Is timing as critical for repair of dextro-transposition of the great arteries with ventricular septal defect without outflow tract obstruction?

Abstract

Objective

We sought to explore the role of timing on outcomes of the arterial switch operation + ventricular septal defect closure.

Methods

Neonates undergoing the arterial switch operation + ventricular septal defect closure from the Pediatric Health Information System database (2004-2022) were identified. Patients with outflow tract obstruction were excluded. Baseline features and outcomes were compared by dividing the cohort by age at the arterial switch operation + ventricular septal defect closure: very early (0-7 days), early (8-14 days), late (15-21 days), and very late (>21 days). A cut-point analysis was performed to identify if an age-cutoff predicted the composite outcome (in-hospital mortality/nonhome discharge/postoperative extracorporeal membrane oxygenation/delayed sternum closure/reoperation due to bleeding).

Results

A total of 1005 patients were identified. The median age at repair was 6 days (interquartile range, 4-9). Repair was performed in the majority of study centers within the patient's first week of life. The distribution was very early in 652 patients (64.9%), early in 247 patients (24.6%), late in 72 patients (7.2%), and very late in 34 patients (3.4%). Late and very late groups had a greater proportion of preterm (6.3% vs 13.8% vs 23.2% vs 26.5%) and low-birthweight (5.8% vs 9% vs 21.9% vs 20%) patients (both P < .05). In-hospital mortality was 3.1% and similar among groups (P > .05). The identified cutoff was 8 days. In-hospital mortality was similar when comparing 0 to 8 days with more than 8 days groups (20 [2.8%] vs 11 [3.9%], P = .38). The more than 8 days group was more likely to develop the composite outcome (69 [24%] vs 125 [17.4%], P = .02), which remained significant in the multivariable analysis (adjusted odds ratio, 1.49; 95% CI, 1.02-2.15; P = .04). Hospitalization costs were significantly higher in the more than 8 days group ($240,742 vs $183,728, P < .001).

Conclusions

This analysis of more than 1000 neonates born with dextro-transposition of the great arteries + ventricular septal defect without outflow tract obstruction revealed that most patients undergo the arterial switch operation + ventricular septal defect closure within the first week of life and had acceptable major outcomes regardless of timing. Earlier arterial switch operation + ventricular septal defect closure may confer an advantage with regard to secondary outcomes and hospitalization costs.