Jatene procedure 3978643 222167450 2008-06-27T21:56:01Z Lightbot 7178666 Units/dates/other The '''Jatene procedure''', or '''arterial switch''', is an [[open heart surgery|open heart]] [[surgical]] procedure used to correct [[dextro-transposition of the great arteries]] ('''d-TGA'''); its development was [[wiktionary:pioneer|pioneer]]ed by [[Canadian]] [[cardiology|cardiac]] surgeon [[William Mustard]] and it was named for [[Brazil]]ian cardiac surgeon [[Adib Jatene]], who was the first to use it successfully. It was the first method of d-TGA repair to be attempted, but the last to be put into regular use because of [[technology|technological]] limitations at the time of its [[concept]]ion. Use of the arterial switch is [[historical]]ly preceded by two [[atrial switch]] methods: the [[Senning procedure|Senning]] and [[Mustard procedure]]s. This surgery may be used in combination with other procedures for treatment of certain cases of [[double outlet right ventricle]] ('''DORV''') in which the [[great arteries]] are [[wiktionary:dextro|dextro]]-[[wiktionary:transpose|transpose]]d. ==Timing== The Jatene procedure is ideally performed during the second week of life, before the [[left ventricle]] adjusts to the lower [[pulmonary]] [[blood pressure|pressure]] and is therefore unable to support the [[systemic circulation]]. In the event of [[sepsis]] or delayed [[diagnosis]], a combination of [[pulmonary artery banding]] ('''PAB''') and [[shunt (medical)|shunt]] construction may be used to increase the left ventricular mass sufficiently to make an arterial switch possible later in [[infant|infancy]]. ==Prognosis== The success of this procedure is largely dependent on the facilities available, the skill and experience of the surgeon, and the general health of the [[patient]]. Under preferable conditions, the [[intra-operative]] and [[post-operative]] success rate is 96% or more, with a comparable survival rate after 5 years. Approximately 10% of arterial switch recipients develop residual pulmonary [[stenosis]] post-operatively, which can lead to [[right heart]] [[heart failure|failure]] if left untreated; treatment usually involves [[endovascular stent]]ing and/or [[xenograft]] patching. ==Method== ====Overview==== *[[General anaesthesia]] and [[cardiopulmonary bypass]] are used. *The [[aorta]] and [[pulmonary artery]] are detached from their [[wiktionary:native|native]] [[root]]s and reattached to the opposite root; thus, the pulmonary root becomes the [[neo-]]aorta, and the aortic root becomes the neo-pulmonary artery. *The [[coronary arteries]] are [[Organ transplant|transplant]]ed from the aorta/neo-pulmonary artery to the pulmonary artery/neo-aorta. *Length of procedure, from initiation of anaesthesia to post-operative cease thereof, is approximately 6-8 hours. ===Preparatory=== If the procedure is anticipated far enough in advance (with [[prenatal]] diagnosis, for example), and the individual's [[blood]] type is known, a family member with a compatible [[blood type]] may [[blood donation|donate]] some or all of the blood needed for [[blood transfusion|transfusion]] during the use of a [[heart-lung machine]] ('''HLM'''). The patient's [[mother]] is normally unable to donate blood for the transfusion, as she will not be able to donate blood during [[pregnancy]] (due to the needs of the [[fetus]]) or for a few weeks after giving [[birth]] (due to [[blood loss]]), and the process of collecting a sufficient amount of blood may take several weeks to a few months. However, in cases where the individual has been diagnosed but surgery must be delayed, maternal (or even [[blood donation#Autologous donation|autologous]], in certain cases) blood donation may be possible, as long as the mother has a compatible blood type. In most cases, though, the patient receives a donation from a [[blood bank]]. A blood transfusion is necessary for the arterial switch because the HLM needs its "circulation" filled with blood and an infant does not have enough blood on their own to do this (in most cases, an adult would not require blood transfusion). The patient will require a number of [[medical imaging|imaging]] procedures in order to determine the individual [[anatomy]] of the great arteries and, most importantly, the [[coronary circulation#Coronary anatomy|coronary arteries]]. These may include [[angiography]], [[magnetic resonance imaging]] ('''MRI'''), and/or [[computed tomography]] ('''CT scan'''). The coronary arteries are carefully mapped out in order to avoid unexpected intra-operative complications in transferring them from the native aorta to the neo-aorta. ===Pre-operative=== As with any procedure requiring general anaesthesia, arterial switch recipients will need to [[fasting#Medical fasting|fast]] for several hours prior to the surgery to avoid the risk of [[asphyxia|choking]] on [[vomit]] while