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Growth of the Neo-Aortic Root and Prognosis of TGA
Quick Takes
- Aortic dilatation occurs commonly in patients after the arterial switch operation, particularly in patients with double outlet right ventricle-TGA type.
- A composite endpoint of moderate-severe aortic regurgitation, neo-aortic valve replacement, or neo-aortic root/ascending aortic replacement occurred in 9.5% of patients.
- No aortic dissections occurred during the study period.
Study Questions:
What are the risk factors and characteristics of aortic growth after the arterial switch operation (ASO) for dextro-transposition of the great arteries (d-TGA)?
Methods:
A retrospective review was performed at a single center. Patients underwent ASO between July 1981 and September 2022. Anatomy was categorized as d-transposition of the great arteries with intact ventricular septum (d-TGA-IVS), d-transposition with ventricular septal defect (d-TGA-VSD), and double outlet right ventricle-TGA (DORV-TGA). Echo-derived aortic measurements were used to calculate z-scores, which were followed over time. The association between underlying anatomy and the composite of moderate to severe neo-aortic regurgitation (AR) and neo-aortic valve or root intervention was determined.
Results:
A total of 1,359 patients underwent ASO during the study period, of which 44% had d-TGA-IVS, 49% d-TGA-VSD, and 7% DORV-TGA. The median follow-up was 8.6 years (range 0.1-39.3 years). At 30 years, DORV-TGA patients demonstrated greater annular and sinus of Valsalva, and sinotubular junction dilatation relative to d-TGA-IVS patients. On multivariable analysis, underlying anatomy, older age at ASO, at least mild AR at baseline, and faster rates of root dilatation were associated with moderate to severe AR and neo-aortic valve or root intervention at late follow-up. The composite endpoint of moderate-severe AR, neo-aortic valve or root replacement, or ascending aortic replacement occurred in 9.5% of patients.
Conclusions:
The authors conclude that longitudinal surveillance of the neo-aortic root is indicated after ASO.
Perspective:
Aortic dilatation after the ASO is common and is of uncertain clinical significance given the absence of any reported aortic dissections in this patient population (this study included). There is a good deal of variability across centers as to the timing of aortic intervention in patients after ASO. We do not know from the study as to how aggressive this center was in intervening on dilated aortas. The study does demonstrate that certain patients are at higher risk for ongoing dilatation, particularly those with underlying DORV anatomy, and supports close follow-up for aortic dimensions and neo-aortic valve function in patients after ASO.
Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and CHD and Pediatrics, Congenital Heart Disease, CHD and Pediatrics and Interventions, Interventions and Structural Heart Disease
Keywords: Aorta, Arterial Switch Operation, Congenitally Corrected Transposition of the Great Arteries
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