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Indian J Radiol Imaging
Indian J Radiol Imaging
10.1055/s-00050590
The Indian Journal of Radiology & Imaging
0971-3026
1998-3808
Thieme Medical and Scientific Publishers Pvt. Ltd. A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

10.1055/s-0044-1787685
IJRI-24-3-3453
Case Report
Delayed Presentation of Baffle Obstruction in an Adult Post–Mustard Repair of Transposition: Computed Tomography Demonstration
http://orcid.org/0000-0002-8982-9821
Nandi Debanjan 1
Malhi Amarinder Singh 1
Shaw Manish 1
Kumar Sanjeev 1
1 Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences New Delhi, New Delhi, India
Address for correspondence Debanjan Nandi, MD, DM Department of Cardiovascular Radiology and Endovascular Interventions, Cardio Neuro Centre, All India Institute of Medical Sciences New DelhiNew Delhi 110029Indiandebanjan007@gmail.com
18 6 2024
10 2024
1 6 2024
34 4 757760
Indian Radiological Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ )
2024
Indian Radiological Association.
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License, which permits unrestricted reproduction and distribution, for non-commercial purposes only; and use and reproduction, but not distribution, of adapted material for non-commercial purposes only, provided the original work is properly cited.
Atrial switch surgery is performed in patients with transposition of the great arteries. One of the complications of this surgery is obstruction of the baffle created. We describe the computed tomography findings of one such case where there was delayed presentation of recurrent Mustard baffle obstruction in addition to pulmonary venous drainage obstruction in an adult previously operated on for intra-atrial repair of transposition of the great arteries.

Keywords

atrial switch surgery
baffle obstruction
transposition of great arteries
Funding None.
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pmcCase History

A middle-aged female patient, who was a known case of transposition of great arteries with an intact ventricular septum, had undergone a Mustard atrial switch surgery at 3 years of age with no significant postoperative complications. The patient was on regular follow-up. At 32 years of age, the patient had an episode of transient ischemic attack with spontaneous recovery. Echocardiography at that time revealed normal biventricular function with stenosis of the common chamber to the right atrium (RA; a gradient of ∼15 mm Hg) and stenosis of the superior vena cava to the left atrial junction (a gradient of ∼20 mm Hg). Moderate tricuspid regurgitation and mild mitral regurgitation were also noted. Computed tomography angiography revealed calcification ( Fig. 1B ) of the baffle with stenosis in the superior vena cava to left atrial communication ( Figs. 1 , 2 ) and significant stenosis of the anastomotic site between the common chamber, draining all four pulmonary veins with the RA ( Fig. 3 ). No obstruction in the inferior vena cava to left atrial communication through the baffle ( Fig. 4B ) was seen. A chest radiograph revealed features of mild pulmonary venous hypertension in the form of the prominence of the upper lobe pulmonary veins ( Fig. 5 ). The patient was considered for revision surgery, and intraoperatively, the baffle was found to have shrunk and calcified. The prepulmonic course of the left coronary artery ( Fig. 4A ) precluded the arterial switch surgery at this time. After longitudinally incising the baffle and left atrial roof, the baffle was reconstructed using a wider Gore-Tex patch, along with widening of the pulmonary venous chamber. The patient was on routine follow-up after this revision surgery. Six years following this revision surgery on routine echocardiography, a superior vena cava baffle obstruction was seen with a gradient of 13/8 mm Hg. Computed tomography angiography at that time revealed tight stenosis of the superior vena cava to left atrium anastomosis ( Figs. 6 – 7A ) with no stenosis in the pulmonary vein to RA anastomosis ( Fig. 7B ). The patient was asymptomatic for this superior vena cava obstruction, hemodynamically stable, and presently on follow-up.

Fig. 1 ( A ) Coronal cinematic volume-rendered computed tomography image showing stenosis (shown by dotted black line ) of systemic baffle. ( B ) Coronal computed tomography image showing stenosis of the systemic baffle (shown by a dotted black line ) and calcification of the baffle (shown by a black arrow ). LA, left atrium; SVC, superior vena cava.

