How I Do It—Arterial Switch Operation

As most know, Dr. James Tweddell lost his battle with cancer on July 1, 2022. This has been—without equivocation—a colossal loss for the congenital heart surgery community. In an ongoing effort to properly preserve a few of his innumerable contributions to the field, this video (one of several in a series) demonstrates his surgical techniques for several operations. It shares his wisdom and skill in perpetuity, considering there is still much to be learned from the late and great Dr. Tweddell.

Specifically, this video aims to provide a detailed demonstration of how Dr. Tweddell performed an arterial switch operation in a neonate with simple transposition.

The patient was a six-day-old 3.12 kg male with an antenatal diagnosis of simple transposition, small secundum atrial septal defect, and persistent left superior vena cava draining to the coronary sinus. The patient was born at an external hospital and transferred to Cincinnati Children’s Hospital Medical Center on DOL0. The newborn was stable on PGE 0.1 mcg/kg/min and 2 L nasal cannula. Furthermore, the he became progressively desaturated, requiring intubation and subsequent balloon atrial septostomy. The newborn’s imaging was reviewed and discussed at case management conference. The consensus was to proceed with definitive surgical repair.

A standard median sternotomy and subtotal thymectomy was performed. The pericardium was opened in the midline and suspended. The aorta, main pulmonary artery, ductus arteriosus, right superior vena cava, left superior vena cava, and inferior vena cava were all circumferentially dissected. The branch pulmonary arteries were mobilized to their first order of division. Then the external origins of the coronary arteries were inspected. The coronary reimplantation sites on the pulmonary root were marked with a simple 7-0 Prolene suture prior to cardiopulmonary bypass.

Full dose heparin was administered. The patient was cannulated aortobicavally, and cardiopulmonary bypass was initiated. An antegrade cardioplegia line was then placed. Next, a cross-clamp was applied and antegrade cold cardioplegia was delivered. The left ventricle was vented via the right upper pulmonary vein. Caval snares were then lowered, and a right atriotomy was performed. An additional vent was placed in the coronary sinus for return from the left superior vena cava. Snares were placed at or near first branches off the right and left pulmonary arteries.

The atrial septal defect was primarily closed with continuous 6-0 Prolene sutures. The aorta was opened approximately 2–3 mm cephalad to the sinotubular junction. Both coronary artery ostia were identified prior to completion of transection. Then the sutures were placed to mark the aortic valve commissure locations and provide traction for coronary artery button excision.

The coronary artery ostia was identified, and proximal courses were probed. The coronary arteries were typical for transposition. Sinus one gave rise to the left main coronary, circumflex, and anterior interventricular arteries. Sinus two gave rise to the right coronary artery and sinus node artery. The coronary artery ostia were then excised with a generous button of sinus aorta. The proximal coronary arteries were mobilized with needle-tip electrocautery.

The ductus arteriosus, aortic arch, and descending thoracic aorta were mobilized. The ductus arteriosus was doubly ligated in continuity and divided. An additional ligature was left on the branch pulmonary arteries. The branch pulmonary arteries were again mobilized beyond the first branches. This helps reduce stretch stress on the branches following the LeCompte maneuver.

The main pulmonary artery was divided at the branch pulmonary artery bifurcation. The pulmonic (neo-aortic) valve was then inspected. The valve was found to be trileaflet with thin mobile leaflets, suitable for use in the aortic position. Next, medially based trapdoor incisions were made on adjacent sinus of Valsalva on the pulmonary (neo-aortic) root. The coronary artery buttons were reimplanted into the neo-aortic root with continuous 8-0 Prolene sutures, slightly cephalad to their original position.

The LeCompte maneuver was performed, bringing the branch pulmonary arteries anterior to the neo-aortic root. Next, the neo-aortic root was anastomosed to the ascending aorta with continuous 7-0 Prolene sutures. The antegrade cardioplegia cannula was then placed in the neo-aorta. This helps re-dose cardioplegia and aids in the identification of suture line leaks.

The neo-pulmonary root was reconstructed with a single pantaloon patch of thin pulmonary homograft secured with continuous 7-0 Prolene sutures. The branch pulmonary artery confluence—now anterior to neo-aorta—was anastomosed to the neo-pulmonary root with continuous 7-0 Prolene sutures. Finally, the atriotomy was closed with a dual layer of continuous 6-0 Prolene sutures.

The heart was de-aired via the aortic root vent. The aortic cross-clamp was then removed. The transesophageal echocardiogram demonstrated normal biventricular function, no left or right ventricular outflow tract obstruction, and laminar flow through the proximal coronary arteries.

The patient was successfully weaned and separated from cardiopulmonary bypass. The newborn’s chest was closed, and the patient was transferred to the cardiac intensive care unit. Lastly, the patient had an uneventful postoperative course and was discharged home on postoperative day 6.

References

1. https://www.optechtcs.com/article/S1522-2942(07)70036-3/fulltext

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