Should I be concerned about arterial issues in this case?

Arterial Issues in Dextro-Transposition of the Great Arteries (d-TGA)

Yes, you should be concerned about arterial issues in this case, particularly coronary artery complications, great arterial anastomotic site stenosis, and neoaortic root dilatation in patients with d-TGA who have undergone arterial switch operation (ASO). 1

Key Arterial Concerns in d-TGA Post-ASO

Coronary Artery Complications

• Coronary ischemia is a significant late complication after ASO, with ischemia or infarction reported in up to 8% of patients 1
• All adults with d-TGA who have undergone ASO should have at least one evaluation of coronary artery patency 1
• If coronary patency cannot be established noninvasively, coronary angiography is recommended 1
• Patients with intramural or single coronary arteries have increased mortality compared with those having typical coronary patterns 1

Great Arterial Anastomotic Site Issues

• Stenosis at arterial anastomotic sites, most commonly pulmonary stenosis, is a recognized complication 1
• Regular monitoring for stenosis development is essential through comprehensive imaging

Neoaortic Root Complications

• Significant neoaortic root dilatation and neoaortic valve regurgitation may develop over time 1
• Risk factors include older age at time of ASO and associated VSD with previous pulmonary artery banding 1

Monitoring Recommendations

Imaging Schedule

• Comprehensive echocardiography should be performed at least every 2 years at a center with expertise in adult congenital heart disease (ACHD) 1
• Periodic MRI or CT should be considered to evaluate anatomy and hemodynamics in more detail 1

Specific Monitoring Focus

• Echocardiography should assess:
  • Arterial anastomotic sites for stenosis
  • Aortic root dimensions
  • Neoaortic valve function
  • Ventricular function
• Stress echocardiography may help detect ischemia when coronary complications are suspected 1

Arterial Monitoring in Special Circumstances

Invasive Assessment

• Cardiac catheterization is indicated for:
  • Assessment of hemodynamics
  • Evaluation of baffle leaks (in patients with atrial baffle repairs)
  • Superior vena cava or inferior vena cava pathway obstruction
  • Pulmonary venous pathway obstruction
  • Myocardial ischemia
  • Unexplained systemic right ventricular dysfunction 1

Clinical Implications

Risk Stratification

• Patients with abnormal coronary patterns require more vigilant monitoring
• Those with evidence of neoaortic root dilatation need regular follow-up to assess progression
• Development of arterial stenosis may require intervention if hemodynamically significant

Warning Signs

• Symptoms of angina or exertional dyspnea should prompt immediate evaluation
• Syncope or presyncope may indicate coronary insufficiency or arrhythmias
• Signs of heart failure may suggest progressive ventricular dysfunction related to coronary issues

Practical Approach

1. Establish baseline coronary anatomy and patency in all adult d-TGA patients post-ASO
2. Implement regular biennial imaging with echocardiography at minimum
3. Consider advanced imaging (MRI/CT) for more detailed assessment
4. Maintain high suspicion for coronary issues with any concerning symptoms
5. Refer to centers with expertise in ACHD for comprehensive care

Arterial complications represent a significant concern in d-TGA patients post-ASO and require vigilant monitoring throughout the patient's lifetime to prevent morbidity and mortality related to coronary insufficiency, anastomotic stenosis, and aortic complications.