Management of Complex Transposition of the Great Arteries

Abstract

The diagnosis is established by cross-sectional echocardiography. We recommend balloon atrial septostomy, as in other patients with transposition of the great arteries (TGA). There is usually no urgency for surgical treatment, although some patients may require a systemic to pulmonary shunt early in infancy. Classic or modified Blalock-Taussig shunt is our first choice. Definitive treatment depends on the location of the ventricular septal defect (VSD) and the attachment of the tricuspid valve mechanism. If the anatomy is suitable, a Rastelli procedure [1] is our treatment of choice. Heterografts calcify rather quickly when used in children. Therefore our current conduit of choice is the “fresh,” antibiotic-preserved aortic or pulmonary homograft. Formation of peel in woven dacron conduits caused serious obstructions [2]. If we require a longer conduit, we extend the homograft with a tube of knitted dacron velour, which is presealed with Tisseel [3]. If the VSD is in the trabecular or inlet septum, it may not be possible to construct a wide tunnel from the left ventricle to the aorta. Attachment of the tricuspid valve to the infundibular septum or straddling of the tricuspid valve also may preclude a Rastelli procedure. Alternative treatment consists of a Senning/ Mustard procedure plus VSD closure and relief of the left ventricular outflow tract obstruction (LVOTO), or placement of left ventricular-pulmonary artery (LV-PA) conduit [4]. Our approach to TGA + VSD + LVOTO is illustrated in Figure 1.