Long term problems after arterial switch (Jatene's) operation

Arterial switch operation is the standard of care for the management of transposition of great arteries (TGA) detected in early neonatal period. Even though it is currently the ideal treatment for TGA, there are certain potential long term problems with this approach as well. The most frequent long term sequelae is supravalvar pulmonary stenosis, though supravalvar aortic stenosis can also occur with lesser frequency. Yacoub MH and associates [Yacoub MH et al. Supravalvular pulmonary stenosis after anatomic correction of transposition of the great arteries: causes and prevention. Circulation 1982;66(Suppl):I193-7] noted that three of their twenty two patients who underwent arterial switch operation developed supravalvar pulmonary stenosis at a follow up of 1-4.6 years (mean 2.0 years). They had used homologous duramater in the majority of cases to bridge the gap between the proximal pulmonary route and the distal pulmonary artery and a Dacron tube in a few cases. Gradients ranged from 45 to 95 mm Hg in those with supravalvar pulmonary stenosis. Two of them were corrected by pericardial patch repair. Carrel T and associates described the results of direct reconstruction of the pulmonary artery during the arterial switch procedure [Carrel T et al. Direct reconstruction of the pulmonary artery during the arterial switch operation: an interesting surgical option with excellent hemodynamic results. Ann Thorac Surg. 1998;65:1115-9]. Forty seven of their one hundred and eighty nine patients underwent direct pulmonary artery reconstruction. Extensive mobilization of both pulmonary arteries into the hilum was needed for this approach. They performed a large anastomosis without any tension between the remnant of the aortic sinus of Valsalva and pulmonary artery. Early mortality was 8.5 percent in this group. Thirty seven of the forty three survivors had a pulmonary gradient of less than 15 mm Hg. Mild pulmonary stenosis with gradient between 15 to 30 mm Hg was noted in four and severe supravalvar pulmonary stenosis with gradient more than 30 mm Hg was noted in two. One patient underwent reoperation for widening of right ventricular outflow tract. The mean follow up period in this report was thirty six months.
Some patients develop dilatation and annuloectasia of the anatomic pulmonary root (neo aortic root). This can lead on to post operative aortic regurgitation. Another important concern with arterial switch operation is the potential for damage to coronary arteries during transfer to the neo aortic root.
The incidence of stenosis or occlusion of main coronary arteries in the survivors is significant [Tanel RE et al. Coronary artery abnormalities detected at cardiac catheterization following the arterial switch operation for transposition of the great arteries. Am J Cardiol 1995;76:153-7 and Bonhoeffer P, et al. Coronary artery obstruction after the arterial switch operation for transposition of the great arteries in newborns. J Am Coll Cardiol 1997;29:202-6]. Sudden death several years after surgery has also been reported [Tsuda E et al. Late death after arterial switch operation for transposition of the great arteries. Am Heart J 1992;124:1551-7].