unconscious. After the patient is anesthetized, they receive the following [[medication|drugs]] via [[intravenous drip]], which continue as necessary throughout the procedure: *[[Aprotinin]], to prevent excessive [[bleeding]] *[[Solumedrol]], to reduce [[edema|swelling]] and [[inflammation]] *[[Regitine]], to prevent [[hypertension]] *[[Prophylactic]] [[antibiotics]], to prevent [[infection]] ===Intra-operative=== The heart is accessed via [[median sternotomy]], and the patient is given [[heparin]] to prevent the blood from [[clot]]ting. A generous section of [[pericardium]] is [[harvest (medical)|harvested]], then [[disinfect]]ed and [[sterilization (microbiology)|sterilized]] with a weak solution of [[glutaraldehyde]]; and the coronary and great artery anatomy are examined. The [[ductus arteriosus]] and [[right pulmonary branch]], up to and including the first branches in the [[Hilum of lung|hilum]] of the right [[lung]], are separated from the surrounding supportive [[biological tissue|tissue]] to allow [[mobility]] of the [[blood vessel|vessels]]. [[Silk]] marking [[suture]]s may be placed in the pulmonary trunk at this time, to indicate the [[wiktionary:commissure|commissure]] of the aorta to the [[neo-]]aorta; alternatively, this may be done later in the procedure. The cardiopulmonary bypass is then initiated by inserting a [[cannula]] into the [[ascending aorta]] as [[anatomical terms of location#Relative directions|distally]] from the aortic root as possible while still supplying all [[artery|arterial]] branches, another cannula is inserted into the [[right atrium]], and a vent is created for the [[left ventricle]] via [[catheterization]] of the [[right superior pulmonary vein]]. The HLM is started at a low-[[circulatory system|flow]] and the patient's [[body]] is [[hypothermia#Medically induced|cooled]] to a [[rectal]] [[temperature]] of 20 [[degree (temperature)|°]][[celsius|C]] (68 °[[fahrenheit|F]]), which prevents the [[brain damage]] otherwise associated with the temporary [[cardiac arrest|circulatory arrest]] necessary during the procedure; the patient must be cooled for a minimum of 20 minutes prior to beginning the repair. While the patient is cooling, the ductus arteriosus is [[ligature (medicine)|ligated]] at both the aortic and pulmonary [[wiktionary:ostium|ostia]], then [[wiktionary:transect|transect]]ed at its center; the [[left pulmonary branch]], including the first branches in the hilum of the left lung, is separated from the supportive tissue; and the aorta is marked at the site it will be transected, which is just below the [[pulmonary bifurcation]], proximal to where the pulmonary artery will be transected. When the patient is fully cooled, the ascending aorta is clamped as close as possible below the HLM cannula, and [[cryocardioplegia]] is achieved by delivering cold blood to the heart via the ascending aorta (below the [[cross clamp]]). The aorta is then transected at the marked spot, and the pulmonary artery is transected a few millimetres below the bifurcation. The vessels are again examined, and the pulmonary root is inspected for [[left ventricular outflow tract obstruction]] ('''LVOTO'''). If a [[ventricular septal defect]] ('''VSD''') is present, it may be repaired, at this point via either the [[aortic valve|aortic]] or [[pulmonary valve]]; it may alternatively be repaired later in the procedure. The great arteries are usually arranged using the [[Lecompte maneuver]], with the aortic cross clamp positioned to hold the pulmonary artery [[anatomical position#Coronal plane|anterior]] to the ascending aorta; though with some congenital arrangements of the great arteries, such as side-by-side, this is not possible and the arteries will be transplanted in the non-anatomic 'anterior aorta' arrangement. If the aortic commissure has not yet been marked, it may be done at this point, using the same method as would be used prior to bypass; however, there is a third opportunity for this still later in the procedure. Coronary arteries are examined closely, and the ostia and proximal arterial course are identified, as are any [[infundibulum#Heart|infundibular]] branches, if they exist. The coronary ostia and a large "button" of surrounding aortic wall are then [[wiktionary:excise|excise]]d from the aorta, well into the [[sinus of Valsalva]]; and the proximal sections of the coronary arteries are separated from the surface of the heart, which prevents [[tension (mechanics)|tension]] or [[distortion]] after [[anastomosis]] to the neo-aorta. Infundibular branches are sometimes unable to be spared, but this is a very rare occurrence. If the aortic commissure has not previously been marked, the excised coronary arteries will be used to determine the [[implant]]ation position of the aorta. The aorta is then transplanted onto the pulmonary root, using either [[absorbable suture|absorbable]] or [[permanent suture|permanent]] continuous suture. The aortic clamp is temporarily removed while small sections of the neo-aorta are cut away to accommodate the coronary ostia, and a continuous absorbable suture is then used to anastomose each coronary "button" into the prepared space. In most cases, the coronary implantation sites will be at left and right anterior positions at the base of the neo-aorta; however, if the [[circumflex coronary artery]] branches from the [[right coronary artery]], the circumflex coronary artery will be distorted if the pair are not implanted higher than normal on the neo-aorta, and in some cases they may need to be implanted above the aortic commissure, on the native aorta itself. The circumflex coronary artery may originate from the same coronary sinus as, rather than directly from, the right coronary artery, in which case they may still be excised on the same "button" and transplanted similarly to if they had a shared ostium, unless one or both have [[wiktionary:intramural|intramural]] communication with another coronary vessel. Sometimes, one or more coronary ostia are located very close to the [[heart valve|valvular]] opening and a small portion of the native aortic valve must be removed when the coronary artery is excised, which causes a generally mild, and usually well-[[physiological tolerance|tolerated]], neo-pulmonary [[Aortic insufficiency|valve regurgitation]]. The HLM is turned off and the aortic and atrial cannula are removed, then an [[incision]] is made in the right atrium, through which the [[congenital]] or [[palliative]] [[atrial septal defect]] ('''ASD''') is repaired; where a [[Rashkind balloon atrial septostomy]] was used, the ASD should be able to be closed with sutures, but cases involving large congenital ASDs or [[Blalock-Hanlon atrial septectomy]], a pericardial, [[xenograft]], or [[Dacron]] patch may be necessary. If there is a VSD which has not yet been repaired, this is performed via the atrial incision and [[tricuspid valve]], using sutures for a small defect or a patch for a large defect. When the septal defects have been repaired and the atrial incision is closed, the previously removed cannula are replaced and the HLM is restarted. The left ventricle is then vented and the cross clamp removed from the aorta, enabling full-flow to be re-established and rewarming to begin; at this point the patient will receive an additional dose of Regatine to keep [[blood pressure]] under control. The previously harvested pericardium is then used to patch the coronary [[explant]]ation sites, and to extend - and widen, if necessary - the neo-pulmonary root, which allows the pulmonary artery to be anastamosed without [[wiktionary:residual|residual]] tension; the pulmonary artery is then transplanted to the neo-pulmonary root. ===Final stages=== The patient is fitted with [[chest tube]]s, temporary [[artificial pacemaker|pacemaker]] leads, and [[ventilator|ventilated]] before [[wean]]ing from the HLM is begun; and administration of post-operative drugs is initiated, these include: *[[muscle relaxant]], to induce temporary [[paralysis]] *[[opioid]] [[analgesic]], to manage pain, cause [[sedation]] and induce [[wiktionary:serenity|serenity]] *[[inotrope]], to assist the heart in [[muscle contraction|contracting]] adequately The [[rib cage]] is relaxed and the [[external]] surgical [[wound]] is bandaged, but the [[sternum]] and chest incision are left open to provide extra room in the [[pleural cavity]], allowing the heart room to swell and preventing pressure caused by [[pleural effusion]]. ===Post-operative=== The sternum and chest can usually be closed within a few days; however, the chest tubes, pacemaker, ventilator, and drugs may still be required after this time. The patient will continue to fast for up to a few days, and [[breastmilk]] or [[infant formula]] can then be gradually introduced via [[nasogastric tube]] ('''NG tube'''); the primary [[wiktionary:goal|goal]] after a successful arterial switch, and before [[hospital]] discharge, is for the [[infant]] to gain back the weight they have lost and continue to gain weight at a normal or near-normal rate. ==History== [[Scotland|Scottish]] [[pathologist]] [[Matthew Baillie]] first described '''[[Transposition of the great arteries|TGA]]''' in [[1797]], presumably as a [[wiktionary:posthumous|posthumous]] diagnosis. [[mortality rate|Early mortality rates]] at this time are estimated to have been as high as 90%; the survivors would have been those with one or more [[wiktionary:concomitant|concomitant]] [[wiktionary:intracardiac|intracardiac]] [[shunt (medical)|shunts]] (ASD, [[patent ductus arteriosus]] ('''PDA'''), [[patent foramen ovale]] ('''PFO'''), and/or VSD), and are unlikely to have survived past [[adolescence]]. In [[1950]], [[United States|American]] surgeons [[Alfred Blalock]] and [[C. Rollins Hanlon]] introduced the ''Blalock-Hanlon atrial septectomy'', which was then routinely used to palliate patients. This would have effectively reduced early mortality rates, particularly in cases with no concomitant shunts, but is unlikely to have reduced late mortality rates. Mustard first conceived of, and attempted, the anatomical repair (arterial switch) for d-TGA in the early [[1950s]]. His few attempts were unsuccessful due to technical difficulties posed by the [[wiktionary:translocate|translocation]] of the coronary arteries, and the idea was abandoned. [[Swedish people|Swedish]] cardiac surgeon [[Åke Senning]] described the first corrective surgery for d-TGA (the ''Senning procedure'') in [[1959]], which involved using the [[atrial septum]] to create an [[wiktionary:intratrial|intratrial]] [[baffle]] that redirected [[circulatory system|bloodflow]] at the [[atrium (anatomy)|atrial]] level; Senning yielded a high success rate using this procedure, significantly lowering both early and late mortality rates. Due to the technical complexity of the Senning procedure, others could not duplicate his success rate; in response, Mustard developed a simpler alternative method (the ''Mustard procedure'') in [[1964]], which involved constructing a baffle from [[autologous]] [[pericardium]] or [[Synthetic fiber|synthetic]] material, such as Dacron. This procedure yielded early and late mortality rates comparable to the Senning procedure; however, a [[morbidity rate|late morbidity rate]] was eventually discovered in relation to the use of synthetic graft material, which does not grow with the recipient and eventually causes [[wiktionary:obstruction|obstruction]]. In [[1966]], American surgeons [[William Rashkind]] and [[William Miller (physician)|William Miller]] transformed the palliation of d-TGA patients with the innovative ''Rashkind balloon atrial septostomy'', which, unlike the [[thoracotomy]] required by a septectomy, is performed through the non-invasive surgical technique of [[cardiac catheterization]]. Although the atrial switch procedures dramatically reduced both early and late mortality rates, these statistics remained high, partly due to the wait time required between [[birth]] and surgery ([[pre-operative]] mortality: 5-10%; early mortality: 0-15%; late mortality: 20-25%). A concomitant VSD raises the early mortality rate for atrial switch to 10-60%, even in cases where the VSD is repaired. The late morbidity rate is also very high in atrial switch recipients, with 13-100% developing post-operative complications related to intra-operative damage caused to the [[sinus node]] and/or the [[wiktionary:inherent|inherent]] unsuitability of the [[heart chamber]]s for role reversal. These statistics, combined with advances in [[microvascular]] surgery, created a renewed interest in Mustard's original concept of an arterial switch procedure. The first successful arterial switch was performed on a forty-two day old d-TGA + VSD infant by Jatene in [[1975]]. [[Egypt]]ian cardiac surgeon [[Magdi Yacoub]] was subsequently successful in treating TGA with [[intact septum]] when preceded by pulmonary artery banding and [[systemic-to-pulmonary shunt]] palliation. [[Austria]]n surgeon [[B. Eber]] was the first to recount a small series of successful arterial switch procedures, and the first large successful series was reported by [[Guatemala]]n surgeon [[Aldo R. Casteneda]]. By [[1985]], the arterial switch had become the procedure of choice, and remains the standard modern procedure for d-TGA repair. Atrial switches are still occasionally used as a standby when coronary artery patterns [[wiktionary:contraindicate|contraindicate]] coronary [[anastomoses]], in cases of delayed diagnosis where pulmonary artery banding is not possible, and when a d-TGA + VSD patient also has left ventricular outflow tract obstruction. The world's smallest infant to survive an [[arterial switch]] was Jerrick De Leon, born 13 weeks premature. At the time of the operation on [[February 6]], [[2005]], he weighed just over 1.5 pounds (700 grams).<ref>[http://cnnstudentnews.cnn.com/2005/HEALTH/02/17/preemie.surgery/ "''Pioneering surgery saves baby born 3 months early''"] - [[CNN.com]] article dated February 17, 2005</ref> ==References== {{Reflist}} ===External links=== *[http://www.ctsnet.org/doc/5518 The cardiothoracic surgery network (CTSNet): Transposition of Great Vessels] *[http://www.inova.org/inovapublic.srt/heart/pediatric_services/cardiac_surgery/arterial_switch.html Inova Heart and Vascular Institute: Arterial Switch for TGA] *[http://med-lib.ru/english/oxford/transp_arteries.shtml Med-Lib: Transposition of the great arteries] *[http://www.pediheart.org/practitioners/operations/ASO.html PediHeart: The Arterial Switch Operation] [[Category:Surgical procedures]]