chapter 22  RANSPOSITION OF

T
THE GREAT ARTERIES

Transposition of the great arteries is a congenital cardiac anomaly defined by

origin of the aorta from the right ventricle and origin of the pulmonary trunk
from the left ventricle. The ventricular septum may be intact (simple transposition of
the great arteries), or there may be a defect in the ventricular septum (transposition
with ventricular septal defect).

Morphology
Figure 22-1

A Transposition of the great arteries, external view.
The aorta originates from the right ventricle
(ventriculoarterial discordant connection). It is
anterior and to the right of the pulmonary artery,
which arises from the left ventricle.
B Transposition of the great arteries, right ventricular
view. The heavily trabeculated anatomic right ventricle
is enlarged and hypertrophied. The right ventricular out-
flow tract, with its well-defined crista supraventricularis
and ventricular infundibular fold, is in continuity with
the aorta. The ostia of the coronary arteries confirm
that this is the aorta. The aortic valve is normal.
C Transposition of the great arteries, left ventricular view.
The finely trabeculated left ventricle is in continuity
with the pulmonary trunk. The pulmonary valve is
continuous with the mitral valve. The left ventricle has
a thin wall because it pumps blood to the low-pressure
pulmonary circulation.
D Transposition of the great arteries with ventricular
septal defect. The aorta originates anteriorly from
the right ventricle. The pulmonary trunk arises from
the left ventricle and is located posterior to and
to the left of the aorta. There is a ventricular septal
defect in the membranous portion of the septum.
The left ventricle is hypertrophied.
E Transposition of the great arteries with ventricular
septal defect, magnified view. This view shows details
of the close relationship between the ventricular septal
defect and the pulmonary valve. The pulmonary valve
is normal.

200
 TRANSPOSITION OF THE GREAT ARTERIES 201

Aorta
Pulmonary artery

Right ventricle

Left ventricle

Coronary artery

Pulmonary valve

Aortic valve
Crista
supraventricularis

Mitral valve

Right ventricle

Left ventricle

B C

Aorta

E
Pulmonary artery

Ventricular
septal defect

Pulmonary valve

Ventricular
septal defect
 202 MALPOSITION OF THE GREAT ARTERIES

Arterial Repair
Arterial repair of transposition of the great arteries has its greatest application
in patients presenting with an associated ventricular septal defect or those with
an intact ventricular septum in the first month of life. In the former group, the
left ventricle is enlarged and hypertrophied due to the ventricular septal defect,
so it is well prepared to function as the systemic ventricle. Likewise, in the latter
group there is normal fetal development of the left ventricle, which has not had
time to involute as it naturally would because it functions as the pulmonary ventricle
in transposition of the great arteries.

Figure 22-2

A The unique arrangement of the coronary arteries
in transposition of the great arteries makes it
possible to exchange the positions of the great
vessels and transfer the coronary arteries to effect
an anatomic correction. The aortic root is usually
located directly anterior to the pulmonary trunk,
and the coronary arteries originate from the poste-
rior sinuses of Valsalva. The coronary ostia are
in close approximation to the anterior wall of the
pulmonary artery in most cases. Even though
there are variations in the anatomic arrangement
of the coronary arteries, in nearly all cases of
transposition of the great arteries it is possible
to transfer the coronary arteries to the pulmonary
artery.
B The aorta and pulmonary arteries are divided. The
aorta is divided above the sinuses of Valsalva,
leaving it slightly longer anteriorly. The pulmonary
artery is divided above the valve at a level approxi-
mating that of the aorta, taking into account the
origin of the right pulmonary artery. The aorta is
mobilized completely away from the pulmonary
artery. The pulmonary artery is then divided under
full exposure. The ligamentum arteriosum is mobilized
and divided.
 TRANSPOSITION OF THE GREAT ARTERIES 203

Left coronary artery

Pulmonary artery Aorta

Right coronary artery

Aorta

Right
ventricle

Right atrium

Pulmonary
artery

Aorta Pulmonary
artery

Incision

Ligamentum
arteriosum
 204 MALPOSITION OF THE GREAT ARTERIES
Figure 22-2 (continued)
C The right and left pulmonary arteries are completely
mobilized. The right and left coronary arteries are
removed from the aorta, along with a generous
amount of sinus aorta, cutting into the sinus from
the free edge of the divided aorta. The proximal
coronary arteries are mobilized minimally, if at all.
D Similar excisions of the pulmonary artery in the
sinuses adjacent to the coronary arteries are
made. The coronary arteries are rotated slightly
to approximate the openings in the pulmonary
artery. The coronary arteries are anastomosed to
the pulmonary artery using continuous stitches
of 6/0 to 7/0 polypropylene, depending on the
thickness of the tissue. Polydioxanone suture mate-
rial can also be considered for this anastomosis
because growth of this part of the repair remains
an unknown factor in late results. Suturing is started
at the lowest point in the sinus opening and contin-
ues in both directions to a knot at the top edge of
the pulmonary artery.
E The distal aorta is drawn behind the bifurcation of the
pulmonary artery (LeCompte maneuver). An anasto-
mosis is created between the proximal pulmonary
artery and the distal aorta. A double-needle 5/0 to
6/0 polypropylene or polydioxanone suture is started
posteriorly, placing several suture loops before drawing
the arteries together. The suture line is continued to
completion anteriorly. At this point the aortic occlusion
clamp can be removed temporarily to check these
critical posterior suture lines.
F The defects in the aortic sinuses created by excision
of the coronary arteries are filled in with pericardium
or polytetrafluoroethylene (PTFE) graft.
 TRANSPOSITION OF THE GREAT ARTERIES 205

