Two-Stage Arterial Switch (Jatene) Operation with Preliminary Training of Left Ventricle by Pulmonary Artery Banding and Blalock-Taussig Shunt : Its Clinical Implication in Surgical Treatment of Simple Transposition of the Great Arteries

摘要

Clinical results of 107 patients who underwent preliminary pulmonary artery banding and Blalock-Taussig shunt between 1983 and 1990 were analyzed to clarify its clinical implication in preparing left ventricle with low pressure in the pulmonary circuit to take over systemic workload in staged arterial switch (Jatene) operation for simple transposition of the great arteries. Through this preparatory procedure, arterial switch was achieved in 82 cases (76.6%) with satisfactory results. However, among the 107, 14 cases were converted to the Senning track for various reasons. Acute left ventricular hypertrophy by pressure overload provided expected systolic left ventricular function in most infants though some limitations were invariably encountered. Adequate preparedness of left ventricle was best assessed with combined left ventricular to right ventricular systolic pressure ratio (LVp/RVp) equal or greater than 0.8 and the diastolic posterior wall thickness of left ventricle (LVPWT) equal or greater than 4.0 mm. Left ventricular mass (LVM) was predominantly influenced by pre-load and was not sensitive to acquisition of systolic function unless corrected by left ventricular end-diastolic volume (LVM/LVEDV). Although this two-stage approach to simple transposition is transitional toward neonatal, primary Jatene operation and the clinical prevalence of this two-stage approach will decline with advances in neonatal cardiac surgery, this new concept of "left ventricular training" has not only changed the surgical strategy for simple transposition but also has the strong impact on strategies for use of left ventricle as a systemic chamber in other complex congenital cardiac anomalies with low pressure left ventricle.