1. REVIEWS
In the Footsteps of Senning: Lessons Learned From
Atrial Repair of Transposition of the Great Arteries
Ali Dodge-Khatami, MD, PhD, Alexander Kadner, MD, Felix Berger, MD,
Hitendu Dave, MD, Marko I. Turina, MD, and Rene´ Preˆtre, MD
Divisions of Cardiovascular Surgery and Cardiology, Center for Congenital Heart Diseases, Children’s Hospital, University of
Zu¨ rich, Zu¨ rich, Switzerland
The Senning operation has evolved from being the initial
surgical correction that allowed survival in complete
transposition of the great arteries to an integral part of
the anatomic repair of congenitally corrected transposi-
tion. In patients with complete transposition, the Sen-
ning operation has given satisfactory initial and long-
term surgical results, but the potential for right
ventricular failure and atrial arrhythmias have drastically
reduced its indications in the current era. The long-term
follow-up and pertinent postoperative issues of the Sen-
ning operation will be reviewed, along with its new-
found role in the anatomic repair of congenitally cor-
rected transposition.
(Ann Thorac Surg 2005;79:1433–44)
© 2005 by The Society of Thoracic Surgeons
In 1958 in Stockholm, Sweden, Ake Senning performed
the first procedure that would later bear his name. It
was initially conceived to be the complete and definitive
surgical correction for transposition of the great arteries
(TGA) [1]. In 1961 Senning moved to Zu¨ rich, Switzerland
and performed all atrial switches at Children’s Hospital
of Zu¨ rich from 1962 to 1978, after which Marko I. Turina
performed the rest of our series until 2003, for a total of
345 patients.
Without this operation, the natural history of patients
with all variants of TGA was dismal, with 55%, 85%, and
90% mortality rates at 1 month, 6 months, and 1 year,
respectively [2]. This ingenious procedure, also known as
the atrial or venous switch, involves rerouting the pul-
monary veins through the tricuspid valve to the systemic
right ventricle (RV) by means of an atrial flap (fashioned
from the free wall of the right atrium) plus the redirection
of systemic venous blood from both vena cavae, through
the mitral valve to the pulmonary left ventricle by using
the intraatrial septum.
The initial results of this procedure were disappointing
[3], as may be seen by the 7 hospital deaths from a series
of 11 patients (63.7% mortality) that was reported by
Kirklin and colleagues [4] in 1961. The high mortality and
difficulty in reproducing Senning’s own better experi-
ence [5] motivated others to modify the procedure. This
ultimately lead to the Mustard operation in 1964 [6], in
which a pericardial baffle was inserted. Quaegebeur and
colleagues revived the Senning operation through tech-
nical modifications, resulting in considerable improve-
ment of in-hospital survival [7].
Until the late 1970s, the atrial baffle operations were the
only established procedures for the repair of complete
transposition, and with increased experience, surgical
mortality steadily decreased to low levels (1% to 9%) [8].
However, intermediate- to long-term survivors were be-
ing recognized with RV failure, systemic and pulmonary
venous pathway leaks and obstructions, varying degrees
of tricuspid valve insufficiency, atrial arrhythmias, and
unexpected late sudden deaths.
Jatene successfully performed the first arterial switch
operation (ASO) in 1975, which increasingly gained pop-
ularity, was reproducible with an acceptable learning
curve, and resulted in lower mortality rates than the
Senning operation. More important, it represented an
anatomic and physiologic repair of transposition, placing
the left ventricle (LV) in the systemic position, thus
avoiding potential long-term RV failure that complicated
the atrial baffle operations. This fact, and mortality that
reaches zero in many centers that perform the ASO [9],
have made the Senning operation a palliative procedure.
As a result, the Senning operation has become nearly
obsolete in the surgical management of neonates with
TGA. It is important to note that the ASO transfers the
pulmonary valve to the systemic position, with the po-
tential for late neo-aortic valve incompetence, the long-
term significance of which is still unknown.
Renewed interest in the Senning operation has
emerged since the 1990s, as it is an essential part of the
anatomic repair in patients with congenitally corrected
transposition of the great arteries (CCTGA). Although
this relatively new strategy achieves anatomic and phys-
iologic repair of CCTGA, the number of large series is
limited and the follow-up is short. Theoretically, the
long-term complications that have been witnessed after a
Senning operation for TGA could be anticipated after
anatomic repair of CCTGA [10].
In this review we present technical details of the
Senning operation, summarize the results of larger re-
Address reprint requests to Dr Dodge-Khatami, Division of Cardio-
vascular Surgery, Children’s Hospital, University of Zu¨ rich, Steinwies-
strasse 75, CH-8032 Zu¨ rich, Switzerland; e-mail: ali.dodge-khatami@
kispi.unizh.ch.
© 2005 by The Society of Thoracic Surgeons 0003-4975/05/$30.00
Published by Elsevier Inc doi:10.1016/j.athoracsur.2004.04.013
REVIEWS

2. cent series, and address its potential long-term iatrogenic
and physiologic implications. In a failing post-Senning
heart, the indications for taking down an atrial baffle and
retraining the left ventricle (LV) en route to an ASO will
be discussed. It is hoped that the lessons learned from
the atrial repair of TGA will serve us to better treat those
patients with CCTGA who need an anatomic repair, in
which the Senning operation has its newfound role.
Material and Methods
We used the PubMed database (National Library of
Medicine) to perform a computerized literature search by
inserting the key words “Senning,” “Mustard,” and
“atrial switch,” with no specific time frame.
