Portal de Periódicos da CAPES

50th Anniversary Perspective on Volume 1: Morgan AD, Krovetz LJ, Schiebler GL, et al. Diagnosis and Palliative Surgery in Complete Transposition of the Great Vessels. Ann Thorac Surg 1965:1;711–22

2015; Elsevier BV; Volume: 100; Issue: 5 Linguagem: Inglês

10.1016/j.athoracsur.2015.09.053

1552-6259

Scott M. Bradley,

Cardiac Structural Anomalies and Repair

To commemorate the 50th anniversary of The Annals of Thoracic Surgery, a special STS presidential task force has selected articles that were published in Volume 1 (1965) describing important topics in cardiothoracic surgery. Each 2015 issue of The Annals will highlight one of these contributions through the eyes of a current thought leader. The expert commentaries will provide personal insight regarding the evolution of these challenges and implications for the future.The surgical treatment of transposition of the great arteries is one of the success stories of congenital heart surgery. Transposition is now routinely corrected by a single operation carried out in the first weeks of life, with low operative mortality and survival to adulthood expected for most patients. The operative results have improved to the point that outcome studies currently focus on late quality of life, general health status, and neurodevelopment. Of course, every success story has its history. To commemorate the 50th anniversary of The Annals of Thoracic Surgery, a special STS presidential task force has selected articles that were published in Volume 1 (1965) describing important topics in cardiothoracic surgery. Each 2015 issue of The Annals will highlight one of these contributions through the eyes of a current thought leader. The expert commentaries will provide personal insight regarding the evolution of these challenges and implications for the future. In the first issue of The Annals of Thoracic Surgery, Anne Morgan and colleagues [1Morgan A.D. Krovetz L.J. Schiebler G.L. Shanklin D.R. Wheat Jr, M.W. Bartley T.D. Diagnosis and palliative surgery in complete transposition of the great vessels.Ann Thorac Surg. 1965; 1: 711-722Abstract Full Text PDF PubMed Scopus (2) Google Scholar] published an article on diagnosis and palliative surgery for transposition. The year 1965 was early in the era of atrial level repair. Senning’s procedure had been introduced 6 years earlier but had not been widely adopted due to its complexity. Mustard’s baffle modification had just been presented 1 year earlier. Many important developments lay in the future: balloon atrial septostomy would not be reported until the next year, the Rastelli procedure was 4 years away. Jatene’s arterial switch and the use of prostaglandin E1 would not arrive for a decade. In 1965, relatively few patients underwent successful surgical repair. Morgan and colleagues [1Morgan A.D. Krovetz L.J. Schiebler G.L. Shanklin D.R. Wheat Jr, M.W. Bartley T.D. Diagnosis and palliative surgery in complete transposition of the great vessels.Ann Thorac Surg. 1965; 1: 711-722Abstract Full Text PDF PubMed Scopus (2) Google Scholar] noted, “Realistically, palliative surgery to allow time for growth and development is the only therapy we have to offer these infants at present.” The palliative approach in most cases was a Blalock-Hanlon atrial septectomy. Much of the paper is devoted to a discussion of findings on physical examination, chest roentgenogram, and electrocardiogram. Cardiac catheterization, not routinely performed, was associated with increased mortality. Overall mortality was high: 25 of the 40 patients in the report were characterized at autopsy. At the time, it would have seemed far-fetched that a newborn baby with transposition could be completely and accurately diagnosed by a 20-minute echocardiogram and then repaired by an operation that switched the great arteries and coronaries. Getting to the switch as we know it today followed a path with many steps. One of the key steps was the development of the arterial switch procedure in neonates. For the purposes of this “Perspective,” I spoke with Drs Castaneda, Norwood, Jonas, Bove, and Sade to get their views on how this unfolded in the early 1980s. Dr Castaneda started his general and cardiothoracic surgical residency at the University of Minnesota in 1958. C. Walton Lillehei’s intracardiac repairs using cross-circulation were 4 years in the past. At the Mayo Clinic, 90 miles