**8.2 Surgical management and procedures**

Surgery is undertaken within the first 1–2 weeks of life. The infants' clinical status and hemodynamics determines the timing. Surgery is generally undertaken after the palliation procedures, but in selected cases, such as DTGA with intact ventricular septum and restrictive foramen ovale with severe metabolic acidosis may be performed without, and within the first few days of life [18]. The arterial switch operation (ASO, Jatene procedure) is the standard surgical procedure for DTGA. ASO has reduced the mortality in DTGA from almost 90% in unoperated infants to <5% in those who undergo surgery [19–21]. The perioperative mortality with ASO in simple DTGA is <1%, while it is 4% in those with complex DTGA. Reportedly a delay of ASO beyond three days after birth may be associated with increased morbidity and health care costs. Other surgical options in DTDA are the Mustard, Senning, and Rastelli procedures. The surgical procedures are selected according to the complexity of DTGA as follows:


LVOO. In this procedure, the LV outflow tract obstruction is baffled through the VSD, thus closing it, and the oxygenated blood from the left ventricle is directed into the aorta. A valved conduit is placed between RV and PA, and the deoxygenated blood from the right ventricle enters the PA via the conduit. The Rastelli procedure with a perioperative mortality of <5 percent generally provides better and more durable relief of LVOT obstruction than ASO but has more postoperative complications.

d.TGA with VSD and pulmonary arterial vascular disease: This is a rare type in which surgery may not be beneficial as PA hypertension is progressive. Palliation may be an option in some cases.

## **8.3 Complications of surgery**

Complications may occur in 5 to 25 percent of patients who undergo ASO; the commonest one that will need reintervention is pulmonary artery stenosis [22–26]. If the right ventricular pressure becomes close to systemic levels or if the lung perfusion scan is abnormal catheter-based dilation and stent placement may be performed. Other less common complications include coronary artery insufficiency, neo-aortic root dilation, and neo-aortic regurgitation. With the Rastelli procedure, complications such as conduit stenosis needing replacement, atrial and ventricular arrhythmias, and right and left ventricular failure are reported. Complications of the atrial switch include right ventricular failure, arrhythmias, and baffle-related sequelae [20, 23, 24].
