Turina, Marko

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J. Ho¨rer et al. / European Journal of Cardio-thoracic Surgery 33 (2008) 1061—1068 1067treat analysis of pulmonary artery banding in conditions with a morpho-logical right ventricle in the systemic circulation with a view to anatomicbiventricular repair. Circulation 2005;111:405—11.[22] Boutin C, Jonas RA, Sanders SP, Wernovsky G, Mone SM, Colan SD. Rapidtwo-stage arterial switch operation. Acquisition of left ventricular massafter pulmonary artery banding in infants with transposition of the greatarteries. Circulation 1994;90:1304—9.[23] Hosseinpour AR, Cullen S, Tsang VT. Transplantation for adults withcongenital heart disease. Eur J Cardiothorac Surg 2006;30:508—14.[24] Horer J, Schreiber C, Dworak E, Cleuziou J, Prodan Z, Vogt M, Holper K,Lange R. Long-term results after the Rastelli repair for transposition ofthe great arteries. Ann Thorac Surg 2007;83:2169—75.[25] Kirjavainen M, Happonen JM, Louhimo I. Late results of Senning opera-tion. J Thorac Cardiovasc Surg 1999;117:488—95.Appendix A. Conference discussionDr J. Stark (London, United Kingdom): In the options for the rightventricular failure, you didn’t include transplantation in your original slide. Isit because you have not performed any transplantations, or in view of the lastslide, you would consider it as an option now?Editorial coDr Lange’s group [1] from the German Heart Centre inMunich has provided further evidence of the long-termreliability of Senning’s operation, and has demonstrated alow incidence of late complications, when the procedure wasperformed properly, respecting the anatomy of the systemicand pulmonary venous inflow. Their results complement ourpreviously published experience [2] with this operation, withsimilar extended outlook for atrial correction of the TGA.Furthermore, their analysis lends strong support to the notionof using patient’s own tissue in correction of cardiacanomalies, especially when performed early in life, becausethe natural growth of the tissue provides superb anatomicalresults into adulthood. The reported long-term survival isexcellent, although it must be mentioned that the paperanalyses only the survivors of the initial operation, i.e. thosewho went home after the total correction of TGA. Oneregrets the lack of some crucial information:1. There is no indication of the age at the initial totalcorrection of the patients with complications whencompared with those surviving without reoperation,especially those presenting later with the failure ofsystemic ventricle. Does the long-term exposure tosystemic hypoxia in patients submitted to total correctionat the higher age (beyond first year of life) represent a riskfactor for development of systemic ventricle failure? Doesthe very early operation (in the first weeks of life)predispose the patient to more baffle and inflowcomplications later in life?2. The authors do not provide information about the cardiacrhythm at the last follow-up. The incidence of atrialdysrhythmias, the stability of sinus rhythm, the incidenceof significant arrhythmias and of pacemaker implanta-Dr Ho¨rer: Yes, that is correct, there was no heart transplantation in thisSenning group. We did one cardiac transplantation in a group of 88 Mustardpatients, but in the Senning group there was no transplantation.Dr Stark: Until what age would you consider conversion to arterial switch?Dr Ho¨rer: This is a difficult question. I don’t think that it’s just a matter ofage. We consider the conversion under the age of 16, but all of our patientsnow are older than 16. The mean age of the Senning patients now is 20. That’swhy I concluded that this will probably no longer be an option for thosepatients.Dr Stark: Because it is also in the literature, certainly from Dr Mee, thatthe results over 16 are poor, so probably transplantation would be a betteroption.Dr Ho¨rer: Yes. It would be the same cut-off point as for patients withcongenitally corrected transposition who are scheduled for a double switchprocedure.Dr R. Pretre (Zurich, Switzerland): You also had some patients in yourcohort with LVOT obstruction who might have a trained left ventricle withoutany banding. Would you consider an anatomical correction then?Dr Ho¨rer: In principle, yes, they are ideal candidates if they have systemicpressure in the left ventricle and at the same time low pressure in thepulmonary artery.mmenttions in this large patient population with atrial correctionare important questions which arise in the late follow-upof this population. Our own data [3] show the necessity ofcareful rhythm monitoring, to detect those patients whomight profit from the pacemaker or defibrillator implan-tation. Such interventions might be considered asreoperations in wider sense.Several remarkable results deserve comment. Conversionto the arterial correction, colloquially known as Mee’sprocedure, does carry a substantial risk, and has caused themajority of early deaths encountered by the authors. Theattempts at the correction of systemic AV valve incompe-tence are also doomed to failure, because they do not attackthe underlying disease, i.e. failure of systemic ventricle. Onthe other hand, the authors provide further evidence for thesurprising efficiency of simple arterial banding after atrialcorrection of TGA, which seems to provide a good palliativerelief. It is a surprising finding in a group of patients thatelsewhere might be considered as good candidates for hearttransplantation, which was indeed performed in a smallproportion of our patients with failure of systemic ventricle,but with excellent long-term results.Good extended results obtained by the authors and byothers in long-term assessment of Senning’s correction lendsupport to two possible clinical indications for this operationin the 21st century: It seems that a careful exploration of thedouble-switch technique for the selected patients withcorrected transposition of the great arteries [4] can bewarranted. Furthermore, this operation is still an option inthe less-developed countries, where one might encounterolder patients with the complete transposition of the greatarteries and normal pulmonary artery pressure, where theJ. Ho¨rer et al. / European Journal of Cardio-thoracic Surgery 33 (2008) 1061—10681068results of preliminary banding, followed by a later arterialswitch, might be burdened with an unacceptable mortality,and Senning’s procedure can lead to a lasting success withminimal operative risk.References[1] Ho¨rer J, Karl E, Theodoratou G, Schreiber C, Cleuziou J, Prodan Z, Vogt M,Lange R. Incidence and results of reoperations following the Senningoperation: 27 years of follow-up in 314 patients at a single center. EurJ Cardiothorac Surg 2008;33:1061—7.[2] Turina M, Siebenmann R, Nussbaumer P, Senning A. Long-term outlook afteratrial correction of transposition of great arteries. J Thorac CardiovascSurg 1988;95(5):828—35.[3] Turina MI, Siebenmann R, von Segesser L, Schonbeck M, Senning A. Latefunctional deterioration after atrial correction for transposition of thegreat arteries. Circulation 1989;80(3 Pt 1):162—7.[4] Brawn WJ. The double switch for atrioventricular discordance. SeminThorac Cardiovasc Surg Pediatr Card Surg Annu 2005;8:51—6.Marko Turina*University Hospital,8091 Zurich, Switzerland*Corresponding author. Tel.: +41 44 255 22 29;fax: +41 44 255 92 70E-mail address: Marko.turina@usz.chdoi:10.1016/j.ejcts.2008.02.027

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