The data from our series and the ones presented in
Table 1 and Table 2 were gathered from a retrospective
chart review of all consecutive patients who had a Sen-
ning operation in each institution. Follow-up was per-
formed by the respective cardiology teams in each hos-
pital, by questionnaires sent to the patients residing
outside of the country where the operation took place, or
both. The term operative mortality in Table 1 refers to any
death that occurred within 30 days of surgery.
Results
Surgical Technique
After median sternotomy and pericardiotomy, the right
atrium is marked with two stitches at the level of the
crista terminalis, with an equal distance between the
marking stitches and the interatrial groove that is gener-
ously developed, indicating the site of the planned right
atriotomy. This forms a square trap door that will be
opened at the top and flipped downwards (Fig 1). The
techniques of cannulation and cardiopulmonary bypass
are fairly standard and present no particularities.
After cross-clamping, cardioplegia, and right atri-
otomy, an incision is made into the interatrial septum
around the limits of the fossa ovalis (Fig 2). This creates a
posteriorly based flap (Fig 3) that is lowered into the left
atrium and sutured above and around the orifices of the
pulmonary veins. This part of the procedure usually
involves the use of a small pericardial patch and a
longitudinal incision in the coronary sinus that allows for
an enlargement of the posterior portion of the pulmonary
venous atrium (Fig 4).
The systemic venous tunnel is completed by suturing
the free edge of the right atriotomy around both caval
orifices and along the remaining cut rim of the atrial
septum (Fig 5). Pulmonary rerouting is accomplished
after a horizontal incision is made into the left atrium,
parallel to the interatrial groove. The free edge of the
right atrium is brought down around the caval tunnel
and anastomosed to the opening in the interatrial groove.
In Zu¨ rich, we have found it important at this stage to use
a generous in-situ pericardial flap that is left attached to
its blood supply from the pericardiophrenic artery, thus
assuring normal patch growth (Fig 5 insert). This modi-
fication of Senning’s original technique has eliminated
Abbreviations and Acronyms
ASO ϭ arterial switch operation
CCTGA ϭ congenitally corrected transposition of
the great arteries
CHSS ϭ Congenital Heart Surgeons Society
ECMO ϭ extracorporeal membrane oxygenation
LV ϭ left ventricle or left ventricular
LVOTO ϭ left ventricular outflow obstruction
MRI ϭ magnetic resonance imagery
NR ϭ not reported
NYHA ϭ New York Heart Association
PA ϭ pulmonary artery
PHN ϭ pulmonary hypertension
RV ϭ right ventricle or right ventricular
SVC ϭ superior vena cava
TGA ϭ transposition of the great arteries
TI ϭ tricuspid insufficiency
VSD ϭ ventricular septal defect
y ϭ years
Table 1. General Results of Recent Series
Center Patients
Operative
Mortality
Late
Mortality Follow-Up Intervala
NYHA Class I
at Follow-Up
Zu¨ rich Current 345 14.3% (7% in
the last 4 years)
8% 15.4 y range 0.7–33.3 y 73%
CHSS (Wells et al, 2000) [11] 173 14% 8% 10.0 y 59%
London (Sarkar et al, 1999) [12] 141 6.4% 9% 13.4 y range 0.32–17.9 y 92%
Helsinki (Kirjavainen et al, 1998) [8] 100 2% 8% 12.8 y range 6.2–18.4 y 85%
Nashville (Bender et al, 1989) [13] 93 5.4% 1% 3.8 y range 0.8–9.4 y 97.5%
Leiden (Helbing et al, 1994) [14] 68 8.8% 16.1% 11.0 y range 0.1–20 y 66%
Boston (Marx et al, 1983) [15] 57 5% 4% 1.1 ϩ/Ϫ 0.7 y range 0.02–3 y NR
Portland (Reddy et al, 1996) [16] 54 9% 0% 6.4 y range 0.5–12.1 y 94%
Milwaukee (Litwin et al, 1987) [17] 40 0% 5% range 0.5–5 y NR
Brussels (Rubay et al, 1987) [18] 26 0% 0% 4 y range 0.08–8 y 96%
a
Follow-up times in median years ϩ/Ϫ standard deviation when available, followed by range in years.
CHSS ϭ Congenital Heart Surgeons Society; NR ϭ not reported; NYHA ϭ New York Heart Association; y ϭ years.
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3. the incidence of pulmonary vein obstruction in our
series.
Review of Recent Surgical Series
The results of recent larger series are summarized in
Table 1. Operative mortality of the Senning correction
ranges from 0% to 15.7%; however, when the rather
disappointing results from the early years of our own
experience are eliminated, mortality would be less than
10%. In older series, higher early mortality was partially
due to an initial learning curve, but more so to patient
selection [19], as illustrated by the number of young
patients undergoing the Senning operation with TGA
plus ventricular septal defect (VSD) and pulmonary vas-
cular obstructive disease. Late mortality is a troublesome
occurrence, seldom preceded by overt failure or active
arrhythmias. Its incidence is reported from 0% to 16.1%
in recent series, most often in the form of sudden death,
without a detectable anatomic or physiologic risk factor
and without relation to the time interval from operative
correction. Other frequent complications are presented
in Table 2, and are discussed more in detail in the
subsequent sections.
