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............................................................................................................................................................................. 4.12.3 Arterial switch operation 4.12.3.1 Clinical presentation after arterial switch Young adults with a simple TGA will probably have had an arterial switch operation. The most common complications are:

• Neo-aortic root dilatation, resulting in AR. • Supravalvular PS and pulmonary branch stenosis (unilaterally or bilaterally), a consequence of the position of the pulmonary bifurcation anterior to the ascending aorta in the Lecompte technique and the dilatation of the neo-aortic root. • LV dysfunction and ventricular arrhythmias are rare but may occur; both may be related to problems with the coronary arteries,281 which were reimplanted in the neo-aorta. • Acute angle of the aortic arch, which may lead to functional obstruction and hypertension. Survival up to 30 years is excellent (>90% of hospital survivors282) and event-free survival is fair (6080%283285). A large majority of these patients are asymptomatic. As a rule, exercise capacity is mildly reduced, but it can be normal. The incidence of late coronary arteryrelated problems is reported to be very low,286,287 which makes it questionable whether routine screening of coronary arteries is justified.

4.12.3.2 Diagnostic work-up See section 3.3 for general principles. Clinical findings of AR or PS may be present. • Echocardiography is the key diagnostic modality, providing information on LV function (global and regional); stenosis at the arterial anastomotic sites, most commonly PS; neo-aortic valve regurgitation; dimension of the neo-aortic root and proximal ascending aorta; and the acute angulation of the aortic arch. RV systolic function can be assessed and, if possible, peak RV systolic pressure (RVSP) should be measured (TR velocity). Due to its position: far anteriorly and just behind the sternum, echocardiographic visualization of the bifurcation and both branches is rarely possible. • Stress echocardiography is used to assess stress-induced wallmotion abnormalities. • CMR provides more reliable quantitative assessment of ventricular volumes, EF, and neo-aortic dilatation or regurgitation. Pulmonary trunk and branches can be visualized, together with their relation to the (dilated) neo-aortic root. Flow distribution between left and right lung can be calculated. Stress CMR is an alternative technique to assess myocardial perfusion and possible coronary artery compromise, where clinically indicated. • CCT is the preferred technique for non-invasive imaging of coronary arteries, including the ostia, when stenosis is suspected. The reported low incidence of coronary-related problems makes it questionable whether routine screening for coronary artery pathologies (with whatever modality) can be justified.286,287 • Nuclear techniques are no longer used as first-choice imaging modality but may still have a role if other techniques are not available or lead to inconclusive or contradictory results. • Cardiac catheterization, including coronary angiography, is indicated in the case of LV dysfunction and suspicion of myocardial ischaemia. In the case of severe pulmonary branch stenosis and

Recommendations for intervention in transposition of the great arteries after atrial switch operation

Recommendations Classa Levelb

Indications for surgical intervention In symptomatic patients with pulmonary venous atrium obstruction, surgical repair (catheter intervention rarely possible) is recommended. I C In symptomatic patients with baffle stenosis not amenable to catheter intervention, surgical repair is recommended. I C In symptomatic patients with baffle leaks not amenable to catheter-based closure, surgical repair is recommended. I C In patients with severe systemic (tricuspid) AV valve regurgitation, without significant ventricular systolic dysfunction (EF >40%), valve repair or replacement should be considered, regardless of symptoms. IIa C PA banding in adults, as LV training with subsequent arterial switch procedure, is not recommended. III C Indications for catheter intervention In symptomatic patients with baffle stenosis, stenting is recommended when technically feasible. I C In symptomatic patients with baffle leaks and cyanosis at rest or during exercise, or with strong suspicion of paradoxical emboli, stenting (covered) or device closure is recommended when technically feasible. I C In patients with baffle leaks and symptoms due to LR shunt, stenting (covered) or device closure is recommended when technically feasible. I C In asymptomatic patients with baffle leaks with substantial ventricular volume overload due to LR shunt, stenting (covered) or device closure should be considered when technically feasible. IIa C In patients with a baffle leak who require a PM/ICD, closure of the baffle leak with a covered stent should be considered, when technically feasible, prior to insertion of transvenous leads. IIa C In asymptomatic patients with baffle stenosis, stenting may be considered when technically feasible. IIb C

AV = atrioventricular; EF = ejection fraction; ICD = implantable cardioverter defibrillator; LR = left-to-right; LV = left ventricle/ventricular; PA = pulmonary artery; PM = pacemaker. aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/42/6/563/5898606 by guest on 07 October 2026