away, John Kirklin was already carrying out his series of cardiac operations using cardiopulmonary bypass. Castaneda felt that he “had come to the field late, that the history of congenital heart surgery was over.” Given what was to occur over the next 30 years, his own achievements in particular, this feeling was more than a bit ironic. At the time, young patient age was a risk factor for cardiac operations, as substantiated in the experiences of both Lillehei and Kirklin. Nonetheless, Castaneda was dedicated to the concept that early correction would not only be tolerated but preferable. This was supported by his laboratory studies in Minnesota [2Visudh-Arom K. Miller I.D. Castaneda A.R. Total cardiopulmonary bypass in puppies: pulmonary studies.Surgery. 1970; 68: 878-883PubMed Google Scholar]. In puppies as small as 2 kg, he demonstrated that 2 hours of cardiopulmonary bypass was well tolerated, even using the bubble oxygenators available at the time. Castaneda was appointed Chief of Cardiac Surgery at Boston Children’s Hospital in 1972. In collaboration with Alexander Nadas, the Chief of Cardiology, he adopted a programmatic commitment to early, complete, single-stage repair. This commitment was to have significant effects on the surgical treatment of congenital heart defects. Bill Norwood left Minnesota to join Castaneda in 1976. In the ensuing years, the standard approach in Boston to babies born with transposition was to perform a balloon atrial septostomy, followed by a Senning procedure at age 6 to 12 months. The results of atrial repair were very good, with operative mortalities in some series below 2% [3Trusler G.A. Williams W.G. Duncan K.F. et al.Results with the Mustard operation in simple transposition of the great arteries 1963–1985.Ann Surg. 1987; 206: 251-260Crossref PubMed Scopus (54) Google Scholar, 4Stark J. Transposition of the great arteries: which operation?.Ann Thorac Surg. 1984; 38: 429-431Abstract Full Text PDF PubMed Scopus (25) Google Scholar]. However, several factors generated discussion about earlier, neonatal repair at the arterial level. Some babies remained quite cyanotic after septostomy, with saturations below 70%, leading to anxiety about delaying their repair. There was also concern about the function of the right ventricle as a systemic pump and about the arrhythmias that were being increasingly observed after atrial repairs. These discussions gained further traction with the first reports of successful arterial repair. On May 8, 1975, Adib Jatene performed the first successful arterial switch in Sao Paulo, Brazil [5Jatene A.D. Fontes V.F. Paulista P.P. et al.Anatomic correction of transposition of the great vessels.J Thorac Cardiovasc Surg. 1976; 72: 364-370PubMed Google Scholar]. The patient was 40 days old, with transposition and a large ventricular septal defect (VSD). Although only 1 of the 7 patients in his original report survived, Jatene persisted. By 1981, he had operated on 33 patients with an overall mortality of 52%, which decreased to 13% in the later patients [6Jatene A.D. Fontes V.F. Souza L.C. Paulista P.P. Abdulmassih Neto C. Sousa J.E. Anatomic correction of transposition of the great arteries.J Thorac Cardiovasc Surg. 1982; 83: 20-26PubMed Google Scholar]. After Jatene’s initial success, others performed successful cases later the same year, including Magdi Yacoub in Harefield and Donald Ross in London on the same day (October 30, 1975), and Guillermo Kreutzer and Rodolfo Neirotti in Buenos Aires, Argentina, in November 1975 [7Yacoub M.H. Radley-Smith R. Hilton C.J. Anatomical correction of complete transposition of the great arteries and ventricular septal defect in infancy.Br Med J. 1976; 1: 1112-1114Crossref PubMed Scopus (57) Google Scholar, 8Ross D. Rickards A. Somerville J. Transposition of the great arteries: logical anatomical arterial correction.Br Med J. 1976; 1: 1109-1111Crossref PubMed Scopus (27) Google Scholar, 9Kreutzer G. Neirotti R. Galindez E. Coronel A.R. Kreutzer E. Anatomic correction of transposition of the great arteries.J Thorac Cardiovasc Surg. 1977; 73: 538-542PubMed Google Scholar]. Other groups followed with small numbers of patients [10Quaegebeur J.M. Rohmer J. Ottenkamp J. et al.The arterial switch operation: an eight-year experience.J Thorac Cardiovasc Surg. 1986; 92: 361-384PubMed Google Scholar, 11Lecompte Y. Zannini L. Hazan E. et al.Anatomic correction of