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Eur J Cardiothorac Surg 2003;24:352-357
© 2003 Elsevier Science NL

Is a learning curve for arterial switch operation in small countries still acceptable? Model for cooperation in Europe

^a Department of Cardiac Surgery, Children's Hospital, Bratislava, Slovakia
^b Department of Pediatric Cardiology, Children's Hospital, Ljubljana, Slovenia
^c Cardiac Intensive Care Unit, Children's Hospital, Bratislava, Slovakia
^d Department of Pediatric Cardiology, Children's Hospital, Bratislava, Slovakia
^e Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA

Received 13 September 2002; received in revised form 12 February 2003; accepted 24 June 2003.

^* Corresponding author. Oddelenie detskej kardiochirurgie, Children's University Hospital, DFNsP, Limbova 1, 833 40 Bratislava, Slovakia. Tel.: +421-2-54792-319; fax: +421-2-54775-766
e-mail: hraska{at}dkch.sk

Objectives: To assess the results of a cooperative arrangement between Slovakia and Slovenia for neonatal cardiac surgery. The aim of the study was to analyze the performance of this approach for complete transposition of the great arteries (D-TGA). Methods: Due to the overall small number of new patients with D-TGA in Slovenia a decision was made to avoid a prolonged learning curve by centralizing the experience of two countries at one center. Since 1995 the center in Slovakia has become the only referral center for Slovenia. Between February 1993 and June 2002 in this center, 147 patients with D-TGA underwent arterial switch operation (ASO). The median age at operation was 11 days, with 110 patients from Slovakia and 37 patients from Slovenia. Results: Overall hospital mortality was 4.8% (seven patients). The 1, 2, 3, 4 and 5 year survival rate was 95% with the mean follow-up of 4 years. Operation before 1997 (P=0.0001) was identified as a risk predictor for death by multivariate analysis. There are no deaths among the 90 patients operated on after 1996. All patients are without medication with normal left ventricular function. Stenosis (gradient >30 mmHg) was noted in the pulmonary artery reconstruction in seven patients (5%). More than mild aortic regurgitation was noted in five patients (4%). The incidence of redo or reintervention was 5% at 5 years of follow-up. Conclusions: In the current era a prolonged learning curve for ASO is not acceptable to most European countries and their patients. The risk of surgery can be minimized by concentrating surgical experience as part of the quality control of congenital heart programs. If the number of new patients is small due to the birth rate and size of the population, institutions should merge activity. Such centralization amplifies the experience to the benefit of the patient.

Key Words: Congenital heart disease • Complete transposition of the great arteries • Learning curve • Centralization of care

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