Table 2. Complications and Reoperations
Center Complications Reoperation Rate Pacemaker
Zu¨ rich Current 3 SVC stenosis, 2 severe TI 10.2% 3 transplantations 3.8%
CHSS (Wells et al, 2000)
[11]
Venous pathway
complications and RV
failure
6.9% 7.5%
London (Sarkar et al, 1999)
[12]
1 SVC stenosis, 1 baffle
leak, 2 LVOTO, 1 RV
failure
3.8% venous pathway complications
and LVOTO relief
1.5%
Helsinki (Kirjavainen et al,
1998) [8]
1 pulmonary vein occlusion,
1 severe TI
4% 1 pneumonectomy for pulmonary
vein occlusion, 1 transplantation,
2 tricuspid valve operations
24%
Nashville (Bender et al,
1989) [13]
1 baffle leak 1.25% 1 reoperation for baffle leak 3.75%
Leiden (Helbing et al,
1994) [14]
9 TI 0% 4.8%
Boston (Marx et al, 1983)
[15]
6 pulmonary vein
obstructions, 7 SVC
stenosis
12% for systemic and pulmonary
venous complications
1.9%
Portland (Reddy et al,
1996) [16]
3 TI 3.7% LVOTO relief 0%
Milwaukee (Litwin et al,
1987) [17]
1 pulmonary vein stenosis,
1 TI
2.5%, 1 reoperation for pulmonary
venous obstruction
5%
Brussels (Rubay et al, 1987)
[18]
2 mild SVC obstructions 0% NR
LVOTO ϭ left ventricular outflow obstruction; nr ϭ not reported; RV ϭ right ventricle; SVC ϭ superior vena cava; TI ϭ tricuspid valve
insufficiency.
Fig 1. Surgeon’s view and the proposed trap door right atrial inci-
sion in dashed lines. The cannulas for cardiopulmonary bypass are
not shown. (IVC ϭ inferior vena cava; SVC ϭ superior vena cava.)
Fig 2. The right atrium has been opened, with the proposed incision
in the interatrial septum (dashed line) for the future septal flap.
Note the extension of this incision into the mouth of the coronary
sinus. (AV ϭ atrioventricular.)
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REVIEWS

4. Long-Term Follow-Up Issues
EXERCISE TOLERANCE. The adequacy of the right ventricle to
sustain the systemic circulation in the long-term can be
questioned by its relative inefficient response to stress
and effort, as illustrated by multiple studies enrolling
patients after a successful atrial switch who are otherwise
asymptomatic, in sinus rhythm, and without medication.
Douard and colleagues performed bicycle ergometry in
43 asymptomatic patients at a mean follow-up of 11 Ϯ 2.8
years after a Senning operation. They found reduced
aerobic capacity, shorter exercise times, and lower max-
imal heart rates, indicating an impaired chronotropic
response to effort [20]. Exercise capacity was inversely
correlated with the time interval elapsed since surgery,
suggesting that better functional results can be antici-
pated when the Senning operation is performed early.
They also found an excessive ventilatory adaptation to
exercise, reflected by an increased respiratory rate, a
relative lesser increase in tidal volumes, and increased
total ventilation, as compared to controls [20].
Matthys and colleagues pinpointed the lack of increase
in stroke volume to be the underlying mechanism of an
inefficient response to effort, stressing that RV dysfunc-
tion can exist without chronotropic impairment [21]. Also
using bicycle ergometry, Gilljam and colleagues [22]
demonstrated low oxygen uptake, low maximal heart
rate, abnormal stroke volume response, and high total
peripheral resistance in 17 adolescent patients after an
atrial switch. The authors suggest contributing factors to
include small and noncompliant atria with subsequent
inadequate filling of the ventricles, ventilation-perfusion
inequality, intrapulmonary shunts, and oxygen diffusion
limitation between the alveoli and pulmonary capillaries
[22].
Buheitel and colleagues [23] compared exercise perfor-
mance of patients after a Senning operation or a Fontan
completion with normal controls. They measured peak
consumption of oxygen, maximal work rate, peak oxygen
pulse, and end-expiratory pressure of carbon dioxide and
found the poorest results in Fontan patients. The reaction
to exercise was qualitatively identical between Fontan
patients and those after a Senning operation, and com-
parable to that of patients with chronic heart failure.
Quantitatively, they found the results of Senning patients
to lie between controls and Fontan patients [23].
RIGHT VENTRICULAR FAILURE. After the atrial switch, the RV
remains in the systemic circulation, similar to unoperated
patients with CCTGA. Numerous reports have demon-
strated the inadequacy of this ventricle to sustain the
Fig 3. The septal flap is dropped down into the left atrium and
sewn over the orifices of the pulmonary veins. Note the pericardial
patch that is sutured to the septal flap, thus filling the defect left by
the foramen ovale, and enlarging the pulmonary venous atrium.
(SVC ϭ superior vena cava.)
Fig 4. The pulmonary veins have been covered by the septal flap.
The white arrows show the redirected systemic venous blood flow,
from the two caval veins towards the mitral valve. (IVC ϭ inferior
vena cava; SVC ϭ superior vena cava.)
Fig 5. The systemic venous tunnel has been completed. The pedicled
pericardial flap is sutured to the opening in the left atrium, and its
free edge will be sutured to the opening in the right atrium, thus
completing the neo-pulmonary atrium. The white arrow shows the
redirected flow of pulmonary venous blood from the left atrium to-
wards the tricuspid valve, traveling over and around the systemic
venous tunnel. The inset shows the completed repair, with the aug-
mented pulmonary venous atrium, and branches of the pericardio-
phrenic artery. (IVC ϭ inferior vena cava; SVC ϭ superior vena
cava.)
1436 REVIEW DODGE-KHATAMI ET AL Ann Thorac Surg
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5. systemic circulation in the intermediate and long term,
with RV dysfunction rates ranging between 4% and 16%
[24–29]. RV failure seems to be more prominent and
occurs earlier in patients with TGA plus VSD, than in
those with an intact interventricular septum [25, 27, 29].
RV failure is not a time-related event and can occur
insidiously after a long period of apparent normal func-
tion in an otherwise asymptomatic patient [26]. This has
been the major impetus towards not only abandoning the
Senning operation for TGA but also for converting an
atrial switch into an ASO and for promoting the anatomic
repair in CCTGA, thus restoring the morphologic LV to
the systemic circulation.