transposition of the great arteries: new technique without use of a prosthetic conduit.J Thorac Cardiovasc Surg. 1981; 82: 629-631PubMed Google Scholar, 12Williams W.G. Freedom R.M. Culham G. et al.Early experience with arterial repair of transposition.Ann Thorac Surg. 1981; 32: 8-15Abstract Full Text PDF PubMed Scopus (29) Google Scholar]. However, success was limited to patients beyond the neonatal period, whose left ventricle remained at high pressure, usually due to the presence of a large VSD. In patients with an intact ventricular septum, Magdi Yacoub undertook a two-stage approach, banding the pulmonary artery to maintain left ventricular afterload, followed by an arterial switch at age 6 to 12 months [13Yacoub M.H. Radley-Smith R. Maclaurin R. Two-stage operation for anatomical correction of transposition of the great arteries with intact interventricular septum.Lancet. 1977; 1: 1275-1278Abstract PubMed Scopus (176) Google Scholar]. By 1979, Yacoub had followed this approach in 10 patients [14Yacoub M.H. The case for anatomic correction of transposition of the great arteries.J Thorac Cardiovasc Surg. 1979; 78: 3-6PubMed Google Scholar]. The two-stage approach was not without its complexities: some patients required the addition of a shunt to maintain oxygenation after band placement. Scarring from the band also contributed to the need for a conduit to reconstruct the right ventricular outflow tract (this was before the introduction of the LeCompte maneuver). It was realized that single-stage arterial repair for most patients with transposition, those with an intact ventricular septum, would require an arterial switch operation as a neonate, while the left ventricle was still adapted to systemic afterload. Paul Ebert had undertaken such an approach in San Francisco but abandoned it after 6 patients, and did not publish the results [12Williams W.G. Freedom R.M. Culham G. et al.Early experience with arterial repair of transposition.Ann Thorac Surg. 1981; 32: 8-15Abstract Full Text PDF PubMed Scopus (29) Google Scholar, 15Castaneda A.R. Norwood W.I. Jonas R.A. Colon S.D. Sanders S.P. Lang P. Transposition of the great arteries and intact ventricular septum: anatomical repair in the neonate.Ann Thorac Surg. 1984; 38: 438-443Abstract Full Text PDF PubMed Scopus (218) Google Scholar]. At the time, many believed that the technical challenge and magnitude of the operation precluded arterial repair in neonates [12Williams W.G. Freedom R.M. Culham G. et al.Early experience with arterial repair of transposition.Ann Thorac Surg. 1981; 32: 8-15Abstract Full Text PDF PubMed Scopus (29) Google Scholar]. However, Castaneda and Norwood believed that if the physiology would work, the technical challenges could be overcome. Castaneda had already pushed the age at repair for a number of defects into early infancy while Norwood had been working out the challenges of neonatal palliation for hypoplastic left heart syndrome. In January 1983, the team in Boston initiated the first successful series of neonatal arterial switch operations. Richard Jonas started his fellowship in Boston the same month, just in time to witness history being made. Dr Castaneda recalls that the first patient’s father, an engineer at Massachusetts Institute of Technology, was educated on the late issues of atrial level repair and open to an alternative approach. Castaneda and Norwood scrubbed together on the first several cases, with Jonas assisting, surely one of the most striking assemblages of congenital cardiac surgical talent ever focused on individual operations. Jonas described Castaneda and Norwood performing “the world’s first successful neonatal arterial switch procedures without any fanfare and in front of an unsuspecting and subsequently astounded operating room team including myself” [16Jonas R. Comprehensive surgical management of congenital heart disease. Oxford University Press, New York2004: xiGoogle Scholar]. Castaneda reported the initial series at the annual meeting of The Society of Thoracic Surgeons in January 1984 [15Castaneda A.R. Norwood W.I. Jonas R.A. Colon S.D. Sanders S.P. Lang P. Transposition of the great arteries and intact ventricular septum: anatomical repair in the neonate.Ann Thorac Surg. 1984; 38: 438-443Abstract Full Text PDF PubMed Scopus (218) Google Scholar]. In his discussion, Hillel Laks raised a number of important questions regarding the potential