Arterial switchesTAPVCNorwood operation
The Jatene procedure, or arterial switch, is an open heart surgical procedure used to correct dextro-transposition of the great arteries (d-TGA).D-Transposition of the great vessels is a congenital cardiac anomaly in which the aorta arises from the right ventricle, and the pulmonary artery arises from the left ventricle. Desaturated venous blood returning from the peripheral tissue is pumped back to the systemic circulation while oxygen rich pulmonary venous blood is pumped back to the pulmonary artery. Patients present with cyanosis. Patients with transposition of the great vessels must have a communication between the systemic circulation and the pulmonary circulation to be consistent with life. Ideally, these patients will have a patent ductus arteriosus and an atrial septal defect. These work together to allow blood to shunt from the left atrium to the right atrium allowing oxygenated blood to enter the systemic circulation.
arterialswitchfinal
The arterial switch procedure requires cardiopulmonary bypass and aortic cross clamping. Following aortic cross clamping, the ascending aorta and main pulmonary artery are transected. The left and right coronary artery ostia are visualized and excised from the aortic root with adjacent aortic wall as “buttons”. The coronary artery buttons are then shifted posteriorly and implanted into the facing sinuses of the main pulmonary artery root. Next, the distal pulmonary artery and its branches are brought forward (LeCompte maneuver), and the distal aorta is moved posteriorly. The distal aorta is now anastomosed to the “new” aortic root. Reconstruction of the pulmonary artery is undertaken next, utilizing a patch of cryopreserved pulmonary artery homograft. Closure of the atrial septal defect completes the arterial switch repair. Transesophageal echocardiography is utilized to help assess adequacy of repair. Delayed sternal closure is sometimes required following surgery.

A defect in the veins leading from the lungs to the heart.

In TAPVC, the blood does not take the normal route from the lungs to the heart and out to the body. Instead, the veins from the lungs attach to the heart in abnormal positions and this problem means that oxygenated blood enters or leaks into the wrong chamber.In the right atrium, oxygen-rich (red) blood from the pulmonary veins mixes with low-oxygen (bluish) blood from the body. Part of this mixture passes through the atrial septum (atrial septal defect) into the left atrium. From there it goes into the left ventricle, then into the aorta and out to the body. The rest of the blood flows through the right ventricle, into the pulmonary artery and on to the lungs. The blood passing through the aorta to the body doesn’t have a normal amount of oxygen, which causes the child to look blue.
Normal heart
Symptoms may develop soon after birth. In other children, symptoms may be delayed. This partly depends on whether the lung veins are blocked as they drain toward the right atrium. Severe obstruction of the pulmonary veins tends to make infants breathe harder and look bluer (have lower oxygen levels) than infants with little obstruction. When surgical repair is done in early infancy, the long-term outlook is very good. However, your child will need regular follow-up with a pediatric cardiologist and, once your child reaches adulthood, lifelong regular follow-up with a cardiologist who’s had special training in congenital heart defects. Follow-up is needed to make certain that any remaining problems, such as an obstruction in the pulmonary veins or irregularities in heart rhythm, are treated. Some children may need medicines, heart catheterization or even more surgery.

Treatment for hypoplastic left heart syndrome requires either a three-step surgical procedure called staged palliation or a heart transplant. The first step is the Norwood operation.This procedure is performed shortly after birth. It converts the right ventricle into the main ventricle pumping blood to both the lungs and the body. The main pulmonary artery and the aorta are connected and the main pulmonary artery is cut off from the two branching pulmonary arteries that direct blood to each side of the lungs. Instead, a connection called a shunt is placed between the pulmonary arteries and the aorta to supply blood to the lungs.

Normal heart

The Norwood operation is the most complex and highest risk procedure in the sequence of staged reconstruction for hypoplastic left heart syndrome. Current management at major pediatric heart centers has resulted in survival rates of 75 percent or better. The recovery period in the hospital following the Norwood operation is often unpredictable and complicated, averaging about three to four weeks. A small percentage of patients who leave the hospital may continue to experience significant problems in the first months of life.

Occasionally, the right ventricle does not function well following the Norwood operation, and in some case, cardiac transplantation may need to be considered.
If a child with hypoplastic left heart syndrome reaches the time for the second stage (about 4 to 6 months of age) without major complications, the survival through the Glenn and Fontan operations are much better, exceeding 90 percent with current methods.

Almost all children with hypoplastic left heart syndrome will continue to need some cardiac medications to maximize the efficient function of their heart, and all will require regular periodic follow-up visits with their cardiologist to evaluate their cardiac function and detect late complications such as arrhythmias.

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about Dr sajan koshy
Pediatric Cardiac Surgeon



Dr Sajan Koshy MS MCh is currently heading the unit of Paediatric & Congenital heart surgery at Aster Medicity. Prior to joining Aster, he was working as senior consultant and head of the department of paediatric cardiac surgery at MIMS Calicut. He started his professional career from alleppey medical college in 1988. He also functioned as a co- convener in first and second symposia on perioperative care of congenital heart disease held in Kochi in the year 2002 and 2004 respectively & as the scientific committee chairman for the national CME of cardio thoracic surgery held at Calicut in September 2007. He has Conducted many lectures in all the districts of North Kerala for the benefit of medical professional bodies to create awareness about congenital heart disease.

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