Using radionuclide ventriculography in 99 patients at a
median of 13 years after an atrial switch, Reich and
colleagues [27] demonstrated systolic dysfunction not
only of the RV in 8% of patients, but also of the LV in 10%
of patients. Diastolic dysfunction of the LV was present in
up to 80% of patients and deteriorated with time [27].
Lubiszewska and colleagues [24] used myocardial perfu-
sion imaging and radionuclide angiography to study 61
patients at rest and at exercise at a mean of 10 years after
an atrial switch. Despite excellent exercise tolerance, RV
systolic dysfunction was illustrated by a significantly
reduced RV ejection fraction in all patients, mild perfu-
sion defects in 14.7% of patients, and extensive perfusion
abnormalities in 54% of patients, more often in the
inferior and anterior wall of the RV. Perfusion abnormal-
ities were more pronounced in patients who were older
at the time of surgery and who had longer follow-up
times. Also, moderate-to-severe tricuspid valve insuffi-
ciency was more frequent in patients with abnormal
perfusion [24].
Confirming these results with a longer follow-up time
of between 10 and 20 years after an atrial switch opera-
tion, Millane and colleagues [30] found perfusion defects
in 21 of 22 patients studied (95%) at rest, during dipyrid-
amole stress testing, or both. More alarming, these per-
fusion defects were irreversible in 55% of patients, indi-
cating infarction or fibrosis, more importantly so in the
anterior, inferior, and septal segments of the systemic
RV. Concomitant wall-thickening abnormalities were
noted in 83% of segments with fixed perfusion defects,
mirrored by reduced wall motion [30].
Labbe and colleagues reported similar results in 43
patients 11.3 Ϯ 3 years after a Senning operation by using
thallium myocardial scintigraphy [31]. In a study compar-
ing patients undergoing either a Senning operation or an
ASO, Okuda and colleagues found reduced systolic
shortening of the anteroposterior diameter of the sys-
temic RV only in the Senning patients [32].
In unoperated patients with CCTGA, a morphologic
RV sustains the systemic circulation and presents the
same shortcomings as after a Senning correction. Hor-
nung and colleagues [33] demonstrated reversible and
fixed perfusion defects in 5 unoperated patients with
CCTGA, correlating with regional wall motion, thicken-
ing abnormalities, and impaired RV contractility. Tu-
levski and colleagues found similar results in 13 adult
patients with unoperated or physiologically repaired
CCTGA by using magnetic resonance imagery (MRI) and
dobutamine stress testing [34]. Both groups of authors
conclude that ischemia and infarction are important
causes of RV failure in patients with CCTGA, drawing
parallels with the systemic RV after the atrial switch
operation.
Somewhat contrary to this evidence, Lorenz and col-
leagues [35], using cine MRI, found markedly elevated
RV mass, normal RV size, and only mildly depressed RV
ejection fraction in 22 patients 8 to 23 years after an atrial
switch procedure. Only 1 patient had clinical RV dys-
function with increased RV mass, a finding also observed
in only 1 out of 40 patients in the series from Milwaukee
[18]. They conclude that inadequate hypertrophy of the
RV is not the cause of late RV dysfunction in patients
after an atrial switch [35].
Using radionuclide cineangiography, Hochreiter and
colleagues [36] studied 22 patients 8 to 18 years after an
atrial switch and found not only normal resting RV and
LV ejection fractions, but also preserved exercise endur-
ance with normal RV ejection fraction at stress in patients
having undergone their repair before the age of 1 year.
They and others [18, 37] suggest that deleterious factors
such as chronic hypoxia may explain the suboptimal
results observed in older patients who undergo the atrial
baffle procedure [36].
The cause of impaired RV function is presently un-
clear, and the available data are still inconclusive as to its
implication. The etiology is probably multifactorial, ei-
ther related to a late operation after chronic preoperative
cyanosis and resultant RV ischemia, to suboptimal intra-
operative myocardial protection, as was certainly the case
in older series that used more primitive cardioprotective
techniques, or to the inherent suboptimal geometry of
the RV [28, 38]. Given the existence of adult patients
whose RV volumes, function, and response to exercise
are normal long after an atrial baffle procedure, it seems
unreasonable to condemn the Senning or Mustard oper-
ations on the basis of inevitable RV dysfunction alone.
BAFFLE STENOSIS OR LEAK. Systemic vena cava stenosis cor-
responds to a pullback pressure difference of more than
5 mm Hg during catheterization [39]. Surprisingly, symp-
tomatic caval obstruction is relatively rare, generally
observed within weeks to several months after an atrial
switch when it does occur, and rarely beyond 1 year
postoperatively [39]. It is observed more frequently in
patients who were operated on as neonates [16, 40, 41].
Superior caval obstruction is much more frequent than
the obstruction of the inferior vena cava. When present,
symptoms include puffiness of the eyelids or facial
edema, pleural effusion, and even chylothorax [12]. Sys-
temic venous obstruction has been reported more fre-
quently after the Mustard operation (10% to 40% ) [15, 19]
than after the Senning operation (0% )[25].
Pulmonary venous obstruction, contrary to systemic
stenosis, is usually symptomatic. The reported incidence
of this complication is 0% to 27%, much less frequently
after the Senning operation [19, 39], although others have
not found a statistical difference between the two proce-
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6. dures (10% after Mustard vs 13% after Senning) [40].
Symptoms consisting of cough, wheezing, dyspnea, and
exercise intolerance usually present during the first year
and indicate surgical reintervention, not infrequently on
an urgent basis [19].