for operative death, anastomotic and coronary stenoses, valve regurgitation, and neoaortic dilation. These questions would form the topics of subsequent studies and have essentially all been answered. The landmark series included neonates weighing as little as 1.8 kg. The Discussion section of the paper mentions a 3-month-old with transposition and VSD (not included in the series of neonates) who underwent an unsuccessful arterial switch, with intraoperative switch takedown and conversion to atrial switch! These patients bear testament to the technical skills of the surgeons and the management skills of the entire perioperative team. Castaneda and Norwood worked out their operative technique on site, designing the operation to achieve the principles to be satisfied. Their approach evolved from case to case; each operation was analyzed in detail and served to direct improvements in the next. Norwood recalls one of the earliest operations being done by switching the great vessels and supplying coronary flow through an aortopulmonary window, without transfer of coronary buttons. This technique was independently developed by Aubert in Marseille, France [17Aubert J. Pannetier A. Couvelly J.P. Unal D. Rouault F. Delarue A. Transposition of the great arteries: new technique for anatomical correction.Br Heart J. 1978; 40: 204-208Crossref PubMed Scopus (69) Google Scholar]. However, the Boston group quickly moved to the technique of arterial switch with coronary transfer. Initially, the coronaries were excised on small circular buttons, separate from the aortic transection site, and minimally mobilized. The excision sites were repaired with individual pericardial patches. This resulted in some cases of coronary compromise and supravalvar pulmonary stenosis. Castaneda then changed the technique to excision of U-shaped patches starting at the aortic transection site, more thorough coronary mobilization, and repair of the excision sites with a single patch. Complex cardiac operations had not been previously done with any regularity in neonates. Norwood termed the undertaking “the move from 2-0 Tevdek to 7-0 Prolene”: it required the development of new pickups and needle holders, which was achieved in consultation with instrument companies. The operations were facilitated by the routine use of circulatory arrest. The Boston team initially felt that not all coronary variations were switchable, and continued to perform the Senning procedure in patients with high-risk coronary anatomy. This placed a premium on accurate preoperative identification of coronary anatomy, leading to improved echocardiography techniques and the development of the “laid-back” aortogram [18Mandell V.S. Lock J.E. Mayer J.E. Parness I.A. Kulik T.J. The “laid-back” aortogram: an improved angiographic view for demonstration of coronary arteries in transposition of the great arteries.Am J Cardiol. 1990; 65: 1379-1383Abstract Full Text PDF PubMed Scopus (35) Google Scholar]. Nonetheless, some neonates underwent intraoperative conversion to a Senning after a planned arterial switch was aborted due to unanticipated coronary anatomy. This was a challenging scenario and carried a mortality of 23% [19D-transposition of the great arteries.in: Castaneda A.R. Jonas R.A. Mayer Jr., J.E. Hanley F.L. Cardiac surgery of the neonate and infant. Saunders, Philadelphia1994: 436Google Scholar]. Yacoub and Quaegebeur argued that all coronary variants were switchable, which was subsequently generally accepted [10Quaegebeur J.M. Rohmer J. Ottenkamp J. et al.The arterial switch operation: an eight-year experience.J Thorac Cardiovasc Surg. 1986; 92: 361-384PubMed Google Scholar, 14Yacoub M.H. The case for anatomic correction of transposition of the great arteries.J Thorac Cardiovasc Surg. 1979; 78: 3-6PubMed Google Scholar]. Ed Bove adopted the arterial switch on his own and pursued an alternative technical approach. During his year as a registrar at Great Ormond Street (1979 to 1980), he learned the Mustard and Senning operations from Professors Stark and de Leval. He also heard discussion about Yacoub’s two-stage switches, which were occurring 20 miles across London. While at Great Ormond Street, he observed one arterial switch operation in a patient who underwent balloon septostomy with resulting disruption of the tricuspid valve. The ensuing arterial switch was unsuccessful. Bove returned to the United States to initially practice in Syracuse. From 1982 to 1984, he undertook a series of 11 switches, 5 in patients with an intact septum [20Bove E.L. Byrum C.J. Kavey R.W. et al.Arterial repair for simple and complex forms of transposition of the great arteries.J Cardiovasc Surg (Torino). 