Pediatric Cardiology

, Volume 25, Issue 4, pp 329–335 | Cite as

Risk Factors for Neo-Aortic Root Enlargement and Aortic Regurgitation Following Arterial Switch Operation

  • C. J. McMahonEmail author
  • W. J. Ravekes
  • E. O’Brian Smith
  • S. W. Denfield
  • R. H. Pignatelli
  • C. A. Altman
  • N. A. Ayres


The objectives of this study were to evaluate changes in dimension of the neo-aortic annulus, aortic root, and aortic anastomosis following arterial switch operation (ASO) and to identify risk factors for developing abnormal neo-aortic root enlargement and aortic regurgitation (AR). Prior studies report development of neo-aortic root dilatation and AR in a small subset of patients after ASO. Predisposing factors for neo-aortic root dilatation and development of moderate/severe AR are poorly understood. We performed a retrospective review of all patients with d-transposition of the great arteries (d-TGA) or double-outlet right ventricle with subpulmonary ventricular septal defect (VSD) who underwent ASO from May 1986 to January 2001. Serial echocardiograms were reviewed to measure neo-aortic annulus, root, and anastomosis diameter (z scores) and to determine progression of AR. Potential risk factors were assessed for developing neo-aortic root enlargement and AR. There were 119 patients (44 female and 75 male): 73 patients had simple d-TGA, 36 had d-TGA with ventricular septal defect, and 10 had a Taussig–Bing heart. The median duration of follow-up was 65 months (range, 12–180). The median neo-aortic root (z = 0.55 ± 2.2; p < 0.01) and aortic annulus dimensions (z = 1.57 ± 1.75; p < 0.01) were significantly increased over the study period. Aortic anastomosis diameter correlated with growth of the ascending aorta (z = 0.55 ± 1.24). Development of severe neo-aortic root enlargement was associated with prior pulmonary artery (PA) banding (p < 0.01), the presence of a VSD (p = 0.03), and Taussig–Bing anatomy (p < 0.01) but was independent of coronary arterial anatomy, coronary arterial transfer technique, or associated lesions (p > 0.05). At latest follow-up, there was no or trivial AR in 88 patients, mild AR in 29 patients, and moderate to severe AR in 3 patients. Risk factors for developing mild or worse AR included severe or rapid neo-aortic root dilatation (p < 0.01). Only 3 patients required surgical intervention for AR. Despite the significant prevalence of neo-aortic root enlargement at intermediate follow-up after ASO, there is a low incidence of significant AR. Prior PA banding, the presence of VSD, and Taussig–Bing anatomy are risk factors for severe root enlargement. Surgical intervention for AR was rare (2%), however, serial surveillance of such patients is vital to monitor for neo-aortic root enlargement and potential aortic valve dysfunction.


Arterial switch operation Transposition of the great arteries Aortic regurgitation Neo-aorta 



Dr. McMahon is supported by an Abercrombie research grant from the Department of Pediatric Cardiology, Texas Children’s Hospital.