Fig. 2 ( A ) Axial computed tomography image showing stenosis of the baffle between the superior vena cava and left atrium (shown by a dotted black line ). ( B ) Axial cinematic volume-rendered image showing stenosis of the baffle between the superior vena cava and left atrium (shown by a dotted black line ). LA, left atrium.

Fig. 3 ( A ) Axial computed tomography image showing stenosis between common chamber draining pulmonary veins (pulmonic veins shown by black arrows ) and right atrium (stenosis shown by dotted black line ). ( B ) Axial volume rendered image showing stenosis between common chamber draining pulmonary veins (pulmonic veins shown by black arrow ) and right atrium (shown by dotted black line ). RA, right atrium.

Fig. 4 ( A ) Volume-rendered image showing the left main coronary artery (shown by thick black arrow ) having a prepulmonic course with division into the left anterior descending (shown by thin black arrow ) and left circumflex artery. ( B ) Oblique coronal volume-rendered image showing drainage of the IVC into the left atrium through a baffle (shown by a thin black arrow ) with no obstruction. IVC, inferior vena cava.

Fig. 5 Chest radiography showing upper lobe venous prominence secondary to pulmonary venous hypertension (shown by black arrowhead).

Fig. 6 ( A ) Coronal computed tomography image showing recurrent stenosis of systemic baffle (shown by dotted black line ), calcification of the baffle shown by black arrow . ( B ) Coronal cinematic volume-rendered computed tomography image showing recurrent stenosis of the systemic baffle (shown by a dotted black line ). LA, left atrium; SVC, superior vena cava.

Fig. 7 ( A ) Axial computed tomography image showing recurrent stenosis of the baffle between the superior vena cava and the left atrium (shown by a dotted black line ). ( B ) Axial computed tomography image showing wide opening between the common chamber draining pulmonary veins (pulmonic veins shown by a black arrow ) and right atrium (shown by a dotted black line ). LA, left atrium; RA, right atrium.

Discussion

This case shows the postoperative complications related to atrial switch surgery, such as baffle occlusion. Both baffle stenosis and pulmonary venous obstruction have been reported in the literature, with varying incidences. In the series of 33 patients by Kron et al, baffle obstruction occurred in one-third of patients (11 of 33) and required reoperation in 8 patients. 1 In a series of 402 survivors of the Mustard operation, described by Williams et al, 3.5% (14) of the children had to undergo reoperation for baffle obstruction. 2 Multiple risk factors have been described as causes of baffle obstruction, and operation at the age of less than 1 year is one of them. 1 2 Other causes include the use of Dacron material, operative techniques, baffle infection, shrinkage, and adhesions of the baffle to the atrial wall. 3

In the series by Kron et al, the latest age when baffle obstruction developed was 18 months following surgery. 1 In the case of systemic venous obstruction, if there is involvement of both the superior and inferior venae cavae, then only repair is required, whereas pulmonary venous obstruction is a more sinister complication and requires urgent treatment. 4

Conclusion

This case demonstrated a very delayed presentation of systemic baffle obstruction with its recurrence post–revision surgery and obstruction of pulmonary venous drainage. Computed tomography, particularly multiplanar reformatted images, helps accurately delineate the anatomy of stenosis and plan for urgent surgical management.

Conflict of Interest None declared.
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References

1 Kron I L Rheuban K S Joob A W Baffle obstruction following the Mustard operation: cause and treatment Ann Thorac Surg 1985 39 02 112 115 3155936
2 Williams W G Trusler G A Baffle obstruction after the Mustard operation Ann Thorac Surg 1985 40 04 416 417
3 Driscoll D J Nihill M R Vargo T A Mullins C E McNamara D G Late development of pulmonary venous obstruction following Mustard's operation using a Dacron baffle Circulation 1977 55 03 484 488 138490
4 Park S C Neches W H Mathews R A Hemodynamic function after the Mustard operation for transposition of the great arteries Am J Cardiol 1983 51 09 1514 1519 6846186