1987; 28: 54-60PubMed Google Scholar]. Two of the cases were performed during return visits to the University of Michigan, Ann Arbor, where he had trained. After his move to Ann Arbor in 1985, with the support of Amnon Rosenthal, the Chief of Pediatric Cardiology, Bove transitioned completely from atrial to arterial repair. Bove initially used an open coronary transfer technique, as in the Boston experience. However, after a coronary issue in an early patient, he switched to a closed coronary transfer technique [21Bove E.L. Current technique of the arterial switch procedure for transposition of the great arteries.J Card Surg. 1989; 4: 193-199Crossref PubMed Scopus (30) Google Scholar]. In this approach, the neoaorta is reconstructed before coronary reimplantation, and the reimplantation sites are then selected on a distended neoaortic root [22Bove E.L. The arterial switch procedure: closed coronary artery transfer.Oper Tech Thorac Cardiovasc Surg. 2009; 14: 309-316Abstract Full Text Full Text PDF Scopus (10) Google Scholar]. The closed technique had been initially described by Jatene in 1982 [6Jatene A.D. Fontes V.F. Souza L.C. Paulista P.P. Abdulmassih Neto C. Sousa J.E. Anatomic correction of transposition of the great arteries.J Thorac Cardiovasc Surg. 1982; 83: 20-26PubMed Google Scholar], and subsequently by Al Pacifico in 6 patients with transposition with VSD [23Pacifico A.D. Stewart R.W. Bargeron Jr., L.M. Repair of transposition of the great arteries with ventricular septal defect by an arterial switch operation.Circulation. 1983; 68: 1149-1155Crossref PubMed Scopus (85) Google Scholar]. Bove popularized the closed coronary transfer technique, teaching it to 30 years of trainees at the University of Michigan, myself included. The success of the arterial switch opened a unique and short-lived period when both atrial and arterial repairs were in use for patients with transposition. The early results for the arterial switch were variable, with operative mortality commonly approximating 20% [24Castaneda A.R. Trusler G.A. Paul M.H. Blackstone E.H. Kirklin J.W. The early results of treatment of simple transposition in the current era.J Thorac Cardiovasc Surg. 1988; 95: 14-28PubMed Google Scholar]. Given the low operative risk of atrial repair, there was skepticism that arterial repair was the right approach, and the merits of atrial vs arterial repair were a subject of heated debate. Should surgeons, centers, and patients accept the newer approach, with a higher operative risk, but the potential for better long-term outcome? Unlike the situation for Norwood’s operation for hypoplastic left heart syndrome, there was another good alternative to the arterial switch. Some of the debate fueled the earliest meetings of the Congenital Heart Surgeons Society (CHSS), leading John Kirklin to initiate the seminal CHSS study of transposition [24Castaneda A.R. Trusler G.A. Paul M.H. Blackstone E.H. Kirklin J.W. The early results of treatment of simple transposition in the current era.J Thorac Cardiovasc Surg. 1988; 95: 14-28PubMed Google Scholar]. This prospective study enrolled patients from 20 institutions over a period of 18 months early in the arterial switch era (January 1985 to June 1986). The study included 187 neonates with simple transposition (intact or nearly intact ventricular septum) who were managed by an atrial or arterial switch protocol. Unlike typical surgical series, the CHSS study enrolled patients from the time of the initial hospital admission. This meant that deaths that occurred even before operation were accounted for. Although the operative mortality for atrial repair was low, 5% of patients died before undergoing a planned atrial switch later in infancy. Overall mortality for the arterial switch patients was 20%. However, when the deaths before repair in the atrial switch group were included, the difference in risk between an atrial and an arterial switch protocol was not significant. The study also highlighted two other characteristics of the arterial switch operation at the time. Results for atrial repair were fairly uniform across centers. In contrast, among