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.