Progression of aortic root dilatation and aortic valve regurgitation after the arterial switch operation

Progression of aortic root dilatation and aortic valve regurgitation after the arterial switch operation.

van der Palen RLF, van der Bom T, Dekker A, Tsonaka R, van Geloven N, Kuipers IM, Konings TC, Rammeloo LAJ, Ten Harkel ADJ, Jongbloed MRM, Koolbergen DR, Mulder BJM, Hazekamp MG, Blom NA.
Heart. 2019 Jul 10. pii: heartjnl-2019-315157. doi: 10.1136/heartjnl-2019-315157. [Epub ahead of print]

PMID: 31292191 Free Article

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Take Home Points:

  • Neo-aortic root dilatation and aortic incompetence in patients post ASO is progressive – does not stabilize over time.
  • More complex subtypes of TGA and male gender were associated with greater increases in root dilatation.
  • A disproportionate increase of aortic root size occurs in the first year post ASO.

Commentary from Dr. Blanche Cupido (Cape Town, South Africa), section editor of ACHD Journal Watch:  The arterial switch operation (ASO) has largely replaced the atrial switch procedure for transposition of the great arteries (TGA) over the last 2 decades. The late survival with this procedure has been excellent but the concern of neo-aortic dilatation (in >2/3 of patients) and aortic regurgitation (AR) remains. There is however limited data, especially in adults, on the progression of neo-aortic dilatation.

This is a retrospective study from the Netherlands, describing neo-aortic growth, neo-aortic valve function and the need for neo-aortic root intervention at long term follow-up and to identify risk factors for root dilatation and AR.


All patients who underwent an ASO for TGA with intact ventricular septum (TGA-IVS), TGA with VSD (TGA-VSD) or double outlet RV with subpulmonary VSD (DORV-SP-VSD) between 1977 and 2015 were included. All patients had 2 or more echocardiograms during follow-up. If possible, echo images at 3,6,9 and 12 months and then at 2,3 and 5 years and 5 year intervals thereafter were evaluated until the last available follow-up. The following neo-aortic measurements were recorded: annulus, mid-sinus and sinotubular junction. For paediatric patients, Z scores were calculated and dilatation defined as a Z score of 2 or more. AR jet and LV dimensions were also assessed.

A total of 452 patients underwent ASO. Fifty-two patients (11.5%) patients died during follow-up of which 42 deaths occurred during the first month post-op. Early deaths were higher in the years 1977-1987, and reduced to 3.3% in subsequent years. The cohort was made up of the following morphological subtypes: TGA-IVS (66.7%), TGA-VSD (25.8%) and DORV-SP-VSD (7.5%).

Figure 2A-C above shows the absolute neo-aortic diameters for all patients with TGA. The dimensions for neo-aortic annulus, root and STJ shows a rapid increase in the first year post- ASO followed by a linear increase in childhood and an ongoing increased growth rate in adulthood. For neo-aortic annulus and root diameters, both TGA-VSD and DORV-PS-VSD showed significantly greater dilatation compared to TGA-IVS. Both morphological subtype and male gender were independent predictors for root dilatation.

Regarding aortic regurgitation, at last follow-up or just before re-operation for root pathology, 33 patients (9.6%) had at least moderate AR.