the 11 institutions performing arterial switches, four were higher risk, with a mortality of 67% compared with 12% among the other 7 institutions. There was also a steep learning curve for the arterial switch: among the 7 lower-risk institutions, operative mortality declined over the time period of the study from 26% to 0% [24Castaneda A.R. Trusler G.A. Paul M.H. Blackstone E.H. Kirklin J.W. The early results of treatment of simple transposition in the current era.J Thorac Cardiovasc Surg. 1988; 95: 14-28PubMed Google Scholar]. The results of the CHSS study were pivotal in driving the transition from atrial to arterial repair. Despite occurring in the pre-Internet era, the shift was also driven by pressure from parents and families who had heard of the newer operation. From a surgeon’s perspective, atrial and arterial repair are fundamentally different operations. One is done inside the heart, with a premium on three-dimensional visualization. The other is done outside the heart, with a premium on fine suturing and precision. For surgeons already in practice, the transition meant relearning, and raised questions of the best approach to adopting a new operation. Some had difficulty with the transition; others made it quickly and smoothly. The transition brought into play a range of factors, including individual surgical expertise and reputation, institutional capabilities with neonatal cardiac operations, and the relative importance of short-term vs long-term outcomes for patients and their families. When asked to what they attributed the success with the neonatal arterial switch in Boston, Drs Castaneda, Norwood, and Jonas all recognized the team and environment at the institution. It was critical that the surgeons, cardiologists, anesthesiologists, and others concur with what was being done, work well together, and be supportive of each other. The collegial atmosphere was fostered by Castaneda and his relationships with the cardiologists, in particular Alexander Nadas. In Castaneda’s words,We hit it off immediately and during the subsequent ten years did not have a single incident or important disagreement. . . Alex proved at times more aggressive than we surgeons—for example, he repeatedly urged us to begin a program of anatomical correction of transpositions of the great arteries soon after birth [25Faculty of Medicine-Memorial Minute: Alexander Sandor Nadas. Harvard University Gazette, February 21, 2002.Google Scholar]. This collaborative team model was similar to that adopted by Bove and Rosenthal in Ann Arbor and forms the core of every successful congenital heart program. Within this environment, Castaneda and Norwood’s iconoclastic approach to challenging dogma and pushing boundaries was highly productive. Their technical abilities were necessary, as were the confidence and courage to follow through on reasoned convictions. The neonatal arterial switch operation transformed the treatment of babies born with transposition. Its development led to a complete transition from an accepted and highly successful alternative. Its adoption, along with Norwood’s first-stage palliation for hypoplastic left heart syndrome, drove the spread of open heart operations in neonates. The arterial switch has certainly proven to be generalizable. More than a generation of congenital heart trainees has learned it as the only approach to a neonate with transposition. The Society of Thoracic Surgeons Congenital Database currently lists 614 arterial switches per year, with an average mortality of 2.2% for intact septum and 4.4% for transposition plus VSD (STS Congenital Heart Surgery Database. 22nd Harvest, January 2011-December 2014. Table 27). The arterial switch is a beautiful operation, both anatomically and physiologically. Dr Castaneda’s words from his American Association for Thoracic Surgery Presidential Address apply well: “Like a work of art, to achieve perfection, an operation must transcend technique and become an intellectual and aesthetic endeavor” [26Castaneda A.R. 1994 AATS presidential address: the making of a cardiothoracic surgeon: an Apollonian quest.J Thorac Cardiovasc Surg. 1994; 108: 806-812Abstract Full Text PDF PubMed Scopus (14) Google Scholar]. The author wishes to thank Drs Aldo Castaneda, Bill Norwood, Richard Jonas, Ed Bove, and Bob Sade, who were generous with their time in sharing their perspectives on the topic of this commentary.