Long-term Survival for Arterial vs. Atrial Switch in d-Transposition of the Great Arteries: A Report from the Pediatric Cardiac Care Consortium Open Access

Kiener, Alexander (Spring 2018)

Permanent URL: https://etd.library.emory.edu/concern/etds/02870v908?locale=en


Background: The arterial switch operation (ASO) was introduced in the US in the early 1980’s and quickly became the procedure of choice for dextro-transposition of the great arteries (d-TGA). Our objective was to compare the long-term transplant-free survival of patients with d-TGA who underwent ASO vs. atrial switch in the Pediatric Cardiac Care Consortium (PCCC), a large international multi-center registry.  


Methods: We performed a retrospective cohort study of d-TGA patients undergoing arterial switch operation (ASO) or atrial switch operation in the US between 1982 and 1991. Long-term transplant-free survival was obtained by linking PCCC 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 for each procedure, adjusted for sex, complexity, and surgical center. We compared both overall long-term survival and survival conditional on discharge following the initial surgery.


Results: Of 554 d-TGA patients who underwent ASO (n=259) or atrial switch (n=295) the 20-year overall transplant-free survival for children who had surgery for d-TGA was 82.1% for those undergoing ASO and 76.3% for those who had atrial switch procedure. Overall transplant-free survival was initially similar between the two surgical groups, but after 10 years post d-TGA repair, the ASO had better long-term transplant-free survival as compared to the atrial switch (HR=0.07, 95% CI 0.01-0.52, p-value=0.009). During this time period the ASO had higher in-hospital mortality than the atrial switch (21.6% vs 12.9%, p=0.007). After excluding those with post-operative in-hospital mortality, the transplant-free survival 20 years post-repair was 97.7% for the ASO vs. 86.3% for the atrial switch. There were 38 post-hospital discharge deaths (4 ASO, 34 atrial switch) and 4 transplants (1 ASO, 3 atrial switch). Among those with atrial switch procedure, long-term results were similar for Mustard operation vs. Senning operation.


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

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