Ann Thorac Surg 2002;73:975-977
© 2002 The Society of Thoracic Surgeons
Case report
Successful arterial switch operation for post-mustard pulmonary venous obstruction and secondary pulmonary hypertension
Masahiro Inoue, MDa,
Osamu Oba, MD*a,
Sadahiko Arai, MDa,
Takeshi Shichijo, MDa,
Taiichi Takasaki, MDa
a Department of Cardiovascular Surgery, Hiroshima City Hospital, Hiroshima, Japan
Accepted for publication March 2, 2001.
* Address reprint requests to Dr Oba, Department of Cardiovascular Surgery, Hiroshima City Hospital, 7-33 Motomachi, Naka-ku, Hiroshima 730-8518, Japan
e-mail: oosamu{at}circus.ocn.ne.jp
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Abstract
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A 16-year-old girl presented with dyspnea 15 years after the Mustard operation for transposition of the great arteries with intact ventricular septum. An echocardiogram revealed secondary pulmonary hypertension due to pulmonary venous obstruction. Cardiac catheterization showed the left (pulmonary) ventricular pressure was over the systemic level. We performed a successful one-stage switch conversion. The patient is doing well 1 year after the switch conversion.
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Introduction
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After atrial switch operations, late problems are seen. Two-stage repair has been performed for right ventricular dysfunction after the atrial switch [1]. Pulmonary venous obstruction is a well-known complication. In our case, the left ventricle was retrained for maintaining systemic circulation due to pulmonary venous obstruction and secondary pulmonary hypertension. We performed a successful one-stage arterial switch conversion.
A 16-year-old girl presented with dyspnea on effort. She had a history of transposition of the great arteries with intact ventricular septum. She was first palliated by balloon atrioseptectomy at 1 day of age. At 11 months of age she underwent the Mustard operation. She was reoperated for superior vena caval obstruction at 19 months of age. She had been well since the second surgical procedure until she presented with the current dyspnea. An echocardiogram demonstrated pulmonary venous baffle obstruction with 4.1 mm (narrowest) diameter and 3.1 m/s pulmonary venous flow velocity. The diastolic left ventricular posterior wall thickness was 6 mm. Cardiac catheterization showed elevated left ventricular and pulmonary artery pressures. The left-to-right ventricular pressure ratio was 1.07 (Table 1).
Right (systemic) ventriculography revealed mild tricuspid valve regurgitation. Pulmonary arteriograms revealed mild pulmonary valve regurgitation (Fig 1A)
and pulmonary venous obstruction (Fig 1B). Based on these findings, we decided to perform a one-stage switch conversion consisting of Mustard takedown, atrial septal reconstruction, and an arterial switch, considering the left ventricle should be suitable for maintaining systemic circulation after the conversion due to pulmonary hypertension.
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Fig 1. (A) Preoperative pulmonary arteriogram (early phase) showing mild pulmonary valve regurgitation and calcification of the Mustard baffle (arrows). (B) Preoperative pulmonary arteriogram (late phase) showing pulmonary venous obstruction (arrows).
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Cardiopulmonary bypass was established with ascending aortic cannulation and bicaval cannulations. The whole body was cooled down to 26°C in rectal temperature. Through a right atriotomy, we found pulmonary venous obstruction due to severe degeneration of the Mustard baffle (porcine pericardium). The baffle was removed, and there was no stenosis in the bilateral pulmonary veins. The atrial septum was reconstructed using a Teflon (L.R. Bard, Tempe, AZ) patch. After atrial septal reconstruction, an arterial switch was performed, as in the original Jatene method, to avoid tension on the neopulmonary artery.
Postoperative cardiac catheterization revealed that the pulmonary-to-systemic pressure ratio was 0.83 (Table 1). Neoaortic valve regurgitation was trivial (Fig 2A)
and there was no neopulmonary valve regurgitation or stenotic region (Fig 2B). Left ventricular function was normal. The patient had an uneventful postoperative course. One year later, an echocardiogram revealed that the tricuspid regurgitant jet was trivial and the round-shaped left ventricle in short axis view suggested low right ventricular pressure. She is in excellent clinical condition.
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Fig 2. (A) Postoperative aortogram showing trivial neoaortic valve regurgitation. (B) Postoperative pulmonary arteriogram showing no neopulmonary valve regurgitation and no stenosis.
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Comment
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Currently, the arterial switch operation is considered the operation of choice for transposition of the great arteries. However, in earlier times, the atrial switch operation was performed for transposition of the great arteries. After atrial switch operations, late problems are seen, mainly right ventricular dysfunction. In 1986, Mee [1] reported two-stage repair (pulmonary artery banding and arterial switch) for treatment of severe right ventricular failure after the Mustard or Senning operation. Pulmonary venous obstruction is a well-known complication after the atrial switch operation. The result of reoperation for pulmonary venous baffle obstruction after the atrial switch was poor. Recently, several one-stage arterial switch operations for pulmonary venous obstruction after the Mustard operation were reported [2–5]. In our case, right ventricular function was normal; therefore, it could have been possible to relieve the baffle obstruction only. However, the left ventricle was retrained suitably for systemic circulation, as the patient had secondary pulmonary hypertension due to pulmonary venous obstruction. Hence we decided to perform a one-stage switch conversion.
We achieved an excellent outcome with the one-stage arterial switch conversion for repair of pulmonary venous baffle obstruction and secondary pulmonary hypertension after the Mustard operation.
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References
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Mee R.B.B. Severe right ventricular failure after Mustard or Senning operation. J Thorac Cardiovasc Surg 1986;92:385-390.[Abstract]
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Wakaki N., Shirotani H., Oku H., Nishioka T., Sunakawa A., Kitayama H. A successful arterial swith operation for a patient with pulmonary venous obstruction and pulmonary hypertension five years after the Mustard procedure. J Jpn Assoc Thorac Surg 1990;38:465-471.
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Shinebourne E.A., Jahangiri M., Carvalho J.S., Lincoln C. Anatomic correction for post-Mustard pulmonary venous obstruction. Ann Thorac Surg 1994;57:1655-1656.[Abstract]
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De Jong P.L., Bogers A.J.J.C., Witsenburg M., Bos E. Arterial switch for pulmonary venous obstruction complicating Mustard procedure. Ann Thorac Surg 1995;59:1005-1007.[Abstract/Free Full Text]
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Cetta F., Bonilla J.J., Lichtenberg R.C., Stasior C., Troman J.E., Deleon S.Y. Anatomic correction of dexterotransposition of great Arteries in a 36-year-old patient. Mayo Clin Proc 1997;72:245-247.[Medline]
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Abstract
Introduction
