Today was surgery day: the baby with TGA s/p BAS was scheduled to have an arterial switch operation. There was a lot of talk about when to have the surgery with some rescheduling to assure that the baby had the operation sooner than later. This was important because a recent study showed that older age at operation was associated with increased morbidity and costs.
I was introduced to the anesthesiologist and waited for the procedure to start. The anesthesiologist was preparing all the induction and maintenance medications. The bypass techs were tinking at their machine to ensure that everything was in order. As I was waiting for the operation to start, I was told that the head surgeon was the one who had made the atrial switch operation safe, resulting in low mortality and good outcomes.
I observed over the blue drapes, as they cut open the chest, through the sternum, and visualized the beating heart. The patient was put on bypass and waited for the patient to cool down to 36 °C. Then, the arteries (aorta and pulmonary artery) were cut, cardiac vessels were identified, and restitched to reflect the physiological circulation. The iatrogenic ASD from the BAS was patched during the procedure as well. It was quite amazing to see such an intricate procedure that not only saved this baby but allowed him to have a normal life.
Flash Article Review:
Anderson BR, Ciarleglio AJ, Hayes DA, Quaegebeur JM, Vincent JA, Bacha EA. Earlier arterial switch operation improves outcomes and reduces costs for neonates with transposition of the great arteries. J Am Coll Cardiol. 2014; 63(5):481-7.
Population: 140 infants, >= 36 weeks gestation, with d-TGA, with or without VSD, admitted to institution at DOL 5 or younger
Intervention: Arterial Switch Operation (ASO)
Comparison: Age at operation
Outcome: Primary – Major morbidity (cardiac arrest, ECMO, delayed sternal closure, systemic infection, NEC, seizure, stroke on MRI with clinical sequelae, diaphragmatic paralysis, reapportion before discharge, or readmission at <= 30 days) and costs (total inpatient hospital reimbursement). Secondary – Length of stay
Bottom line: Infants with TGA will be treated with prostaglandin and BAS immediately after birth but ASO is the treatment of choice for infants with d-TGA. Prostaglandin and BAS buys time and the timing of the operation has largely been based on the physician’s judgment. This retrospective cohort study used multivariable regressions to show that older age at operation is associated with increased morbidity and costs.