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TGA AND LVOTODYNAMIC LVOTO IN TGA• Caused By Septal Shift – Seen Only InTGA/IVS• More Common When Aorta Anterior AndLeftward• SAM Can Contribute To Gradient• ASO Alone Reliably Relieves Obstruction• May be Significant ifi tLate Problem AfterAtrial Switch

TGA AND LVOTOFIXED LVOTO IN TGAP l V l Ab liti• Pulmonary Valve Abnormalities• Subvalvar Fibrous Membrane• Subvalvar Fibromuscular Tunnel• Septal Malalignment• Accessory Mitral Or Tricuspid ValveTissue• Anomalous Insertion Of MV OnInfundibular Septum (Straddle)

TGA AND LVOTOLVOTO IN TGA-SURGICALOPTIONS• ASO, Resection Of LVOTO• Atrial Switch, Resection Of LVOTOOr LV-PA Conduit• Rastelli Or REV Procedure• Nikaidoh-Bex Procedure• Single Ventricle Repair (Fontan-Kreutzer)

TGA AND LVOTOPULMONARY VALVEABNORMALITIES• May Occur With IVS Or VSD• Unequal Cusp Sizes And Bicuspid Valves,Dysplasia, Commissural Fusion• Abnormal PV May Not Be Obstructive• May Result In Neoaortic Insufficiency/Root Dilation• Rare For PS To Be Isolated; Usually InAssociation With Complex SubAS, PVAnnular Hypoplasia (Rastelli)

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The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.TGA AND LVOTOASO WITH PV HYPOPLASIA AND BICUSPID PVFrom: Park, C S, et al. JTCVS 2010;139:135-8

TGA AND LVOTOSUBVALVAR FIBROUSMEMBRANE• Seen In IVS And VSD• Usually ResectableSUBVALVARFIBROMUSCULAR TUNNEL• Seen In IVS And VSD• Often Associated With Hypoplastic PV• Difficult To Resect• Rastelli/REV, Nikaidoh-Bex (Konno),ASO All Options

TGA AND LVOTOACCESSORY TV TISSUE• May Be Present With VSD, Usually NotOutlet Type• Prolapses Into LVOT• Usually Resectable Or Excluded By VSDPatchACCESSORY MV TISSUE• Usually Seen With IVS, Rarely VSD(ECD Tissue)• Mitral Tissue Tags/ Accessory Tissue• Usually Resectable Without Damage ToValve

TGA AND LVOTOSEPTAL MALALIGNMENT• Deviation Of Outlet Septum IntoLVOT• Seen Only In TGA/VSD• Difficult To Resect• Nikaidoh-Bex i Or REV Good Options

TGA AND LVOTOABNORMAL VALVEINSERTION• Abnormal Attachment t MV Chordae OrPap Muscle To Outlet Septum• Straddling TV• May Not Preclude ASO, VSD Closure, ButResection May Not Be Possible• Various Techniques Such As Nikaidoh-BexMay Be Necessary• Single Ventricle Approach If Severe MVAbnormalities

TGA AND LVOTOARTERIAL SWITCH/LVOTOOPTIONSFrom: Sohn, et al. Ann Thorac Surg 1998;66:842-8

TGA AND LVOTOASOWITHLVOTO• Sohn, et al. Ann Thorac Surg1998;66:842-8842 826 Pts. Mean Age 69 Days Mean Wt. 4.5Kg.Bicuspid PV - 4, Dysplastic PV – 5LVOT Abnormalities – 17Preop Gradient 30 mm Hg g( (0-93)Death – 2 (7.7%), No Late DeathsFreedom From Reop 87% @ 130 mo.Gradient At Followup 0 mm Hg.

TGA AND LVOTOARTERIAL SWITCH/LVOT RESECTION-CAUSE OF OBSTRUCTIONFrom: Sohn, et al. Ann Thorac Surg 1998;66:842-8

TGA AND LVOTOARTERIAL SWITCH/LVOT RESECTION-GRADIENT ON FOLLOWUPFrom: Sohn, et al. Ann Thorac Surg 1998;66:842-8

TGA AND LVOTOASO WITH RESECTION LVOTO• Sharma et al. Ann Thorac Surg2002;74:1986-9123 Pts., Median Age 90 Days Wt. 4.3 Kg.2 Early Deaths8 Pts. Mild AR At DischargeMean Followup 60 Months4/8 (50%) AR Progressed To Moderate Or Severe AtFollowup

TGA AND LVOTORASTELLI PROCEDURE FORTGA/LVOTO• Kreutzer, et al. JTCVS 2000;120:211-23101 Pts. Median Age 3.1 Yr., Wt. 12.6 Kg.PS - 73, Pulm. Atresia – 187 Early Deaths (7%)Risk factors For Death – Straddling TV, Long X-ClampMedian FU 8.5 Yr. – 17 Late Deaths, 1 TransplantLate Reop/Arrhythmias/Sudden Death Common