Baffle leaks (Fig 6) lead to residual interatrial shunts,
either bidirectionnal or predominantly right to left. They
are usually without hemodynamic significance and rarely
indicate surgical reintervention for this reason alone [19].
Right-to-left shunting occurs in the absence of elevated
systemic venous pressures and has to do with the stream-
ing of blood underneath the interatrial baffle. The inci-
dence ranges from 20% to 73% after the Mustard opera-
tion and from 0% to 50% after the Senning operation [39].
ATRIAL ARRHYTHMIAS. Arrhythmias are frequent after an
atrial switch operation, including sinus node dysfunction,
sinus rhythm with intermittent junctional escape, junc-
tional rhythm, supraventricular tachycardia, atrial flutter
or fibrillation, and ventricular tachycardia. Byrum and
colleagues found sinus node dysfunction in 30% of oper-
ative survivors, more frequently in patients younger than
5 months of age at the time of surgery, and relate this to
intraoperative damage that is caused by the proximity of
sutures lines to the sinus node in the smaller patient [42].
Sinus node dysfunction is a progressive occurrence.
Deanfield and colleagues reported normal sinus
rhythm in 84% of their patients in the immediate post-
operative phase of an atrial baffle procedure, falling to
56% in stable sinus rhythm after a Senning correction,
and to 66% after a Mustard operation, at a mean fol-
low-up of 7 years [43]. They found no relation between
the loss of sinus rhythm or active arrhythmia and sudden
death, which occurs in up to 11% of patients as docu-
mented by Holter recordings [43]. In a more recent study
from the same institution comparing the Senning and
Mustard operations, the incidence of postoperative atrial
flutter was similar and was strongly associated with late
sudden death [12].
Intraatrial reentry tachycardia occurs in 2% to 10% of
patients after the atrial switch operation [44]. It induces a
rapid ventricular response and is thought to be one
explanation for the 3% to 15% incidence of postoperative
sudden death. Atrial tachyarrhythmias are induced by
reentrant circuits that result from the extensive atrial
suture lines involved in a Senning or Mustard operation
[45]. Concealed entrainment techniques can be used to
map reentry sites, which are most often found in the
mouth of the coronary sinus and the tricuspid valve
annulus, and in the atrial myocardium of right atrial
origin, whether they are part of the surgically created
pulmonary or venous atrium [45]. These sites can be
successfully silenced with radiofrequency catheter abla-
tion, and recurrence at midterm follow-up is low. This
treatment modality aims to eliminate the electrical sub-
strate for the arrhythmia and is hence more attractive
than medication, which can result in breakthrough tachy-
cardia or proarrhythmia, or both. Antitachycardia pacing
has been used to treat intraatrial reentry tachycardia, but
it carries the risk of accelerating the tachycardia into
atrial fibrillation [45].
TRICUSPID VALVE INSUFFICIENCY. Various degrees of tricuspid
valve insufficiency (TI) have been reported after the atrial
switch, with an incidence that reaches as high as 52% in
some series [8]. Relevant TI occurs more frequently after
the Mustard correction than after a Senning operation
[12]. It is more frequent in patients with TGA plus VSD,
and may be related to intrinsic abnormalities of the
tricuspid valve in these patients [25, 29, 46] or to intraop-
erative injury or distortion of the valve during VSD
closure [25, 29, 39]. The incidence varies from 5% when
the interventricular septum is intact to 30% with an
associated VSD [19].
The degree of severity is usually mild, and symptoms
or hemodynamic relevance are rare when TI occurs in the
absence of RV failure [14,15, 39]. Accordingly, few reop-
erations are needed for isolated TI (see Table 2). Accord-
ing to Poirier and Mee [47], differences in outcome and
eventual failure of the RV after a Senning procedure are
related to the degree of TI in the immediate postopera-
tive period, particularly in patients with TGA plus VSD.
In the series from Melbourne [25], tricuspid valve dam-
age at VSD closure or by jet lesions contributed to the
difference in outcomes, suggesting that mild postopera-
tive (post-Senning) TI could become significant and po-
tentially lethal because it adds to the RV workload,
further precipitating RV failure [25, 47].
When severe TI occurs, it is a precursor and near
surrogate of impending RV failure, which it precedes by
years [8, 29]. This may be addressed by tricuspid valve
repair or replacement, although the results are disap-
pointing [26, 28, 29, 37, 48], with minimum improvement
in hemodynamics. When TI is associated with RV failure,
Fig 6. Cardiac angiography with contrast injection of the systemic
venous tunnel and the bend it performs around the septal flap.
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7. atrial switch takedown, pulmonary artery (PA) banding
and conversion to an ASO [28, 29], or transplantation,
may be better options [8, 28, 48].
PULMONARY VASCULAR OBSTRUCTIVE DISEASE. The appearance
and progression of pulmonary vascular obstructive dis-
ease and resultant pulmonary hypertension (PHN) in
unoperated patients with TGA is related to age; the
degree to which it persists, stabilizes, or regresses after
an atrial switch is also a function of age at correction [39].
Mild-to-severe PHN occurs in 4% to 35% of patients with
TGA plus an intact ventricular septum after an ASO [39].
This incidence is only 1% to 3% when the repair is
performed before 1 year of age, and increases steadily
thereafter. As a corollary, risk factors to develop PHN
include older age at repair, the preoperative presence of
a large patent ductus arteriosus, and a large VSD [39].
The progression of PHD after an atrial baffle procedure is
rare but has been reported, as well as the even more rare
decrease in pulmonary arteriolar resistance after surgical
correction [39].
