**8.1 Medical management**

Once the diagnosis is confirmed after a though evaluation, the focus should be on cardiorespiratory stabilization and adequate systemic oxygenation by ensuring optimum mixing of blood. As the first step, DA's patency is maintained with continuous intravenous PGE1 infusion, which is followed by balloon atrial septostomy (BAS, Rashkind procedure) [15, 16]. The presence of a significantly lower preductal oxygen saturation (SaO2) than the post ductal suggests inadequate atrial shunting and mixing of blood and indicates CC and BAS [17]. BAS is used to increase the atrial level shunt. The procedure can be performed at the bedside under echocardiographic guidance or in the catheterization laboratory under fluoroscopy

**159**

*Transposition of Great Arteries*

management.

*DOI: http://dx.doi.org/10.5772/intechopen.99205*

**8.2 Surgical management and procedures**

the complexity of DTGA as follows:

and echocardiography. It involves accessing the heart via the umbilical or femoral vein and then inserting a deflated balloon across the atrial septum into LA. The balloon is then inflated and pulled back across the septum. The procedure is repeated, and follow-up echocardiography and clinical hemodynamic assessment are done to ensure the formation of an effective ASD and optimum intracardiac mixing.

Intravenous fluid and bicarbonate should be given to correct metabolic acidosis, and pulmonary support should be provided as and if indicated. Congestive heart failure should be treated if present. Appropriate nutrition is an essential part of the

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

a. Simple DTGA with intact VS and no other cardiac anomalies: ASO is the preferred surgery and is performed within the first month of life for the LV to be able to sustain the systemic pressure circulation. In this procedure, the two great arteries are transected and translocated to the opposite root, thus reestablishing the ventriculoarterial concordance. In addition, the coronary arteries are mobilized and reimplanted into the neo-aortic roots with the formation of buttons around them. If coronary arterial reimplantation or mobilization is not possible, the atrial switch operation, known as the Mustard or Senning procedures, may be undertaken. In this operation, the oxygen-rich blood is redirected to RV and Ao, and the oxygen-poor blood to the LV and PA via a two-way interatrial baffle, created by the patient's own tissue or synthetic material. The atrial switch is less preferred due to its late complications. It may

c.D-TGA with VSD and LVOO due to pulmonary stenosis (PS): The Rastelli procedure is the standard surgery, and ASO can be done with or without relieving the LVOO obstruction. The decision about choosing one procedure over the other depends on the size of VSD, the severity, and type of LVOO, the status of neo aortic, i.e., pulmonary valve, and the anatomy of coronary arteries. The objective and considerations are to minimize the recurrence risk of LVOO (i.e., PS) or future repeat surgeries and to optimize the pulmonary valve functions. Both ASO and Rastelli procedures involve an arterial switch following which the LV functions as the systemic ventricle and the RV as the pulmonary ventricle [14, 17]. The principle is to redirect the ventricular outflows. Rastelli procedure is undertaken in patients of D-TGA with a large VSD and significant

be used for palliation in selected complex cases of LTGA.

b.DTGA with VSD: ASO and VSD closure are performed.

#### *Transposition of Great Arteries DOI: http://dx.doi.org/10.5772/intechopen.99205*

*Congenital Anomalies in Newborn Infants - Clinical and Etiopathological Perspectives*

a narrow mediastinum, created by the anteroposterior positioning of the aorta and pulmonary artery and by involuted thymus (**Figure 5**) [7, 8, 13, 14]. The pulmonary vascular markings may be normal or increased. In the presence of a large VSD or straddling tricuspid valve, the pulmonary flow is increased, and cardiomegaly with congestive heart failure may supervene soon after birth. Cardiac catheterization (CC) and coronary angiography should be done to determine the origin, anatomy, and course of CA, espy if the echocardiography fails to visualize it well before surgery. CC is also used for performing balloon septostomy as a palliative measure

The conditions which should be clinically differentiated from DTAG are other cyanotic congenital cardiac defects, such as double-outlet right ventricle with malposed great arteries; tricuspid atresia; pulmonary atresia with an intact ventricular septum or with VSD; Tetralogy of Fallot with absent pulmonary valve, pulmonary

Once the diagnosis is confirmed after a though evaluation, the focus should be on cardiorespiratory stabilization and adequate systemic oxygenation by ensuring optimum mixing of blood. As the first step, DA's patency is maintained with continuous intravenous PGE1 infusion, which is followed by balloon atrial septostomy (BAS, Rashkind procedure) [15, 16]. The presence of a significantly lower preductal oxygen saturation (SaO2) than the post ductal suggests inadequate atrial shunting and mixing of blood and indicates CC and BAS [17]. BAS is used to increase the atrial level shunt. The procedure can be performed at the bedside under echocardiographic guidance or in the catheterization laboratory under fluoroscopy

atresia or severe pulmonary valve stenosis; TAPVR and truncus arteriosus.

**158**

to establish mixing of blood.

*Chest radiograph in DTHA showing "egg on string appearance".*

**8. Management**

**Figure 5.**

**8.1 Medical management**

and echocardiography. It involves accessing the heart via the umbilical or femoral vein and then inserting a deflated balloon across the atrial septum into LA. The balloon is then inflated and pulled back across the septum. The procedure is repeated, and follow-up echocardiography and clinical hemodynamic assessment are done to ensure the formation of an effective ASD and optimum intracardiac mixing.

Intravenous fluid and bicarbonate should be given to correct metabolic acidosis, and pulmonary support should be provided as and if indicated. Congestive heart failure should be treated if present. Appropriate nutrition is an essential part of the management.
