Fast-Track Arterial Switch Operation

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.

References

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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