Arterial Switch OperationEdit
The arterial switch operation (ASO) is the definitive surgical repair for most infants born with d-transposition of the great arteries (d-TGA), a congenital heart defect in which the aorta and the pulmonary artery arise from the wrong ventricles. In a successful ASO, the great arteries are detached from their original connections and reattached to the correct ventricles, with the coronary arteries transferred to the new aorta. This restores normal oxygenated blood flow and preserves a two-ventricle circulation, which generally yields better long-term outcomes than earlier approaches. For context, the ASO stands in contrast to older “atrial switch” repairs such as the Mustard and Senning procedures, which rearranged blood flow at the atrial level rather than switching the great arteries themselves Mustard procedure Senning procedure.
The arterial switch procedure is sometimes referred to by the name of its most widely recognized form, the Jatene procedure, after Adib Jatene and colleagues who popularized the technique in the 1970s. Over the ensuing decades, improvements in sequencing, surgical exposure, and postoperative care transformed ASO from a high-risk operation into a reliably performed, life-changing repair in experienced centers Adib Jatene Jatene procedure. In modern practice, ASO is performed in newborns or very young infants, and it has become the standard of care for uncomplicated d-TGA and for many variants that involve additional lesions, such as a ventricular septal defect (VSD) or coexisting anomalies of the great vessels d-transposition of the great arteries.
The procedure
Indications and timing
ASO is indicated for most neonates with d-TGA, with or without associated lesions such as a VSD or outflow tract obstruction. Because the repair reconfigures the systemic and pulmonary circulations, timing is critical: the goal in most cases is to complete the switch within the first week of life if the infant is stable enough to undergo surgery. Preoperative management often includes establishing systemic oxygen delivery and, when needed, stabilizing the ductus arteriosus with prostaglandin E1 to improve systemic blood flow and to maintain pulmonary and systemic mixing until repair can be performed Prostaglandin E1 ductus arteriosus.
Surgical technique
The core steps of ASO involve detaching the great arteries from the incorrect ventricles and reattaching them to the correct chambers, followed by transfer of the coronary arteries to the neoaorta. A hallmark maneuver used in many repairs is the LeCompte maneuver, which places the pulmonary arteries anterior to the aorta to reduce tension on the coronary vessels and facilitate subsequent reconstruction. The coronary arteries are carefully detached as buttons, reimplanted onto the neoaorta, and perfusion is maintained throughout the operation via cardiopulmonary bypass (CPB) with myocardial protection strategies tailored to the infant patient LeCompte maneuver coronary transfer cardiopulmonary bypass.
Postoperative care focuses on ensuring adequate systemic perfusion and stabilizing the infant as the heart adapts to its new physiology. Complications, if they occur, may include temporary or persistent arrhythmias, residual or recurrent obstruction of the neoaorta or the neopulmonary outflow tract, and issues related to the coronary transfer. Long-term follow-up is essential to monitor ventricular function, valve integrity, and conduit patency, as well as to assess growth and development of the pulmonary and systemic circuits neoaorta neopulmonary artery.
History and development
The conceptual shift from atrial-level repairs to a true arterial switch occurred in the 1970s as surgeons sought to restore normal physiology by aligning the great arteries with the correct ventricles. Early work in this area demonstrated that transferring the coronaries and establishing a two-ventricle circulation could yield superior long-term results compared with atrial switches. The first successful arterial switch procedures emerged in the 1970s and 1980s, with rapid spread to high-volume congenital heart centers. Over time, refinements in myocardial protection, coronary transfer techniques, and postoperative management led to markedly improved survival and quality of life for patients who underwent ASO Mustard procedure Senning procedure Adib Jatene.
Outcomes and long-term considerations
Contemporary ASO outcomes in experienced centers are characterized by high early survival and excellent long-term function. Reported survival in many high-volume programs exceeds 90% at 10 years and remains favorable into adolescence and adulthood, with most patients achieving normal or near-normal activity levels. Long-term issues that require monitoring include neoaortic root dilation and potential neoaortic or neopupmonary valve regurgitation, branch pulmonary artery stenosis, and, less commonly, coronary insufficiency related to the coronary reimplantation. Regular follow-up with a cardiovascular team is recommended to detect late complications and to plan interventions if needed neoaorta neoaortic regurgitation coronary transfer.
Controversies and debates
As with any major surgical program, ASO generates ongoing discussion about optimal pathways to care, resource allocation, and the balance between access and excellence.
Centralization and access: A prominent debate centers on whether arterial switch procedures should be concentrated in a relatively small number of high-volume, specialized centers. Proponents argue that centralization improves results because surgeons gain experience, teams optimize perioperative protocols, and multidisciplinary care is more cohesive. Critics worry about travel burden and equity of access for families in rural or underserved regions. In practice, patient outcomes correlate strongly with center volume and operator experience, which has driven policy considerations about regional networks and referral patterns pediatric cardiac surgery.
Training and workforce: The complexity of ASO demands highly trained teams. Some contend that broad training across many centers risks dilution of expertise, while others emphasize scalable training models that preserve quality without sacrificing access. The underlying point is to ensure that every center performing ASO meets rigorous standards of volume, outcomes, and ongoing quality improvement cardiothoracic surgery training.
Innovation and cost: Supporters of innovation stress the value of continual technique refinement, better imaging for planning coronary transfer, and improvements in postoperative care that reduce ICU stays and hospital costs. Critics sometimes frame high upfront costs as a barrier to access, particularly in healthcare systems with constrained budgets. From a policy perspective, the aim is to maximize patient outcomes per dollar spent while maintaining safe and effective care.
Woke criticisms and public discourse: Critics who emphasize broad social critiques of medicine may label specialized pediatric cardiac care as an arena where policy or ideology intrudes on clinical practice. Proponents of the ASO approach argue that the core measure of value is survival, functional status, and long-term health, not the politics of funding or discourse. In practical terms, the insistence on evidence-based practice, transparency in outcomes, and patient-centered care remains the common ground that transcends ideological debates. When criticisms appear disconnected from clinical data, supporters typically view them as distractions from the central goal: giving infants with d-TGA the best chance at a healthy, active life.