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PubMed This is a summary of 23 peer-reviewed journal articles Updated
Pediatric Cardiothoracic Surgery · Dextro-Transposition of the Great Arteries

The Arterial Switch and Complex Repairs

At a Glance

The Arterial Switch Operation is the gold-standard surgery for D-TGA. Surgeons detach and swap the aorta and pulmonary artery to their correct positions, along with the coronary arteries. Hospital recovery takes 2 to 4 weeks, with infant feeding being a key milestone before going home.

The Arterial Switch Operation (ASO) is the definitive surgical repair for D-TGA. Unlike older surgical methods, the ASO is considered an “anatomic” repair because it restores the heart to its intended structural design [1][2].

The Arterial Switch Operation (ASO)

The primary goal of the ASO is to “switch” the aorta and the pulmonary artery back to their correct positions [1].

  1. Repositioning the Arteries: The surgeon detaches the aorta and the pulmonary artery from their incorrect locations and reattaches them to the correct pumping chambers (ventricles) [2].
  2. The Lecompte Maneuver: To make everything fit properly, the surgeon often performs the Lecompte maneuver, which involves bringing the pulmonary artery in front of the aorta to create a more natural alignment [3][4].
  3. Moving the Coronary Arteries: This is the most critical and delicate step of the surgery. The surgeon must carefully remove the tiny coronary arteries—which provide blood to the heart muscle itself—from the old aorta and “replant” them into the new one [5][6]. Ensuring these tiny vessels are positioned perfectly is vital for the heart’s long-term health [5][7].

Why ASO is the Gold Standard

Before the ASO became widely used, babies were treated with “atrial switch” procedures known as the Mustard or Senning operations [2][8].

  • Older Method (Atrial Switch): Instead of moving the arteries, surgeons built “tunnels” (baffles) inside the heart to redirect blood flow [8]. This worked, but it forced the right ventricle to do the heavy lifting of pumping blood to the entire body [2]. Over time, the right ventricle—which is designed for the low-pressure task of pumping to the lungs—often failed [9].
  • Modern Method (ASO): The ASO ensures that the left ventricle (the heart’s strongest pump) is the one sending blood to the body [2][8]. This leads to better long-term heart function and survival [10][11].

Repairs for Complex D-TGA

In some “complex” cases where D-TGA is combined with a hole in the heart (VSD) and a narrowing of the lung valve (pulmonary stenosis), a standard ASO may not be possible [12][8]. Surgeons may use alternative repairs:

  • Rastelli Procedure: Uses a “tunnel” inside the heart and an external tube (conduit) to route blood [13][14]. While effective, the external tube often needs to be replaced as the child grows [15][16].
  • Nikaidoh Procedure: A more modern, complex technique that “relocates” the aortic root itself to create a more natural path for blood flow [17][18]. It is often preferred for specific anatomies because it may require fewer future surgeries than the Rastelli [19][20].

Recovery and Hospital Stay

Following the surgery, your baby will recover in the Cardiac Intensive Care Unit (CICU). A common concern for families is how long the hospital stay will be. Generally, you should expect a total hospital stay of 2 to 4 weeks, depending on how smoothly the recovery progresses [21][22].

One of the largest hurdles before discharge is often feeding and weight gain. Transitioning from an IV or feeding tube back to oral feeding takes energy that the baby is still regaining after surgery [23]. Patience is key during this phase.

Common questions in this guide

What is the Arterial Switch Operation for D-TGA?
The Arterial Switch Operation is a surgery that corrects D-TGA by moving the aorta and pulmonary artery to their correct pumping chambers. It also involves carefully replanting the tiny coronary arteries into the new aorta to ensure the heart muscle gets enough blood.
Why is the Arterial Switch better than older surgeries like the Mustard procedure?
Older methods used tunnels to redirect blood flow, forcing the weaker right side of the heart to pump blood to the entire body. The modern Arterial Switch ensures the heart's strongest pump, the left ventricle, does this work, leading to much better long-term survival.
What happens if my baby has complex D-TGA with a VSD?
If a standard Arterial Switch isn't possible due to other heart defects like a hole in the heart or a narrowed lung valve, surgeons may use alternative operations like the Rastelli or Nikaidoh procedures. These complex repairs create a new, natural path for blood flow inside your baby's heart.
How long will my baby stay in the hospital after an Arterial Switch?
You can generally expect your baby to stay in the hospital for two to four weeks after surgery. A major milestone before going home is ensuring your baby can feed properly and gain weight, as recovering from surgery takes a lot of energy.

