Left ventricle is better suited to be the systemic ventricle therefore
arterial switch operation is best. This could be done in infants less than
2 weeks with an intact ventricular septum or infants within the first 2-3
months of age with a ventricular septal defect.
The left ventricle should be at or close to the systemic pressure to
withstand becoming the systemic ventricle after the arterial switch
operation. Patients with significant left ventricular outflow tract
obstruction (anatomic) with VSD may be better candidates for a Rastelli
Patients with severe right ventricular hypoplasia secondary to AV canal
defect and tricuspid valve anomalies will be better candidates for the
Main pulmonary artery banding is employed in patients with multiple
VSD’s or to prepare the left ventricle in older children for the
arterial switch operation.
The Mustard and Senning procedures were commonly performed ten years
ago. In the Mustard procedure the baffling of the atrium is done with
precordium or prosthetic material and the Senning procedure made of
material are used to baffle the atrium.
Conversion of atrial switch procedure to arterial switch procedure will
require that the MPA is banded first for a period of time until the left
ventricle is able to tolerate the systemic pressure. In the past,
palliative atrial switch procedure could be performed in patients with
d-TGA with VSD and pulmonary vascular obstructive disease to lessen the
extent of cyanosis.
Complications of atrial switch procedure:
1. Rhythm problems: All patients after 15 years have abnormal rhythms.
Twenty-five per cent
(25%) have disorders of the SA node and 1% per year develop late sudden
Tricuspid regurgitation: Frequent with VSD closure done through the
tricuspid valve. This is not well tolerated unlike VSD closure without
Right (systemic) ventricular failure: This occurs because the right
ventricle is performing the job of the left ventricle in addition to
possible tricuspid regurgitation.
Complete AV block: This would require a pacemaker.
CNS abnormalities is hard on those with prolonged cyanosis or IV
manipulations, for example, cardiac catheterization which may result in
emboli to the central nervous systemic from the venous circulation. As
many as 10% of the population, particularly in the past developed a lower
IQ and motor development delay.
Patients with d-TGA and intact ventricular septum with left ventricular
outflow tract obstruction. The left ventricular outflow tract obstruction
is usually dynamic and results after the arterial switch operation. Those
with anatomical LVOT obstruction can benefit from atrial switch and LVOT
d-TGA with coarctation of the aorta. This is rare and usually
associated with patients who also have VSD. There will be increased
pulmonary blood flow in these patients due to the high systemic vascular
resistance secondary to the coarctation resulting in congestive heart
failure. Management is staged usually by fixing the coarctation first and
then performing an arterial switch operation. Occasionally both could be
performed through an anterior mid-sternotomy.
d-TGA with pulmonary stenosis or pulmonary atresia. This pulmonary
stenosis can be relieved without damage to the pulmonary valve in arterial
switch operation is preferred. However, if the pulmonary stenosis is
severe then if there is a VSD the Rastelli procedure could be performed
and if there is no VSD or if the VSD is muscular than an atrial switch and
relief pulmonary stenosis could be performed. Pulmonary atresia