.2%), respectively. The median time spent in hospital during the ASO spell was 19 days (IQR: 14, 24). Over the first year after the ASO patients spent 7 days (IQR: 4-10 days) in hospital in total, decreasing to 1 outpatient day/year beyond the fifth year. In a subgroup with complete risk factor data (n = 652), ASO age, and balloon atrial septostomy (BAS) use were not associated with late mortality and reintervention, but cardiac or congenital comorbidities, low weight, and circulatory/renal support at ASO were. After matching for patient characteristics, BAS followed by ASO and ASO as first procedure, performed within the first 3 weeks of life, had comparable early and late outcomes, including hospital resource utilization.

Conclusions: Mortality and hospital resource utilization are low, while reintervention remains relatively frequent. Early ASO and individualized use of BAS allows for flexibility in treatment choices and a focus on at-risk patients.

Keywords: arterial switch; balloon atrial septostomy; hospital resource utilization; morbidity; multicenter study; reintervention; transposition of the great arteries.

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Conflict of interest statement

This study is supported by the Health Foundation, an independent charity committed to bringing about better health and health care for people in the United Kingdom (Award number 685009). D.M. Dorobantu is supported by a PhD Studentship (grant MR/N0137941/1 for the GW4 BIOMED DTP), awarded to the Universities of Bath, Bristol, Cardiff, and Exeter from the 10.13039/501100000265Medical Research Council (MRC)/UKRI, unrelated to this work. The views expressed are those of the authors and not necessarily those of the National Health Service, National Institute for Health Research, or Department of Health. The Linking AUdit and National datasets in Congenital HEart Services (LAUNCHES) project received ethical approval from the Health Research Authority (reference: IRAS 246796) and the Confidentiality Advisory Group (reference: 18/CAG/0180). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Flowchart of Study Population and Excluded Groups ASO = arterial switch operation; IVS = intact ventricular septum; NCHDA = National Congenital Heart Disease Audit; TGA = transposition of the great arteries.
Figure 2
Figure 2
Variation in Treatment Choices and Age by Year and Center (A) Bar chart showing proportion of patients undergoing arterial switch operation (ASO) as first procedure and balloon atrial septostomy (BAS) followed by ASO, by treatment year. (B) Bar chart showing proportion ASO as first procedure and BAS followed by ASO, by treatment center. (C) Box and Whisker chart showing median age (IQR) at ASO by treatment year. (D) Box and whisker chart showing median age at ASO by center. Centers are anonymized, and 2 centers not shown due to low numbers (1 and 2 ASO Respectively). Overall average is represented by solid red horizontal line.
Figure 3
Figure 3
Mid and Late Outcomes after ASO in Simple TGA-IVS (A) Probability of death (Kaplan-Meier) over 21 years. (B) Probability of cardiac reintervention conditional on survival (conditional probability function) over 16 years. (C) Probability of cardiac reintervention conditional on survival (conditional probability function) by reintervention type (surgical or transcatheter). Survival median follow-up is 12.4 (IQR: 8.6-16.6; max: 21.8) years; reintervention follow-up is 8.2 (IQR: 4.0-12.7; max: 16.9) years. All inserts are enlarged for the first year of follow-up. All numerical data (for A-C) in Supplemental Tables 6 to 9. ASO = arterial switch operation; TGA-IVS = transposition of the great arteries with intact septum.
Figure 4
Figure 4
Days Spent in Hospital After the ASO Spell Ended, by Type Total (inpatient/outpatient/A&E) (green), inpatient (orange), or outpatient (blue). (A) Hospital days for any reason (cardiac and noncardiac/ambiguous). numerical data in Supplemental Table 10, including split by inpatient (Supplemental Table 11) and outpatient (Supplemental Table 12). (B) Hospital days for cardiac reasons only. numerical data in Supplemental Table 10, including split by inpatient (Supplemental Table 11) and outpatient (Supplemental Table 12). No variations of >1 day from median were observed at year 2. The median for inpatient time in hospital was 0 (IQR: 0-0) beyond year 2. A&E = accidents and emergencies.
Central Illustration
Central Illustration
Current Results and Ongoing Issues in the Treatment of Transposition of Great Arteries With Intact Septum: An Overview From a National Registry
See this image and copyright information in PMC

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