C
Incision to mobilize
coronary artery

Pulmonary artery
bifurcation

Anastomose
coronary arteries
to pulmonary
artery
E

Aorta behind
pulmonary artery
bifurcation

Repair aorta

F
 206 MALPOSITION OF THE GREAT ARTERIES
Figure 22-2 (continued)
G An anastomosis is created between the proximal
aorta and the distal pulmonary artery. The pulmo-
nary artery bifurcation lying anterior to the distal
aorta is usually long enough to reach to the aorta,
especially if the aorta was left with a slightly longer
anterior portion when divided. The anastomosis
is performed using 5/0 to 6/0 polypropylene or
polydioxanone suture material in continuous stitches.
The suture line is started posteriorly, and several
suture loops are placed prior to drawing the ends
of the arteries together.
H The completed repair is an anatomic correction
of the defect, in that the left ventricle becomes the
systemic ventricle and the right ventricle becomes
the pulmonary ventricle.
 TRANSPOSITION OF THE GREAT ARTERIES 207

Pulmonary
artery to aorta
anastomosis

Completed repair
 208 MALPOSITION OF THE GREAT ARTERIES

Atrial Repair: Senning Operation

Atrial repair of transposition of the great arteries has become less frequent as
arterial repair has become more popular. Nevertheless, there are circumstances
when atrial repair is desirable. Atrial repair by the Senning operation may be
preferred in patients who present with transposition of the great arteries after
the first month of life or in those referred for operation after successful palliation
by atrial septectomy or balloon septostomy.

Figure 22-3

A The superior vena cava is cannulated directly using
a right-angled cannula through a purse-string stitch
of 3/0 polypropylene at the pericardial reflection.
The inferior vena cava is cannulated through the
right atrium just above the diaphragm. An incision is
made in the right atrium anterior and parallel to the
crista terminalis. The incision should be sufficiently
anterior to the interatrial groove to provide a strip
of right atrium at least as wide as the venae cavae.
The incision is extended around the base of the right
atrial appendage and into the tip of the appendage
on its medial wall. The incision should be anterior
to the sinoatrial node. The right atrium is mobilized
off the anterior wall of the left atrium by dissection
in the interatrial groove. An incision is made in
the anterior wall of the left atrium in a location as
medial as possible. The incision may be extended
to the right superior pulmonary vein to achieve
maximal opening.
B With a retractor placed in the tricuspid valve, the
atrial septum can be visualized. The foramen ovale
atrial septal defect is identified. The atrial septum is
mobilized by incising the septum anterior and superior
to the septal defect, creating a flap of the atrial sep-
tum. A small patch is fashioned from double-velour
knitted Dacron to fill in the atrial septal defect. A PTFE
patch could also be used.
This patch should be just large enough to fill in the
defect; it should not enlarge the atrial septum. The
patch is sutured to the lateral wall of the right atrium
and to the septal flap with a continuous stitch of
4/0 polypropylene. When an atrial septectomy
(Blalock-Hanlon operation) has been performed
previously, a larger, trapezoid-shaped patch
is used.
C The retractor is moved into the mitral valve orifice,
posterior to the remnant of the atrial septum. This
exposes the posterior wall of the left atrium, the left
atrial appendage, and the left pulmonary veins. The
mobilized portion of the atrial septum is displaced
posteriorly and attached to the left atrial wall, ante-
rior to the left pulmonary veins and posterior to the
left atrial appendage and the mitral valve. A continu-
ous stitch of 4/0 polydioxanone is used to attach
the atrial septum to the left atrial wall. This slowly
absorbable suture should allow better growth poten-
tial. The suture line is started anterior to the left
pulmonary veins and continued to the right side
of the atrium, posterior to the superior and inferior
caval orifices. As the suture line proceeds laterally,
the stitches are kept close to the venae cavae so that
a wide channel is maintained posteriorly between
the suture lines. The opening into the left atrium will
be widened as the right atrial wall is pulled medially,
along with the atrial septum as it is displaced to
be attached to the left atrial wall. The size of the
prosthetic patch added to the septum must therefore
be kept small to ensure this effect.
D With the retractor returned to the tricuspid valve, the
size of the passageway from the venae cavae to
the mitral valve beneath the atrial septal remnant is
determined. If it is judged adequate, a suture line
can be placed along the atrial septal remnant and
to the right of the coronary sinus, which reduces
the possibility of injury to the atrioventricular node
and proximal conduction bundle. If the passageway
seems too narrow, it can be enlarged by dividing the
common wall between the coronary sinus and the
inferior wall of the left atrium. The caval passageway
is thereby enlarged equivalent to the circumference of
the coronary sinus.
 TRANSPOSITION OF THE GREAT ARTERIES 209

