Surgical repair of transposition of the great arteries (TGA) is a complex procedure, requiring extensive experience with the anomaly. View brief excerpts from the arterial switch operation as performed at The Children’s Hospital of Philadelphia.
Surgical Repair - Transposition of the Great Arteries
Peter Gruber: My name is Peter Gruber. I'm an attending cardiothoracic surgeon at The Children's Hospital of Philadelphia. This is an image of a heart, which has been exposed through a median sternotomy. The patient's feet are to your right. The patient's head is to your left, and the patient's right side is to the floor. The forceps are retracting the aorta to the patient's right, identifying the left coronary artery. And here are the patient's right coronary artery.
We're looking where on the pulmonary artery we should implant the vessels. Here a cross-clamp has been applied, and we're dividing the aorta. The aorta has now been completely divided, and we're dividing the pulmonary artery. The pulmonary artery has now been completely divided.
After the aorta and pulmonary arteries have been divided, we perform what is called the Lecompte maneuver, which is placing the pulmonary arteries anterior to the aorta. This allows the aorta to be connected to the more posterior now pulmonary artery. The cross-clamp is now applied proximal to the pulmonary arteries. We are now looking down the native aortic root, and the right coronary artery is being excised. Care is taken not to damage the aortic leaflets or the course of the coronary artery as it inserts in the heart.
After removal of the right coronary artery, this is reimplanted into the neoaorta by excising a small portion of the neoaorta. It's then carefully sewn into place. Note above the suture line the aorta where the right coronary artery was previously excised.
After completion of the right coronary anastomosis, attention is turned to the left coronary artery, which is now excised from the aorta in a similar fashion to the right. We take care not to damage the aortic leaflets or the course of the left coronary artery on the surface of the heart. After the left coronary button is removed from the aortic root, electrocautery is used to raise it from the surface of the heart. This provides some additional mobility. The left coronary artery is now anastomosed to the neoaorta in a fashion identical to the right coronary artery. Then the neoaorta is anastomosed in end-to-end fashion to complete the aortic connection.
After completion of the aortic anastomosis, we turn to the pulmonary root, which is reconstructed using a piece of the homograft. This homograft is sewn into place to reconstruct the sinuses where the coronary buttons were removed. First on the left, as demonstrated here, and later on the right. After the sinus reconstruction, the homograft is trimmed to the appropriate length and the neopulmonary anastomosis is completed. Here we're sewing the homograft to the new pulmonary artery, which is anterior to the aorta. Next, the final part of the neopulmonary anastomosis is completed. The aortic cross-clamp is removed and the heart begins to beat. The right and left coronary arteries are checked for evidence of bleeding and distortion. Patients are generally returned to the intensive care unit with their chests closed and extubated in the first 24 hours.
Topics Covered: Transposition of the Great Arteries
Related Centers and Programs: Cardiac Center