Psychosocial Outcomes and Neurodevelopment
After the various surgical repairs for TGA, children have
more neurologic impairment, learning disabilities, be-
havioral disorders, and poorer motor and vocabulary
abilities than their healthy peers [49–51]. Although this
has been extensively documented after the ASO by the
group from Boston Children’s Hospital [49–51], the def-
icits found in this cohort do not seem specific to children
with TGA, but are similar to those found in others
undergoing repair of a congenital or acquired heart
defect [51].
Alden and colleagues [52] studied 31 children who
were operated on in one institution at a mean of 11.5
years after a Senning or Mustard repair, with varying
cardiac functional status at last follow-up. Nineteen per-
cent had a psychiatric diagnosis, mostly of an internaliz-
ing nature that tended to be predicted by the severity of
the cardiac condition. This is still considerably lower than
what has been reported after cardiac surgery for other
cyanotic cardiac conditions. These children had good
psychosocial functioning, and only one in five had severe
emotional or behavioral problems. Intelligence quotient
scores were marginally lower than the general popula-
tion, but only one child was mentally retarded (3%) [52].
Culbert and colleagues [53] compared patients having
undergone an ASO operation, a Senning or Mustard
operation, and a Rastelli operation with healthy age-
matched children. After TGA repair, children and ado-
lescents functioned well both physically, and psychoso-
cially. The complete patient population scored higher on
the Child Health Questionnaires than control norms in
all categories except self-esteem. Patients achieved
higher scores after an ASO [53] than both subsets of
patients undergoing an atrial baffle procedure. Contrary
to this study, Ellerbeck and colleagues found no differ-
ence in cognitive and motor development, neurologic
impairment, learning disabilities, behavior disorders, or
motor, vocabulary and acquired abilities, between chil-
dren after an ASO and an atrial switch operation [54].
Given the vast list of pre-, intra-, and postoperative
variables that may affect the mid- to long-term neurode-
velopmental status of a patient, it is currently difficult to
establish whether the underlying disease itself, the type
of surgical correction, or the technical aspects of cardio-
pulmonary bypass are responsible for the adverse out-
comes [51].
Senning Versus Mustard
After the Senning procedure was abandoned in the
mid-1960s and early 1970s in favor of the Mustard oper-
ation, renewed interest in the Senning procedure was
gained after the technical modifications introduced and
promoted by Quaegebeur and colleagues [7].
The theoretical and practical relative advantages of the
Senning operation include avoidance of foreign material,
potential for growth of native tissues forming the neo-
chambers, potential functional capacity with muscular
contraction of the atrial chambers, and avoidance of
akinetic patches that can scar, shrink, thicken and further
obstruct atrial inflow, such as that seen with the Mustard
operation [41]. In a population-based cohort study that
looked at mortality 25 years after surgery for congenital
heart diseases, Morris and Menasche found an improve-
ment in survival with the Senning operation compared
with the Mustard operation (late cardiac mortality 2% at
10 years, and 15% at 15 years, respectively) [55]. Arrhyth-
mias were a major cause of morbidity and mortality in
survivors of the Mustard operation, but not with the
Senning operation, after which no arrhythmia-related
deaths were noted [55].
The recent multicenter study from Belgium compared
the long-term outcome in 339 patients up to 30 years after
one of the two atrial switch procedures [56]. Both groups
had a relatively high early mortality rate, but actuarial
survival at 10, 20, and 30 years was satisfactory at 91.7%,
88.6%, and 79.3%, respectively. This was slightly better
for the Senning group, although not significantly. At late
follow-up, Senning patients had better functional status,
participated more actively in sports, and had fewer
baffle-related problems than did the Mustard group [56].
Sarkar and colleagues [12] compared their series of 141
patients who underwent a Senning operation with 249
patients who underwent the Mustard operation during
the same time period. Survival was significantly better
for the Senning group, reinterventions for baffle-related
problems or left outflow tract obstruction were signifi-
cantly lower, and pacemaker insertion was less frequent.
The loss of stable sinus rhythm was comparable in the
two groups and unrelated to death. The incidence of
atrial flutter was similar in both groups and strongly
associated with late sudden death. The authors con-
cluded that the Senning operation had superior results,
with good late functional status, and argued that elective
atrial baffle takedown and conversion to an ASO cannot
be justified in asymptomatic post-Senning patients [12].
During the same historical period in which patients
were enrolled to undergo either of the atrial baffle pro-
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8. cedures, Helbing and colleagues [14] compared 60 pa-
tients after a Mustard operation with 62 patients after a
Senning procedure. At respective median follow-up
times of 16 and 11 years postoperatively, there were no
differences with regards to baffle-associated problems,
RV failure, sudden death, or functional status between
the Mustard and Senning patients. Satisfactory long-
term survival was similar, and excluding pacemaker
implantation, no reoperations were necessary in either
subset of patients. The only significant risk factor for the
occurrence of sinus node dysfunction was the Mustard
operation [14].
A technical pitfall of the Mustard operation involves
the difficulty in shaping an appropriate baffle without
creating systemic or pulmonary venous obstruction, par-
ticularly in neonates. In a meta-analysis that reviewed
multicentric postoperative angiographic data, Graham
[39] found both caval obstruction and pulmonary venous
stenosis to be more frequent after the Mustard operation
than after a Senning operation. Risk factors to develop
systemic venous obstruction included the use of a Dacron
(DuPont, Wilmington, DE) baffle, operation in early in-
fancy (Յ 6 months), and the use of a “trouser-shaped”
baffle instead of a “dumbbell-shaped” baffle, such as that
originally described by Mustard [39].