Right atrial
incision

Previous septectomy
Left atrial
incision

Septal
mobilization

Dacron
patch

Mitral
valve
Septal
suture line

Coronary
sinus
Left atrium
 210 MALPOSITION OF THE GREAT ARTERIES
Figure 22-3 (continued)
E The posterior rim of the right atriotomy is attached
to the atrial septal remnant with a continuous stitch
beginning at the superior end of the atriotomy. A
Hegar dilator is passed into the superior vena cava
to ensure an adequate caval orifice. The sinoatrial
node is located posterior to the suture line. Another
suture line is started inferiorly, attaching the posterior
rim of the atriotomy to the eustachian valve or the
floor of the right atrium and the lateral rim of the
coronary sinus. This creates a passageway for blood
to flow from the venae cavae to the left atrioventricu-
lar valve between the atrial septal remnant and the
posteriorly displaced atrial septum.
F The anterior rim of the right atriotomy is attached
to the lateral rim of the left atriotomy by continuous
suture. Several loops of 4/0 polydioxanone suture
are placed between the atrial flap and the right
pulmonary veins prior to approximating these
structures. The suture line should be placed only
on the lateral half of the left atrial orifice to avoid
creating a circumferential closure, which might
constrict the left atrial opening. A transition must be
made across pericardial-mediastinal tissues to reach
the vena cava or right atrium at the halfway point.
At the superior end, the suture line crosses a tenuous
point along the roof of the left atrium, right pulmo-
nary artery, and posterior aspect of the superior
vena cava. Adequate tissue to hold the suture and
to conform the atrial flap closure to the irregular
contour must be ensured. Extra length of the atrial
flap should be worked into the area over the supe-
rior vena cava to avoid tension. The suture line is
cephalad to the sinoatrial node. A similar transition
across the interatrial groove to the right atrial wall
must be accomplished inferiorly. The completed
repair directs blood flow from the left atrium to the
right atrioventricular valve.
 TRANSPOSITION OF THE GREAT ARTERIES 211

Tricuspid
Sinoatrial valve
node

Left Tricuspid
atrium valve

Completed repair
 212 MALPOSITION OF THE GREAT ARTERIES

Atrial Repair: Mustard Procedure

This operation had widespread application at one time, and although it is
performed less often today, it still has utility. It is also important to know the
details of this operation because the systemic ventricle is the right ventricle,
which is subject to failure after some years. Cardiac transplantation may be
required after the Mustard procedure, and knowledge of how the operation
was performed helps the surgeon take it apart efficiently and safely.

Figure 22-4

A A rectangular patch is fashioned from the anterior
pericardium. The pericardium for the intraatrial
baffle is excised over the great vessels superiorly,
to the level of the diaphragm inferiorly. This pattern
of excision provides the heart’s appropriate premea-
sured length as contained within the pericardium.
The width of the rectangular pericardial patch is
about two-thirds the length. The superior vena cava
is cannulated directly through a purse-string stitch
at the pericardial reflection. The inferior vena cava
is cannulated through the right atrium above the
diaphragm. An incision is made in the right atrium
parallel to the atrioventricular groove.
orifice, to the junction of the atrial septal remnant
and the right lateral wall of the right atrium. The
suture line is taken inferiorly along the wall of the
left atrium, posterior to the mitral valve, and posterior
to the inferior vena cava orifice, to the septal remnant
at the right side of the atrium. An incision is made in
the pericardial patch approximately halfway across
it to form two limbs and to shorten the waist of the
pericardial patch so that it will not bulge into the
pulmonary venous outflow. With the suture line
beginning at the apex of the incision in the patch,
the pericardium is attached to the midportion of the
septal remnant.

B A retractor is placed in the tricuspid valve, exposing
the atrial septum. The atrial septum is excised superi-
orly and laterally to the right atrial wall. The medial
portions of the atrial septum are preserved.
C The pericardial patch is attached to the left atrium
using double-armed 4/0 polypropylene suture. The
suture line is begun anterior to the left pulmonary
veins and posterior to the left atrial appendage.
D The suture line is taken along the superior wall of
the left atrium, posterior to the superior vena cava
E The suture line is taken superiorly along the edge of
the septal remnant near the commissure of the septal
and anterior leaflets of the tricuspid valve. At this
point the suture line is taken across the right atrial
wall and around the orifice of the superior vena
cava anteriorly.
F The suture line is taken inferiorly along the septal
remnant and to the right side of the coronary sinus.
It is continued across the floor of the right atrium
and anterior to the orifice of the inferior vena cava
to complete the repair.
 TRANSPOSITION OF THE GREAT ARTERIES 213

A Right atrial
incision

Tricuspid
valve

Coronary
sinus

C Excision of
atrial septum

Pulmonary
veins

Atrial
septum
Pericardial patch
Coronary
sinus

Superior
vena cava
Tricuspid
valve

E
Atrial
septum

Tricuspid
valve

Pulmonary
veins

Completed repair