Arterial switch operation (ASO), transposition of the great arteries (TGA)

Indication

Identification of the heart defect represents the indication for surgery. Balloon atrioseptostomy (Rashkind maneuver) is necessary preoperatively (also in patients with a VSD) if adequate mixing of the blood is not achieved via the open ductus. Usually this can be performed under echocardiographic monitoring.

TGA before surgery
TGA, VSD and PFO before surgery

Operation

cArterial switch operation (the heart-lung machine is used) consists of ductus transection, mobilization of the pulmonary arteries up to the hilum, clamping of the aorta and cardioplegia, transection of the great vessels and antepositioning (Lecompte maneuver) of the pulmonary artery, explantation and mobilization of the coronary arteries and re-implantation to the neo-aorta, re-anastomosis of the ascending aorta, closure of ASD, reconstruction of pulmonary artery with pericardium and re-anastomosis of the neo-pulmonary artery with the anteposed right and left pulmonary arteries. Additional correction, e.g. VSD closure or arch enlargement.

REV, Rastelli, Nikaidoh operation: high-grade pulmonary stenosis is a contraindication to the arterial switch operation. In the REV and Rastelli operation the PA is closed; in the Nikaidoh operation the aortic arch together with the mobilized coronary arteries is transposed into the former PA after resection of the conal septum in posterior direction. Thus the aorta comes to lie over the VSD. In REV and Rastelli the aorta remains further anterior so that, to create a nonrestrictive intraventricular tunnel, VSD enlargement is usually necessary. Ensuring RV-PA continuity requires a conduit in the Rastelli operation; with REV and the Nikaidoh operation a direct RV-PA anastomosis (following Lecompte maneuver) is performed.

TGA arterial switch 02
TGA arterial switch 03