CONGENITAL – Original Submission
Intraoperative Extubation Post Arterial Switch Operation for Transposition of the Great Arteries With Intact Ventricular Septum: A One-Year, Single Center Experience

https://doi.org/10.1053/j.semtcvs.2020.06.038Get rights and content

We sought to examine the clinical impact of intraoperative extubation (IE) in neonates undergoing the arterial switch operation (ASO) for D-transposition of the great arteries with intact ventricular septum (dTGA/IVS). This was a single center retrospective study of patients who underwent ASO for dTGA/IVS in the 12 months after an institutional change in practice favoring IE when clinically feasible. A control group was obtained by identifying the same number of consecutive patients with dTGA/IVS who underwent ASO immediately prior to this institutional change in practice, none of whom were extubated intraoperatively. Primary outcome measures included morbidity, mortality, length of hospital and intensive care unit stay and reintubation rates. There were no significant differences in the preoperative and operative characteristics between the 2 groups. Of the 10 patients who underwent ASO for dTGA/IVS in the 12 months post institutional change in practice, all (100%) were extubated intraoperatively and none (0%) required reintubation. The median length of intensive care unit stay was 2 days for both the intraoperative and non-IE groups (mean 2.2 and 3 days respectively). The median length of stay in hospital was 4 days in the IE group and 5.5 days in the non-IE group (mean 4.5 and 6 days respectively). No patients died and there was no significant difference in morbidity between the 2 groups. Our data suggests IE post ASO for dTGA/IVS is safe and displays a statistically insignificant trend toward earlier discharge from hospital.

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INTRODUCTION

Transposition of the great arteries is a cyanotic congenital heart defect characterised by atrioventricular concordance with ventriculoarterial discordance. The improving mortality rates from the arterial switch operation (ASO) have shifted the focus from survival to quality improvement and optimizing clinical outcomes.1 Ongoing mechanical ventilation after cardiac surgery is known to risk direct airway trauma, lung injury from barotrauma, infection, atelectasis, undesirable hemodynamic effects

METHODS

We conducted a retrospective chart review of all patients who underwent ASO for dTGA/IVS in the 12 months after the institutional change in practice favoring IE. Ten patients were identified (IE group). To obtain a control group (non-IE group), we examined the records of the 10 consecutive patients with dTGA/IVS who underwent ASO immediately prior to this institutional change in practice, none of whom were extubated intraoperatively. The date range for the IE group was September 1, 2016–August

Preoperative characteristics

There were no significant differences in characteristics recorded between the IE and non-IE group preoperatively (see Table 1). Seven of the 10 in the non-IE group were diagnosed with dTGA/IVS antenatally, compared to 5 of the 10 in the IE group. None of the patients had known chromosomal abnormalities. Three of the 20 patients had extracardiac anomalies, 1 in the non-IE group (this neonate had chronic neonatal lung disease, retinopathy of prematurity and hypothyroidism) and 2 in the IE group

DISCUSSION

Our series describes 10 consecutive neonates who were safely extubated in the operating room after ASO for dTGA/IVS. None of these patients were reintubated. There was no relative increase in morbidity or mortality when compared to their counterparts who were extubated postoperatively in the ICU.

There was a trend toward a shorter length of stay in hospital (median 4 vs 5.5 days, mean 4.5 vs 6 days) in those patients who were extubated intraoperatively, though this difference did not reach

STUDY STRENGTHS AND LIMITATIONS

The most obvious limitations to our study are the small sample size and single center, retrospective nature of our data. Whilst a statistically insignificant trend toward shorter hospital length of stay was shown, a larger sample size would be required to examine for any statistically significant differences. Outcomes in our study were continuous and analyzed using the nonparametric Wilcoxon-Mann-Whitney test. A power analysis for the Wilcoxon-Mann-Whitney test can be based on the concordance

CONCLUSION AND FUTURE DIRECTIONS

Our first year experience with IE for neonates with transposition of the great arteries and intact ventricular septum suggested the practice is safe and may reduce length of hospital stay. It was not associated with an increase in reintubation, morbidity or mortality. It is also likely to improve resource utilization and parental satisfaction.

For the successful implementation of IE in any patient population, it is vital that cardiac surgeons, anesthetists, intensivists, cardiologists as well as

REFERENCES (15)

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Conflict of Interest and Source of Funding Statement: There are no conflicts of interest and this manuscript is an unfunded work.

Research Ethics Board Approval Number: H17-01481 (November 1, 2018). University of British Columbia, Children's and Women's Health Research Ethics Board.

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