Contrary to these reports, The Congenital Heart Sur-
geons Society [11] found better early and late survival
after the Mustard operation than after a Senning opera-
tion in a prospective cohort of patients with TGA who
were destined to have either an ASO, or one of the two
atrial switch procedures. Twenty-one patients who were
intended to have an ASO had a Senning operation
instead owing to unfavorable conditions or anatomy that
were discovered in the operating room. This cross-over
with higher risk patients undergoing the Senning oper-
ation may have influenced the difference in early survival
in favor of the Mustard operation, but does not explain
the difference in late survival. In the atrial switch sub-
group, risk factors for long-term pacemaker requirement
included patients with TGA plus VSD undergoing a
Senning operation, and previous surgical atrial septec-
tomy [11]. Institutional preference or experience could
partially explain the better early and late results with the
Mustard variation, although this is purely speculative.
LV Retraining and Senning Takedown En Route to an
ASO
When RV failure after a Senning correction reaches an
advanced stage, treatment options are limited to tricus-
pid valve replacement, orthotopic cardiac transplanta-
tion, or atrial baffle takedown and conversion to an ASO.
As the first two procedures have their own set of disap-
pointing results and long-term complications [25, 28, 29,
37], more groups advocate restoring the morphologic LV
to the systemic circulation [25, 29, 57]. Most often, this
cannot be done in one step, as the LV has accustomed
itself to the low pressures found in the pulmonary
circulation. Before a Senning or Mustard takedown and a
successful ASO are attempted, the LV must be retrained.
Pulmonary artery (PA) banding is required to achieve
adequate LV muscle mass, as was first described by Mee
[29].
Currently, there are no clear indications or discrimi-
nating points to decide when a patient should no longer
be treated medically for heart failure, whether transplan-
tation is deemed a better option, or whether one should
directly proceed to LV retraining. This controversial topic
finds proponents and adversaries for each therapeutic
arm and may be institutional-based; its answer is beyond
the scope of this review. As medical treatment and
transplantation are well described in the literature, LV
retraining en route to an ASO is briefly reviewed here.
Foremost, contraindications to LV retraining include
irreversible LV dysfunction, pulmonary valve abnormal-
ities that render it unsuitable as a future neo-aortic valve,
LV outflow tract obstruction that cannot be relieved, and
uncontrolled arrhythmias [47]. The response to LV re-
training is poorer in patients who are older than 15 years,
although a successful Senning takedown and ASO were
performed in a 28-year-old patient [47]. The degree of
preexisting RV failure does influence the response to LV
retraining, owing to the common interventricular septum
that bulges towards the LV that induces LV outflow tract
obstruction and eventual LV failure at lower than ex-
pected LV pressures [25, 47]. For these reasons, earlier PA
banding is advocated, before decongestive therapy for
RV failure becomes necessary [25, 28].
The aims of PA banding are to achieve a LV/RV
pressure ratio of 0.7 or greater. One or more bandings
may be required over a period of approximately 1 year to
induce adequate LV hypertrophy, although this period is
generally shorter in younger children [47]. The prepara-
tory stage of retraining is better tolerated in patients after
a previous atrial baffle procedure than in patients with an
unoperated TGA who present late [48]. The former do
not require systemic-to-pulmonary shunts in addition to
a PA band to maintain adequate saturations, as they
already have a physiologic circulation [48]. PA banding
can induce neo-aortic valve insufficiency [28, 48, 57, 58],
and the relative cumbersome need to perform multiple
operations to tighten or loosen a band before adequate
LV retraining is achieved may promote wider applica-
tions for the new adjustable and teleguidable FloWatch-
R-PAB (EndoArt SA, Lausanne, Switzerland) band [59].
Before debanding, Senning takedown, and conversion
to an ASO, transthoracic echocardiography, cardiac cath-
eterization, and MRI are performed. These seek to con-
firm a LV that generates more than 80% of systemic blood
pressures at rest, suprasystemic pressures with isopro-
terenol, or normal LV mass and wall thickness, indexed
for weight and age [47, 58]. The size of the coronary
arteries, and namely, that of the left coronary artery
before PA debanding, may influence the success of a
subsequent ASO with regards to the increase in coronary
flow reserve that is required to adequately perfuse the
future systemic LV [60].
In appropriately selected patients, the results of the LV
retraining protocol after a failed Senning en route to an
ASO are good to excellent in prepubescent patients [25,
28, 47, 58], but give unpredictable results in patients older
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9. than 15 or 16 years [47, 58]. LV retraining has failed when
inadequate LV hypertrophy or LV dysfunction occurs, or
if atrial arrhythmias progress [47]. When LV retraining is
unsuccessful with uncontrollable ongoing RV dysfunc-
tion before an ASO, or LV deterioration after a secondary
ASO, then early transplantation should be considered
[28, 48, 57, 58]. The results of transplantation for a failed
atrial switch have been satisfactory when performed in a
timely fashion, although the long-term consequences
that are general to all posttransplant patients, namely
issues pertaining to a lifelong immunosuppressive regi-
men, are of concern [28, 48].
Rebirth of the Atrial Baffle Procedures for Patients
With CCTGA
Although the Senning operation seems outdated and is
used only in exceptional cases to treat patients with TGA,
increasing interest and experience is being gained with
this procedure in patients with congenitally corrected
transposition as part of the double switch or Senning-
Rastelli procedures. These operations reposition the
morphologic LV in the systemic circulation, also referred
to as the “anatomic repairs” of CCTGA, and are currently
the treatment of choice in patients with this anomaly [28,
47, 61–66]. Most authors recommend anatomic repair
when tricuspid valve regurgitation or RV dysfunction are
present [62, 64]. Others are more aggressive and recom-
mend anatomic repair for all patients with an adequate
or trainable LV, although until which age this is feasible
or gives acceptable results is still controversial [62, 65, 66].
