Comparative long-term outcomes of anatomical and physiological repair for corrected transposition

Abstract OBJECTIVES The optimal surgical strategy for congenitally corrected transposition of the great arteries (ccTGA) remains debated. This study aimed to compare the long-term outcomes of each surgical approach and to explore the optimal management strategy. METHODS We retrospectively reviewed 107 consecutive patients with ccTGA who underwent biventricular repair at our institution between 1978 and 2023. Patients were categorized into four groups: atrial switch with arterial switch (AR-A, n = 17), atrial switch with Rastelli (AR-R, n = 59), physiological repair with Rastelli (PR-R, n = 17), and physiological repair with a native pulmonary valve (PR-N, n = 14). The primary end-point was all-cause mortality. Secondary end-points included reoperation, heart failure, arrhythmia, and pacemaker implantation. RESULTS Median follow-up was 16 years (IQR, 5.2–25). Twenty-year survival did not differ between anatomical and physiological repair (79% vs 82%, p = 0.97). Among the four groups, survival was 94% (AR-A), 75% (AR-R), 86% (PR-R), and 77% (PR-N). Reoperation-free survival was lowest in PR-R (29%) and significantly lower in Rastelli-type repairs (p = 0.009). Heart failure occurred more often in Rastelli groups. AR-A achieved the most favorable functional outcomes, with preserved systemic ventricular function, the highest maximum oxygen uptake (37 ml/kg/min), and the lowest brain natriuretic peptide (13 pg/mL). CONCLUSIONS In this 40-year experience, survival after physiological repair was comparable to anatomical repair. However, AR-A yielded the most favorable long-term functional outcomes and should be considered the preferred strategy when anatomically feasible. Rastelli-type repairs were associated with increased reoperation and heart failure, underscoring the need for refinement of systemic ventricle outflow tract reconstruction techniques.