  1. 1.
    Angouros, D, Sokolis, DP, Dosios, T,  et al. 2000Effect of impaired vasa vasorum flow on the structure and mechanics of the thoracic aorta: implications for the pathogenesis of aortic dissection.Eur J Cardiothoracic Surg17468473Google Scholar
  2. 2.
    Arensman, F, Sievers, H, Lange, P,  et al. 1985Assessment of coronary and aortic anastomoses after anatomic correction of transposition of the great arteries.J Thorac Cardiovasc Surg90597604PubMedGoogle Scholar
  3. 3.
    de Leval, MR 2001Lessons from the arterial switch operation.Lancet35718261830CrossRefPubMedGoogle Scholar
  4. 4.
    Formigari, R, Giardini, A, Bonvicini, M 2001Incidence and predictive factors of neoaortic regurgitation after arterial switch operation.J Am Coll Cardiol (suppl).471AGoogle Scholar
  5. 5.
    Gittenberger-de Groot, AC, Sauer, U, Oppenheimer Dekker, A 1983Coronary arterial anatomy in transposition of the great arteries: a morphological study.Pediatr Cardiol41524Google Scholar
  6. 6.
    Hourihan, M, Colan, SD, Wernovsky, G,  et al. 1993Growth of the aortic anastomosis, annulus, and root after the arterial switch procedure performed in infancy.Circulation88615620PubMedGoogle Scholar
  7. 7.
    Hutter, PA, Thomeer, BJ, Jansen, P,  et al. 2001Fate of the aortic root after arterial switch operation.Eur J Cardiothorac Surg208288CrossRefPubMedGoogle Scholar
  8. 8.
    Jatene, AD, Fontes, VF, Paulista, PP,  et al. 1975Successful anatomic correction of transposition of the great vessels. A preliminary report.Arq Bras Surg28609618Google Scholar
  9. 9.
    Jenkins, KJ, Hanley, FL, Colan, SD,  et al. 1991Function of the anatomic pulmonary valve in the systemic circulation.Circulation84173179Google Scholar
  10. 10.
    Lacour-Gayet, F, Piot, D, Zoghbi, J, Serraf, A,  et al. 2001Surgical management and indication of left ventricular retraining in arterial switch operation for transposition of the great arteries with intact ventricular septum.Eur J Cardiothorac Surg202429Google Scholar
  11. 11.
    Lecompte, Y, Neveux, JY, Leca, F,  et al. 1982Reconstruction of the pulmonary outflow tract without prosthetic conduit.J Thorac Cardiovasc Surg54727733Google Scholar
  12. 12.
    Losay, J, Touchat, A, Serraf, A,  et al. 2001Late outcome after arterial switch operation for transposition of the great arteries.Circulation70411381142Google Scholar
  13. 13.
    Massoudy, P, Baltalarli, A, de Leval, MR,  et al. 2002Anatomic variability in coronary arterial distribution with regard to the arterial switch operation.Circulation10619801984CrossRefPubMedGoogle Scholar
  14. 14.
    Planche, C, Bruniaux, J, Lacour-Gayet, F,  et al. 1998Switch operation for transposition of the great arteries in neonates. A study of 120 patients.J Thorac Cardiovasc Surg96354363Google Scholar
  15. 15.
    Pretre, R, Tamisier, D, Bonhoeffer, P,  et al. 2001Results of the arterial switch operation in neonates with transposed great arteries.Lancet35718261830CrossRefPubMedGoogle Scholar
  16. 16.
    Schmid, FX, Hilker, M, Kampmann, C, Mayer, E, Oelert, H 1998Clinical performance of the native pulmonary valve in the systemic circulation.J Heart Valve Dis7620625PubMedGoogle Scholar
  17. 17.
    Schmidtke, C, Bechtel, JF, Hueppe, M, Noetzold, A, Sievers, HH 2000Size and distensibility of the aortic root and aortic valve function after different techniques of the Ross procedure.J Thorac Cardiovasc Surg11990997Google Scholar
  18. 18.
    Schoof, PH, Gittenberger-de Groot, AC, de Heer, JA,  et al. 2000Remodelling of the porcine pulmonary autograft wall in the aortic position.J Thorac Cardiovasc Surg1205565CrossRefPubMedGoogle Scholar
  19. 19.
    Sidi, D, Planche, C, Kachaner, J,  et al. 1987Anatomic correction of simple transposition of the great arteries in 50 neonates.Circulation75429435PubMedGoogle Scholar
  20. 20.
    Sievers, H, Lange, P, Arensman, F,  et al. 1984Influence of two-stage anatomic correction on size and distensibility of the anatomic pulmonary functional aortic root in patients with simple transposition of the great arteries.Circulation70202208PubMedGoogle Scholar
  21. 21.
    Tantengco, MV, Humes, RA, Clapp, SK,  et al. 1999Aortic root dilation after the Ross procedure.Am J Cardial83915920CrossRefGoogle Scholar
  22. 22.
    Yacoub, MH, Radley-Smith, R 1978Anatomy of the coronary arteries in transposition of the great arteries and methods for their transfer in anatomical correction.Thorax33418424PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2004

Authors and Affiliations

  • C. J. McMahon
    • 1
    Email author
  • W. J. Ravekes
    • 2
  • E. O’Brian Smith
    • 3
  • S. W. Denfield
    • 1
  • R. H. Pignatelli
    • 1
  • C. A. Altman
    • 1
  • N. A. Ayres
    • 1
  1. 1.Lillie Frank Abercrombie Division of Pediatric CardiologyTexas Children’s Hospital and Baylor College of Medicine, 6621 Fannin, Houston, 77030, TXUSA
  2. 2.Department of Pediatric CardiologyJohns Hopkins University, 600 N Wolfe Street, Baltimore, MDUSA
  3. 3.Department of BiostatisticsChildren’s Nutrition and Research Center, Houston, TXUSA

Personalised recommendations