Questions for Your Doctor

5 questions

  • •Is my baby a candidate for the standard Arterial Switch Operation (ASO)?
  • •How will you move the coronary arteries during the surgery, and are there any specific risks based on my baby's anatomy?
  • •What is the anticipated length of our hospital stay after the surgery?
  • •If my baby needs a Rastelli or Nikaidoh procedure, what is the optimal timing for that surgery, and how does it differ from a standard ASO?
  • •How do you manage feeding and weight gain leading up to the surgery and immediately after?

Questions for You

3 questions

  • •Do I feel prepared for the length and complexity of my baby's upcoming surgery?
  • •What support systems do I have in place for the day of the surgery and the initial recovery period in the hospital?
  • •How am I preparing logistically (time off work, childcare for siblings) for a 2-4 week hospital stay?

References

References (23)
  1. 1

    Management of the Adult with Arterial Switch.

    Breinholt JP, John S

    Methodist DeBakey cardiovascular journal 2019; (15(2)):133-137 doi:10.14797/mdcj-15-2-133.

    PMID: 31384376
  2. 2

    Dextro-Transposition of the Great Arteries: Long-term Sequelae of Atrial and Arterial Switch.

    Haeffele C, Lui GK

    Cardiology clinics 2015; (33(4)):543-58, viii.

    PMID: 26471819
  3. 3

    Arterial Switch Using an Autologous Aortic Sinus Tube With the Lecompte Maneuver.

    Kim JY, Sollie ZW, Kavarana M

    Annals of thoracic surgery short reports 2025; (3(4)):1087-1089 doi:10.1016/j.atssr.2025.04.002.

    PMID: 41425407
  4. 4

    30 years' experience with the arterial switch operation: risk of pulmonary stenosis and its impact on post-operative prognosis.

    Sobczak-Budlewska K, Łubisz M, Moll M, et al.

    Cardiology in the young 2023; (33(9)):1550-1555 doi:10.1017/S1047951122002670.

    PMID: 36040409
  5. 5

    Mid-Term Outcomes of Primary Arterial Switch Operation for Taussig-Bing Anomaly.

    Gu M, Hu J, Dong W, et al.

    Seminars in thoracic and cardiovascular surgery 2023; (35(3)):562-571 doi:10.1053/j.semtcvs.2022.06.001.

    PMID: 35691468
  6. 6

    Arterial switch operation in a child with commissural malalignment and unusual coronary anatomy.

    Konstantinov IE, Moscoso B, Fricke TA, et al.

    Multimedia manual of cardiothoracic surgery : MMCTS 2024; (2024()) doi:10.1510/mmcts.2024.027.

    PMID: 38775126
  7. 7

    Clinical Outcome of Patients with Transposition of the Great Arteries and Intramural Coronary Artery.

    Sun H, Dun Y, Yan J, et al.

    Pediatric cardiology 2021; (42(2)):417-424 doi:10.1007/s00246-020-02499-5.

    PMID: 33591387
  8. 8

    Pathogenesis and Surgical Treatment of Dextro-Transposition of the Great Arteries (D-TGA): Part II.

    Zubrzycki M, Schramm R, Costard-Jäckle A, et al.

    Journal of clinical medicine 2024; (13(16)) doi:10.3390/jcm13164823.

    PMID: 39200964
  9. 9

    Mechanisms for heart failure in systemic right ventricle.

    Andrade L, Carazo M, Wu F, et al.

    Heart failure reviews 2020; (25(4)):599-607 doi:10.1007/s10741-019-09902-1.

    PMID: 31853794
  10. 10

    Long-Term Survival After Arterial Versus Atrial Switch in d-Transposition of the Great Arteries.

    Kiener A, Kelleman M, McCracken C, et al.

