Discussion
In the case of d-TGA, Mustard procedure was performed before Jatene procedure 2, providing with progressive failure of the sRV resulting late after surgery. Implantable ventricular assist device (VAD) therapy has been reported in the latter scenario, however, with mixed results of VAD in sRV, which may suggest to favor HTX as the first choice in this particular patient cohort 5.
Beyond pre-operative stabilization and postoperative management, intraoperative technical issues represent important components for successful treatment of d-TGA patients with failing systemic ventricle. Anatomical abnormalities represent a considerable challenge, particularly after previous operations. A thorough diagnostic workup utilizing modern imaging modalities for precise localization of native structures (e.g., course and ostia of PVs) and reconstructive implant material (e.g., atrial baffle) should be obtained to improve the quality of preoperative decision finding regarding operative strategy. Although not experienced in this case, further reconstruction steps may be necessary for complex anatomic scenarios to enable HTX, e.g., using a baffle or vascular grafts 3.
The point devised in the surgery of this case was the creation of the left atrial anastomosis. Since the adhesion between the right atrium and PV was severe, ascending aorta was clamped, the right atrium was incised to confirm the left atrium and PV from the atrium and pericardium, and the heart can be removed safely without injury. In this case, IVC and SVC were located on the right side, no special reconstruction was required, and reconstruction with the normal bicaval method was possible.