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Arterial Switch Operation (ASO)

Surgical repair for D- Transposition of the Great Arteries (TGA)

Objectives
Provide a brief overview of d-TGA Describe and discuss Arterial Switch Operation (ASO) Review post-op care and what to look for in the immediate post surgical period. Discuss parental needs and teaching prior to discharge

D-Transposition of the great arteries


Occurs in 5% of congenital heart disease. More common in boys 3:1 Discordant ventricular arterial relationship. Pulmonary Artery arises from left ventricle Aorta arises from the right ventricle (anterior and rightward of PA)

D-Transposition of the Great Arteries


Hemodynamics: Parallel circulation Aorta comes off of right ventricle therefore receiving desaturated venous blood from RV and circulating de-oxygenated blood to the body Pulmonary artery comes off left ventricle receiving oxygenated blood from the pulmonary veins and returning oxygen rich blood to lungs.

Survival dependent upon some type of communication. Mixing of oxygenated blood from pulmonary circulation and deoxygenated blood from systemic circulation. Occurs at Atrial level via Atrial septal defect (ASD)/Patent Foramen Ovale (PFO) and at great artery level via patent ductus arteriosus (PDA). At ventricular level if VSD present Prostaglandin to maintain patency of PDA Atrial septostomy if ASD/PFO restrictive continued severe hypoxemia.

Arterial Switch Operation

Surgical development started in the early 1950s but were unsuccessful continued development in the 60s. 1975 breakthrough by Jatene and colleagues in Brazil with first successful arterial switch procedure in infants with TGA and VSD. Lecompte and colleagues made technical modification of Jatene procedure with direct anastamosis of both great arteries without interposition tube graft.

Arterial Switch Operation


Operation occurs 1-3weeks of life. Newborn LV has been pumping against high PVR so is ready Procedure: Open heart on CPB - transfer over to LV Aorta and both coronary arteries. Coronary artery buttons created. - transfer over to RV Main Pulmonary Artery (MPA). MPA brought anterior (le Comte maneuver), left and right branch pulmonary arteries are straddle the ascending aorta. Branch PA stenosis can occur if MPA is not mobilized adequately anteriorly. - repair all other lesions: ASD, PDA, VSD LV is now systemic pump post-op.

Arterial Switch Operation

Arterial Switch Operation


Cardiopulmonary Bypass- supports body during surgery Aortic cross clamp time-Aorta clamped between the aortic cannula and the coronary ostia cardioplegia solution injected to arrest and protect heart Circulatory Arrest-Bypass turned off, entire circulation arrested. Using deep hypothermia temps less than 20 degrees celsius TEE- Transesophageal echo before and after surgery to assess heart prior to and after repair.

Post-op care ASO


LV is weak it is now the systemic ventricle LV dysfunction: watch for high LAP LA line placed in OR: normal LAP 5-10 LV failure LAP> 15-20. LV less compliant LAP will rise quickly with volume infusions Risk decreased CO and Pulmonary edema, LAP greater than 20 Monitor LAP; give slow volume infusions Monitor EKG- signs of coronary artery injury, obstruction e.g. ST segment changes, new arrythmias Monitor Bleeding: many suture lines, suture lines in the aorta etc, BP monitoring and control important as increased BP= increased risk of bleeding

Post-op care ASO


Monitor s/s cardiac tamponade: Increased HR, Decreased ABP, Poor CO, little response to volume infusion. sudden decrease or stop in the CT output in a patient who has had significant bleeding. surgical emergency, mediastinal exploration for clot evacuation, bleeding control. Monitor urine output- good indicator of cardiac output, organ perfusion.

Late Post-op Complications


Aortic Insufficiency - rare Pulmonary Stenosis- main cause of re-operation Coronary Anomaly - rare Late death low no deaths after 5 years Despite late complications the arterial switch operation is better than the atrial switch operation. Patients with complex TGA more prone to reintervention Good left ventricular function and sinus rhythm maintained in most patients

Parent Teaching
Initial Post-op: Discuss with parents/family lines, machines, medications etc. Encourage them to ask questions Update frequently as to baby status and progress Re-assure the parents about their babys progress

Parent teaching
Remember these patients usually need no further intervention and go home to live a normal life, participate in normal activities. In addition to orienting parents to their critically ill child initially post-op we need to begin preparing for discharge Discharge planning and teaching needs to be started on POD#2-3 (use extubation as a marker) Incision site care, activity restrictions e.g. no picking up the baby under the armpits for 6weeks. Plans for feeding: breast milk/ formula what is a normal intake for a baby at home. What do we expect the baby to be taking prior to discharge Set the parents up from early in the admission for rooming in i.e. they will be expected to provide complete care for the baby for at least 24 hours prior to discharge. Who to contact after discharge should there be any more questions. When is follow-up as an outpatient with the cardiologist.

Questions?

References

DeBord, S., Cherry, C., Hickey, C. (2007). The arterial switch procedure for transposition of the great arteries. AORN Journal, 86, 211-226. Everett, A & Lim, D. (2007). Iillustrated Field Guide to congenital heart disease and repair (2nd ed.0. Charlottesville, VA: Scientific Software Solutions. Hazinski, MF (2012). Nursing care of the critically ill child, (3rd ed). St. Louis:MO: Elsevier Losay, J., Touchot,A., Serraf, A., Litvinova, A., Lambert, V., Piot, J.D., Lacour-Gayet, F., Capderou,A. & Planche,C. (2001). Late outcome after arterial switch operation for transposition of the great arteries. Circulation, 104, I121-I126. Martins, P. & Castela, E. (2008). Transposition of the great arteries. Orphanet Journal of Rare Diseases, 3. Doi: 10.1186/1750-1172-3-27 Wernovsky, G: Transposition of the great arteries: In Allen, HD, Driscoll, DJ., Feltes, TF, & Shaddy, RE. editors. (2008). Moss and Adams heart disease in infants, children, and adolescents, including the fetus and young adult, (7th ed)., Philadelphia, PA: Lippincott Williams & Wilkins. Wheeler, D., Dent, C., Manning, P., & Nelson, D. (2008). Factors prolonging length of stay in the cardiac intensive care unit after the arterial switch operation. Cardiology in the Young, 18, 41-50.