Double Switch Operation (Senning and Rastelli)

Awais Ashfaq

doi:doi:10.25373/ctsnet.11501007

Monday, January 6, 2020

By

Awais Ashfaq

Alan ODonnell

James Tweddell

Ashfaq A, ODonnell A, Tweddell J. Double Switch Operation (Senning and Rastelli). January 2020. doi:10.25373/ctsnet.11501007.

The patient was a 23-month-old, 8.6 kg girl with complex congenital heart disease consisting of dextro-mesocardic position, double outlet right ventricle, subaortic ventricular septal defect, pulmonary atresia, atrioventricular discordance, and left atrial isomerism. In addition, she had left superior vena cava connecting to right innominate vein, a midline inferior vena cava, and right aortic arch with mirror image branching.

The patient was palliated in the neonatal period with a 4 mm left modified Blalock-Taussig shunt and PDA ligation and division on DOL four via a left thoracotomy. Indication for surgery at that point was ductal dependent pulmonary blood flow in the setting of pulmonary atresia. The patient had a right aortic arch with PDA inserting into the proximal right pulmonary artery, thus BT shunt was placed on the left.

Subsequent cath at four months of age showed discontinuous pulmonary arteries, and the patient underwent right modified BT shunt via right thoracotomy. It was found at this time that her proximal right pulmonary artery had been inadvertently ligated (instead of her ductus) during her first operation. Thus, her ductus supplied her right pulmonary artery with flow and allowed it to grow. The patient’s left and right pulmonary artery became discontinuous when her ductus spontaneously closed.

The patient was determined to be a poor candidate for a biventricular repair at OSH. She was transferred to Cincinnati Children’s Hospital Medical Center for a second opinion. After reviewing her hemodynamics, she was considered to be a candidate for biventricular repair consisting of double switch that involved Senning and Rastelli (right ventricular outflow reconstruction with 18 mm pulmonary homograft), VSD enlargement, unifocalization, and patch arterioplasty of bilateral branch pulmonary arteries.

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Comments

Submitted by Sandeep Sainathan on Tue, 2020-01-07 13:21

Great video and excellent presentation! However, not sure if this is technically a double-switch though.

Submitted by Alan ODonnell on Thu, 2020-01-16 08:29

Thank you very much. It was an excellent operation. The double switch was originally described as restoration of atrioventricular and ventriculoarterial concordance in congenitally corrected transposition of the great arteries. Restoration of atrioventricular concordance is accomplished by atrial level switch (Senning or Mustard procedures). Restoration of ventriculoarterial concordance is accomplished by VSD closure (or baffle, as in this case) and either an arterial switch operation or Rastelli (in the setting of severe pulmonary stenosis or atresia, as seen in this case).

Submitted by James Tweddell on Fri, 2020-01-17 14:40

Fair enough Sandeep. Perhaps we should have titled it: Anatomic Correction. But Senning Rastelli is also in the title.

Submitted by Sameh Said on Sun, 2020-01-26 21:02

Great Video and Congratulations on this BiV repair in such a challenging case. I have a couple of questions about the Senning portion of the procedure: 1. I noticed that you created the floor of the systemic venous baffle as in the original Senning description of the procedure. Does this mean, you tend not to resect the interatrial septum completely and the area of the limbus fossa ovalis in these cases? Any chance of potential future obstruction? 2. What do you think of the coronary sinus cut back as a way of enlarging the IVC entrance into the systemic venous baffle? Again, thank you for sharing this great video.

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