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Archives of cardiovascular diseases
Volume 110, n° 2
pages 124-134 (février 2017)
Doi : 10.1016/j.acvd.2016.11.002
Received : 29 August 2016 ;  accepted : 4 November 2016
Transposition of the great arteries: Rationale for tailored preoperative management
Transposition des gros vaisseaux : rationnel pour une prise en charge préopératoire sur-mesure
 

Figure 1




Figure 1 : 

Schematic representation of transposition of the great arteries with an intact ventricular septum at birth. The aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle. Thus, aortic blood saturation is poor and newborns become cyanotic. At birth, two foetal communications exist concomitantly: the foramen ovale and the ductus arteriosus. Ao: aorta; DA: ductus arteriosus; FO: foramen ovale; LV: left ventricle; PA: pulmonary artery; RV: right ventricle.


Figure 2




Figure 2 : 

Schematic representation of foetal blood circulation in: A. A healthy foetus. Left ventricle ejects high saturated blood into the aorta. The brain receives a blood with a saturation of 65%; B. A foetus with transposition of the great arteries. Right ventricle ejects less oxygenated blood into the aorta. The brain is exposed to a blood with a saturation of 45%.


Figure 3




Figure 3 : 

Balloon atrial septostomy. At birth, when the foramen ovale is restrictive, atrial mixing is inadequate, leading to profound hypoxia. Then, a balloon atrial septostomy is mandatory to enlarge the atrial communication. A. Schematic representation of the manoeuvre. A balloon-tipped catheter is introduced via the inferior vena cava into the right atrium. After passing through the foramen ovale, the balloon is inflated into the left atrium and then pulled across the septum to enlarge the opening. Finally, the balloon is rapidly deflated and the catheter is removed. B. Angiographic images showing the different steps of the manoeuvre.


Figure 4




Figure 4 : 

Doppler recordings of the anterior cerebral artery in three full-term newborns with transposition of the great arteries and patent ductus arteriosus. Diastolic velocity depends directly on the importance of ductal steal phenomenon. A. Normal pattern of Doppler velocities in a newborn with small ductal steal phenomenon. Systolic velocities are high. B. Moderate ductal steal phenomenon resulting in null diastolic values. Systolic velocities are high. C. Spectral waveforms showing a reverse diastolic flow confirming a severe ductal steal phenomenon. Systolic velocities are too low.


Figure 5




Figure 5 : 

Proposal for clinical decision making in newborns with transposition of the great arteries with intact ventricular septum according to current monitoring technologies. Neonates with persistent pulmonary hypertension of the newborn are excluded from this algorithm. ASO: arterial switch operation; BAS: balloon atrial septostomy; FO: foramen ovale; PGE1: prostaglandin E1; rc SO2 : cerebral regional oxygen saturation; rs SO2 : somatic regional oxygen saturation; TGA: transposition of the great arteries; TTE: transthoracic echocardiography; US: ultrasound.

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