Arterial Switch Operation in Congenital Heart Disease

The arterial switch operation is the established corrective procedure for transposition of the great arteries and related malformations characterised by ventriculoarterial discordance. First performed in the mid-1970s, it entails transection of the aorta and pulmonary artery, followed by reimplantation of the coronary arteries into the neoaortic root and anatomical realignment of the great vessels. Its adoption has transformed survival after transposition of the great arteries from a palliative to a curative paradigm, with early mortality now below 5% in experienced centres. Attention has shifted towards medium- and long-term outcomes, including reintervention for pulmonary or neo-aortic valve stenosis, neoaortic root dilatation and coronary artery complications. Optimisation of timing—often within the first two weeks of life—and judicious use of balloon atrial septostomy to enhance intercirculatory mixing underpin a tailored approach that balances operative risk against the need to stabilise comorbid conditions. Advances in perioperative imaging and intensive care have facilitated the procedure in low-volume settings, while comprehensive follow-up programmes integrate echocardiography, cardiovascular magnetic resonance and coronary computed tomography angiography to detect subclinical myocardial dysfunction and anatomical high-risk features. The procedure’s global adoption has generated a robust body of evidence supporting survival rates of over 90% at 15 years, accompanied by satisfactory quality-of-life metrics, albeit with a persistent need for lifelong surveillance and occasional reintervention.

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Arterial Switch Operation in Congenital Heart Disease publication trend

The graph below shows the total number of articles in arterial switch operation in congenital heart disease across all publications each year (not limited to Nature Index journals).

Technical terms

Arterial switch operation (ASO): A neonatal surgical procedure that corrects transposition of the great arteries by transecting and switching the positions of the aorta and pulmonary artery, with reimplantation of the coronary arteries into the neoaortic root.

Transposition of the great arteries (TGA): A congenital heart defect characterised by atrioventricular concordance and ventriculoarterial discordance, in which the aorta arises from the right ventricle and the pulmonary artery from the left.

Balloon atrial septostomy (BAS): A catheter-based intervention performed in neonates to enlarge an atrial septal communication, improving systemic oxygenation prior to definitive surgical repair.

Neoaortic root dilatation: Progressive enlargement of the reconstructed aortic root following ASO, which may lead to neoaortic valve regurgitation and necessitate surgical or transcatheter intervention.

Coronary computed tomography angiography (CCTA): A non-invasive imaging modality that provides high-resolution visualisation of coronary artery anatomy, ostial configuration and high-risk features post-ASO.

References

1. Arterial Switch for Transposition of the Great Arteries Treatment Timing, Late Outcomes, and Risk Factors. JACC Advances (2023).
2. Outcomes after corrective surgery for congenital dextro-transposition of the arteries using the arterial switch technique: a scoping systematic review. Systematic Reviews (2020).
3. Usefulness of Routine Coronary CT Angiography in Patients with Transposition of the Great Arteries After an Arterial Switch Operation. Pediatric Cardiology (2017).