Factors influencing choice of procedure in transposition of the great arteries: A decision analysis approach

Clinicians have a difficult choice between the arterial switch (Jatene et al.) and the atrial baffle operation (Mustard or Sensing) for transposition of the great arteries. The surgical decision is essentially a determination of whether the long-term course after the arterial switch procedure (thought to be more favorable than after the atrial bale procedure) plus elimination of presurgical attrition with the atrial baffle is substantial enough to offset the higher early mortality rate associated with the arterial switch. Decision analysis was undertaken to answer the following questions: 1) are there clinical circumstances under which published surgical results support a clear procedure of choice la transposition of the great arteries? and 2) what short- and long-term outcomes must be anticipated for the arterial switch to compare favorably with the published experience with the atrial baffle? A decision tree was constructed accounting for the major variables influencing mortality and morbidity in the surgical management of transposition of the great arteries. Presuming that the arterial switch has moderate advantages over the atrial baffle in terms of late morbidity and mortality for staple transposition of the great arteries at an institution with average results from the atrial baffle, the early mortality rate of the arterial switch must be <24% to recommend the switch operation. Assuming extremely good surgical results from the atrial baffle, an early mortality rate of the arterial switch < 20% is required to recommend the switch procedure over the atrial baffle operation. The poor results with the atrial baffle to transposition with ventricular septal defect make the arterial switch the procedure of choice, even when early mortality rates for the switch procedure are as high as 39%. Careful reevaluation of the surgical results of the arterial switch procedure is imperative to establish that its Ugh early surgical mortality rale is, indeed, offset by low rate of late mortality and morbidity. Decision analysis is an ideal tool for clinicians at specific institutions to account for unique institutional variations in surgical results.