    The Annals of thoracic surgery 2018; (106(6)):1827-1833 doi:10.1016/j.athoracsur.2018.06.084.

    PMID: 30172857
  11. 11

    Pregnancy outcomes and mid-term prognosis in women after arterial switch operation for dextro-transposition of the great arteries - Tertiary hospital experiences and review of literature.

    Horiuchi C, Kamiya CA, Ohuchi H, et al.

    Journal of cardiology 2019; (73(3)):247-254 doi:10.1016/j.jjcc.2018.11.007.

    PMID: 30579805
  12. 12

    Transposition of the Great Arteries With Intact Ventricular Septum and Left Ventricular Outflow Tract Obstruction: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD).

    Esmaeil H, Jacobs JP, Bleiweis MS, et al.

    World journal for pediatric & congenital heart surgery 2025; (16(6)):751-760 doi:10.1177/21501351251329911.

    PMID: 40420779
  13. 13

    Transposition of great arteries with left outflow tract obstruction and non-committed VSD: surgical management and late results.

    Kari FA, Uzdenov M, Kroll J, et al.

    European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 2022; (61(5)):1043-1053 doi:10.1093/ejcts/ezab477.

    PMID: 34747469
  14. 14

    Rastelli Operation for D-Transposition of the Great Arteries, Ventricular Septal Defect, and Pulmonary Stenosis.

    Huang ES, Herrmann JL, Rodefeld MD, et al.

    World journal for pediatric & congenital heart surgery 2019; (10(2)):157-163 doi:10.1177/2150135118817765.

    PMID: 30841838
  15. 15

    Fate of the Left Ventricular Outflow Tract After Rastelli With Selective Infundibular Muscle Resection.

    Barron DJ, Mehsood DK, Kutty RS, et al.

    The Annals of thoracic surgery 2019; (107(4)):1226-1231 doi:10.1016/j.athoracsur.2018.10.069.

    PMID: 30529669
  16. 16

    A 34-Year-Old Thai Man Presenting with Pulmonary Stenosis and Heart Failure 24 Years After Surgical Correction with the Rastelli Procedure for Congenital Dextro-Transposition of the Great Artery, Ventricular Septal Defect, and Pulmonary Atresia.

    Pongbangli N, Jai-Aue S, Rotchanapanya W, Wongcharoen W

    The American journal of case reports 2022; (23()):e933078 doi:10.12659/AJCR.933078.

    PMID: 35039470
  17. 17

    Options for coronary translocation and other considerations in aortic root translocation (Bex-Nikaidoh procedure).

    Vaidyanathan S, Supreet M, Shilpa M, et al.

    Annals of pediatric cardiology 2019; (12(3)):228-232 doi:10.4103/apc.APC_183_18.

    PMID: 31516279
  18. 18

    Aortic root translocation: the Bex-Nikaidoh procedure.

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    Indian journal of thoracic and cardiovascular surgery 2021; (37(Suppl 1)):36-41 doi:10.1007/s12055-020-00956-7.

    PMID: 33603284
  19. 19

    Optimizing Surgical Selection for Transposition With Left Ventricular Outflow Tract Obstruction.

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    The Annals of thoracic surgery 2024; (117(2)):370-377 doi:10.1016/j.athoracsur.2023.09.022.

    PMID: 37774760
  20. 20

    Transposition of the Great Arteries, Ventricular Septal Defect, and Pulmonary Stenosis: Modified REV versus Rastelli.

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    Pediatric cardiology 2021; (42(4)):762-767 doi:10.1007/s00246-021-02538-9.

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  21. 21

    Incidence and long-term outcomes of dextro-transposition of the great arteries (d-TGA) in the Kingdom of Bahrain.

    AlAraibi AJ, Shakeeb FN, Shakeeb ZN, et al.

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  22. 22

    Prostaglandin E1 overdose in a term neonate with congenital heart disease.

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  23. 23

    Successful Balloon Atrial Septostomy in a Premature Infant.

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This page provides educational information about surgical treatments for D-TGA. Always consult your pediatric cardiologist and surgical team for medical advice tailored to your baby's specific heart anatomy and recovery needs.

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