Jatene Procedure - History

History

Scottish pathologist Matthew Baillie first described TGA in 1797, presumably as a posthumous diagnosis. Early mortality rates at this time are estimated to have been as high as 90%; the survivors would have been those with one or more concomitant intracardiac shunts (ASD, patent ductus arteriosus (PDA), patent foramen ovale (PFO), and/or VSD), and are unlikely to have survived past adolescence.

In 1950, American surgeons Alfred Blalock and C. Rollins Hanlon introduced the Blalock-Hanlon atrial septectomy, which was then routinely used to palliate patients. This would have effectively reduced early mortality rates, particularly in cases with no concomitant shunts, but is unlikely to have reduced late mortality rates.

Mustard first conceived of, and attempted, the anatomical repair (arterial switch) for d-TGA in the early 1950s. His few attempts were unsuccessful due to technical difficulties posed by the translocation of the coronary arteries, and the idea was abandoned.

Swedish cardiac surgeon Åke Senning described the first corrective surgery for d-TGA (the Senning procedure) in 1959, which involved using the atrial septum to create an intratrial baffle that redirected bloodflow at the atrial level; Senning yielded a high success rate using this procedure, significantly lowering both early and late mortality rates.

Due to the technical complexity of the Senning procedure, others could not duplicate his success rate; in response, Mustard developed a simpler alternative method (the Mustard procedure) in 1964, which involved constructing a baffle from autologous pericardium or synthetic material, such as Dacron. This procedure yielded early and late mortality rates comparable to the Senning procedure; however, a late morbidity rate was eventually discovered in relation to the use of synthetic graft material, which does not grow with the recipient and eventually causes obstruction.

In 1966, American surgeons William Rashkind and William Miller transformed the palliation of d-TGA patients with the innovative Rashkind balloon atrial septostomy, which, unlike the thoracotomy required by a septectomy, is performed through the minimally invasive surgical technique of cardiac catheterization.

Although the atrial switch procedures dramatically reduced both early and late mortality rates, these statistics remained high, partly due to the wait time required between birth and surgery (pre-operative mortality: 5-10%; early mortality: 0-15%; late mortality: 20-25%). A concomitant VSD raises the early mortality rate for atrial switch to 10-60%, even in cases where the VSD is repaired. The late morbidity rate is also very high in atrial switch recipients, with 13-100% developing post-operative complications related to intra-operative damage caused to the sinus node and/or the inherent unsuitability of the heart chambers for role reversal.

These statistics, combined with advances in microvascular surgery, created a renewed interest in Mustard's original concept of an arterial switch procedure. The first successful arterial switch was performed on a forty-two day old d-TGA + VSD infant by Jatene in 1975. Egyptian cardiac surgeon Magdi Yacoub was subsequently successful in treating TGA with intact septum when preceded by pulmonary artery banding and systemic-to-pulmonary shunt palliation. Austrian surgeon B. Eber was the first to recount a small series of successful arterial switch procedures, and the first large successful series was reported by Guatemalan surgeon Aldo R. Casteneda.

By 1991, the arterial switch had become the procedure of choice, and remains the standard modern procedure for d-TGA repair. Atrial switches are still occasionally used as a standby when coronary artery patterns contraindicate coronary anastomoses, in cases of delayed diagnosis where pulmonary artery banding is not possible, and when a d-TGA + VSD patient also has left ventricular outflow tract obstruction.

The world's smallest infant to survive an arterial switch was Jerrick De Leon, born 13 weeks premature. At the time of the operation on February 6, 2005, he weighed just over 1.5 pounds (700 grams).