TGA AND LVOTORASTELLI PROCEDURE-PATIENT CHARACTERISTICSFrom: Kreutzer, et. Al. JTCVS 2000;120:211-23

TGA AND LVOTORASTELLI PROCEDUREFrom: Kreutzer, et. Al. JTCVS 2000;120:211-23

TGA AND LVOTORASTELLI PROCEDURE-SURVIVALFrom: Kreutzer, et. Al. JTCVS 2000;120:211-23

TGA AND LVOTORASTELLI PROCEDURE-SURVIVAL BY ERAFrom: Kreutzer, et. Al. JTCVS 2000;120:211-23

TGA AND LVOTORASTELLI PROCEDURE-FREEDOM FROM REINTERVENTIONFrom: Kreutzer, et. Al. JTCVS 2000;120:211-23

TGA AND LVOTORASTELLI PROCEDURE-LVOT, RVOT REINTERVENTIONFrom: Kreutzer, et. Al. JTCVS 2000;120:211-23

TGA AND LVOTORASTELLI AND VSD ENLARGEMENTFrom: Navabi, MA et al. JTCVS 2009;138:390-6

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The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.TGA AND LVOTORASTELLI AND VSD ENLARGEMENTFrom: Navabi, MA et al. JTCVS 2009;138:390-6

TGA AND LVOTOREV PROCEDURE(REPARATION A L’ETAGE VENTRICULAIRE)• Extensive Resection Of Conal Septum +/-VSD Enlargement• Direct Reimplantation Of PulmonaryTrunk On RV• LeCompte Maneuver• VSD Size And Abnormal TV AttachmentsTo Septum Not Limiting – LessRecurrent LVOTO• No Conduit – Reoperation Less LikelyDespite PR

TGA AND LVOTORASTELLI VS LECOMPTE(REV)From: Lee, et al. Eur JCTS 2004;25:735-41

TGA AND LVOTORASTELLI VS LECOMPTE(REV)From: Lee, et al. Eur JCTS 2004;25:735-41

TGA AND LVOTORASTELLI VS LECOMPTE(REV)From: Lee, et al. Eur JCTS 2004;25:735-41

TGA AND LVOTORASTELLI VS LECOMPTE(REV)From: Lee, et al. Eur JCTS 2004;25:735-41

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.TGA AND LVOTOAORTIC TRANSLOCATION VS. RASTELLIFrom: Morrell, VO et al. Ann Thorac Surg 2005;79:2089-93

TGA AND LVOTOAORTIC TRANSLOCATION (NIKAIDOH-BEX)From: Bautista-Hernandez, V, et al. JACC 2007;49:485-90

TGA AND LVOTOAORTIC TRANSLOCATION (NIKAIDOH-BEX)From: Bautista-Hernandez, V, et al. JACC 2007;49:485-90

TGA AND LVOTOAORTIC TRANSLOCATION (NIKAIDOH-BEX)From: Bautista-Hernandez, V, et al. JACC 2007;49:485-90

TGA AND LVOTORASTELLI, REV OR NIKAIDOH?From: Hu, S, et al. JTCVS 2008;135:331-8

The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.TGA AND LVOTOAORTIC TRANSLOCATIONFrom: Hu, S, et al. JTCVS 2008;135:331-8

TGA AND LVOTOMODIFIED REV PROCEDUREFrom: Hu, S, et al. JTCVS 2008;135:331-8

TGA AND LVOTOPREOPERATIVE CHARACTERISTICSFrom: Emani, SM, et al. Circulation 2009;120:S53-58

TGA AND LVOTOLATE COMPLICATIONSFrom: Emani, SM, et al. Circulation 2009;120:S53-58

TGA AND LVOTOFREEDOM FROM LVOT REINTERVENTIONFrom: Emani, SM, et al. Circulation 2009;120:S53-58

TGA AND LVOTOSUMMARY• Surgical Results Good – Low Mortality, Similar ToTGA/VSD• TGA/VSD Or TGA/IVS With Isolated PVAbnormality – ASO• TGA/VSD/IVS With Subvalvar ar Obstruction – Choice OfOperation Varies Based On Resectability Of LVOT,PV Annulus Size• Nikaidoh-Bex Useful For VSD/PS With Moderate PVHypoplasia Or Septal Malalignment• Rastelli/REV For Pulmonary Atresia, Significant ValvarPS And Hypoplasia –REV May Have Less Reop• Results With Rastelli Suboptimal – LVOTO & ConduitChanges Common• Late Function Of AV And Root Still Unknown

TGA AND LVOTOQUESTIONS• When is PV too small for ASO?• What is long-term function of bicuspid PV?• Is the fate of the AV and root same as in Rossoperation?• Is the aortic valve at more risk for late AR after aortictranslocation?• Is coronary transfer with aortic translocationassociated itdwith ithlt late occlusion/stenosis?/t i?• Is the REV operation associated with less LVdysfunction and recurrent LVOTO than theRastelli?• Is VSD enlargement technique at Rastelli or REVassociated with long-term survival?• Will REV patients all require PV implantation late?