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Fast-Track Arterial Switch Operation

Friday, October 8, 2021

Said SM, Sainathan S. Fast-Track Arterial Switch Operation. October 2021. doi:10.25373/ctsnet.16776121

This is the case of a 3. 3 kg, male neonate who was born with a prenatal diagnosis of dextro-transposition of the great arteries (d-TGA) and an intact ventricular septum. At birth, he was deeply cyanotic and was intubated and prostaglandin infusion was initiated to maintain ductal patency. Transthoracic echocardiogram confirmed the prenatal diagnosis and normal coronary pattern for d-TGA (1 LCx, 2RCA). Due to restricted atrial communication, a bedside echo-guided balloon atrial septostomy was performed. He was subsequently extubated and weaned off prostaglandins.

On day of life 9, the patient was taken to the operating room for an arterial switch operation with Lecompte maneuver, ligation and division of the ductus arteriosus and closure of the atrial septal defect.

The procedure was performed via median sternotomy with aortic and single right atrial cannulation at 32 degrees celsius. A left atrial line was placed through the left atrial appendage. Intraoperative fluorescent angiography with indocyanine green confirmed excellent flow in all epicardial coronary arteries and good myocardial perfusion. The chest was closed and the patient was extubated in the operating room. The eft atrial line was removed 48 hours later with subsequent weaning of inotropic and pressor support. Chest tubes were removed on the third postoperative day. He experienced a short episode of supraventricular tachyarrhythmias that was controlled medically, otherwise the remaining part of his postoperative course was uneventful and he was transferred to the ward on the fifth postoperative day, and discharged eight days after his arterial switch.

Pre-discharge transthoracic echocardiogram showed good biventricular function, no atrial level shunt, widely patent both right and left ventricular outflow tracts, and competent neo-aortic and neo-pulmonary valves. The patient continued to do well during his follow-up.


  1. Jatene AD, Fontes VF, Paulista PP et al (1976) Anatomic correction of transposition of the great vessels. J Thorac Cardiovasc Surg 72:364–370
  2. Said SM, Marey G, Hiremath G. Intraoperative fluorescence with indocyanine green in congenital cardiac surgery: Potential applications of a novel technology. JTCVS Tech. 2021 Feb 25;8:144-155
  3. Fast-track postoperative care for neonatal cardiac surgery: a single-institute experience. Yamasaki Y, Shime N, Miyazaki T, Yamagishi M, Hashimoto S, Tanaka Y. J Anesth. 2011 Jun;25(3):321-9


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Well done and excellent demonstration. For the fast track strategy, I was encouraging my colleagues to send those straight forward d-TGA/IVS to ASO rather than doing BAS unless further work up is needed. The youngest I did was 8-hour-old, 3.4 kg. We tend to harvest the coronaries as circular button from old aorta and implant them as button unless coronary variation mandates otherwise. It maintains native to native circumferential pulmonary reconstruction since the coronary defect is small, circular and requires small patch. Good work.
Thank you for your kind comment. I think there are pros and cons for each approach. Taking a neonate with some degree of restrictive interatrial septum straight to the OR to do what it seems like a straight forward arterial switch, while carry the advantage of saving a cath procedure that may result in losing a groin access or carries a stroke risk, may result in a bit of a tricky post-bypass and postoperative course due to elevated PVR and may not save time in the big picture. On the other hand, allowing them to have a better mixing, complete all the work-up needed, ruling out other problems and may be even discontinuing the prostaglandins allow faster recovery postoperatively with better lung conditions. I do however belief in early arteriaI switch (3-5) days. I also get a Brain MRI on every baby went to the cath lab for BAS.I guess there is definite institutional and practice differences in these points. Regarding the coronary buttons, I have done this with larger kids, otherwise I try not to compromise the harvested button for any reason and avoid suturing close to the ostia. But to your point, I find it good to maintain the sinotubular junction of the aorta as well. Good points and thank you for your comments.

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