Combined arterial switch and Senning operation for congenitally corrected transposition of the great arteries: patient selection and intermediate results.

OBJECTIVE: Late results after traditional methods of repair of congenitally corrected transposition of the great arteries are poor. The combined arterial switch and Senning (double switch) operation may improve outcomes by using the morphologically left ventricle and mitral valve in the systemic circulation. In this report we review patient selection and intermediate results after the double switch operation for congenitally corrected transposition of the great arteries.

METHODS: Since 1993, a total of 35 patients with congenitally corrected transposition of the great arteries with two ventricles of adequate size and no valvular pulmonary stenosis were potential candidates for a double switch operation. Eleven were not yet in need of further treatment, and 1 died during evaluation. The remaining 23 patients were entered into a protocol leading to anatomic repair. Their hospital records were reviewed, and follow-up data were obtained to evaluate early and intermediate outcomes.

RESULTS: The 23 patients were candidates for anatomic repair because of right ventricular dysfunction or tricuspid regurgitation (n = 15) or associated uncorrected defects (n = 8). Pulmonary artery banding was performed in a total of 15 patients, either for left ventricular retraining (n = 11) or for congestive heart failure (n = 4). In 2 patients, aged 12 and 14 years, retraining was unsuccessful because of left ventricular dysfunction. Four patients with banding are currently awaiting repair. Eight patients proceeded to undergo double switch operations without preliminary pulmonary artery banding. To date, 17 patients have undergone double switch operations, with no early or late mortality. One patient required cardiac transplantation for progressive left ventricular failure after a preliminary banding and double switch operation done at 7 years of age. Ventricular function and tricuspid regurgitation remained stable or improved in all other cases. No patient has surgically acquired arrhythmias or significant residual hemodynamic conditions. All patients are alive and clinically well at a mean follow-up of 36 months (range 1 month-8 years).

CONCLUSIONS: Congenitally corrected transposition of the great arteries with a normal pulmonary valve and two adequate ventricles can be managed with combined arterial switch and Senning operation with excellent intermediate results. Reconditioning the left ventricle may not be suitable for older patients. Late follow-up will be necessary to determine whether this management strategy provides a survival advantage for these patients.