Proponents of the anatomic repair have demonstrated
better results when the double switch is performed, with
or without prior LV training, before the age of 15 to 16
years [47, 62]. Results have been less satisfactory in older
patients, and in some instances, the LV is simply no
longer trainable, leaving transplantation as the only sal-
vage alternative. Some controversy concerning the dou-
ble switch still revolves around asymptomatic patients,
with or without associated intracardiac defects [67]. In-
deed, drawing parallels between unoperated patients
with CCTGA and patients after atrial correction for TGA,
normal or near normal RV function in the long-term has
been demonstrated in minimally symptomatic or asymp-
tomatic adult patients with CCTGA [67].
When an anatomic repair of CCTGA is performed, the
Senning operation is the preferred atrial baffle procedure
for most [47, 61, 63], although in the presence of dextro-
cardia, the Mustard operation may be technically easier
to perform [10, 61]. The timing of an anatomic repair is
based on the size of the VSD. When the VSD is restric-
tive, LV pressures remain low (infra-systemic), resulting
in an untrained LV, and the procedure should be per-
formed before 1 month of age [61]. If it is performed later,
preliminary PA banding may be required to redevelop
the LV. With a large VSD that results in unrestricted
pulmonary blood flow and systemic PA pressures, the
repair should be performed by 6 months of age to
prevent the development of pulmonary vascular disease
[61].
The results of this complex procedure are good to
excellent, with mortality rates ranging from 0% to 15%
[62–65]. Long-term follow-up of the anatomic repair for
CCTGA is still required for patients with valved conduits
who have undergone a Senning-Rastelli procedure and
for the aortic valve and the morphologic LV in patients
after the double switch [64]. Although the LV is restored
to the systemic circulation, the long-term complications
related to the atrial part of the Senning operation, namely
the venous pathway problems and atrial arrhythmias,
may still be expected [10].
Indications to Perform an Atrial Switch Operation for
TGA
There are still instances where the Senning operation
may be indicated for patients with TGA. These include
complex coronary anatomy precluding an ASO, or late
referral in patients with TGA plus VSD, which is very
commonplace in developing countries. In this situation,
PNH and a LV that is inadequate or untrainable may
both contraindicate an ASO [16]. Even in older infants
with an intact ventricular septum and low LV pressures,
there still may be a place for the atrial baffle procedure
[37].
A certain subset of patients may be more common than
reported, mostly in developing countries with subopti-
mal medical control and access to diagnosis, namely
those with TGA plus an intact ventricular septum, and
severe PHN without a correctable cause. In the absence
of overt left-to-right shunting, idiopathic PHN tends to
last well beyond the neonatal period, if it regresses at all,
and is more difficult to manage with medical therapy.
Successful surgical correction has been achieved in
neonates with TGA plus an intact septum and PHN with
an ASO [68], at the cost of a lengthy and stormy postop-
erative course that required inhaled nitric oxide or even
extracorporeal membrane oxygenation (ECMO) [69, 70].
In these patients, Sharma and colleagues reported 75%
mortality with an attempted ASO [68]. Despite what
seemed to be a “prepared” LV preoperatively, RV failure
in the face of systemic pulmonary artery pressures re-
sulted in death. In addition, neopulmonary valve insuf-
ficiency is also a well-documented possibility after an
ASO and will worsen with poor right-sided hemodynam-
ics in the face of PHN. In 6 similar infants presenting
consecutively, they opted for a Senning repair that re-
sulted in early extubation and hospital discharge as well
as 100% survival. Four of the patients had normal pul-
monary artery pressures at 1 year postoperatively. A
morphologic LV is better suited to face systemic pulmo-
nary pressures in the setting of patients with PHN, and
may give better chances for survival [69].
The group from Great Ormond Street, London, has
recently presented their evolving practice to expand the
indications for an ASO, either for late referral or diagno-
sis, prematurity, or intercurrent illness [70]. In these
difficult patients, increased experience and the availabil-
ity of postoperative ECMO has allowed post-ASO sur-
vival in selected patients up to 6 months of age [70].
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10. Conclusions
After being the only viable surgical solution for patients
with TGA, the Senning operation successfully enjoyed
popularity, followed by abandonment in favor of the
Mustard operation, then an initial revival after modifica-
tions introduced by Quaegebeur, and colleagues [7],
before finally finding its most frequent current indication
as part of the anatomic repair for patients with CCTGA.
Surgeons can perform the Senning operation low mor-
tality and minimal morbidity by applying technical mod-
ifications and paying meticulous attention to large and
unobstructed venous pathways. The results of this pro-
cedure may be compared with the newer ASO for TGA
with regards to initial operative success, although long-
term complications of the atrial baffle procedure cur-
rently speak in favor of the ASO. Eventual RV failure is
not a time-related event [26], and still hampers the late
follow-up of patients after the Senning operation. There
is some evidence that the onset or degree of RV failure
[18, 24, 36–38] or exercise intolerance [20, 36] may be
reduced when the Senning operation is performed ear-
lier, particularly before the age of 1 year [36]. Currently,
no diagnostic tool exists that allows for prediction of
eventual RV failure in patients after an atrial correction
for TGA. Long-term arrhythmias remain a problem after
the atrial switch. In some instances this may be treated
conservatively, although more invasive radiofrequency
catheter ablation is required in others. The insidious
nature of the various arrhythmias and their potential but
unproven relation to sudden death emphasizes the need
for closer arrhythmia follow-up.
It is noteworthy that reports from Europe and Australia
that compare the Senning and the Mustard operations
point to better immediate and long-term results with the
Senning operation. However, the successive meta-
analyses from the Congenital Heart Surgeons Society,
which enrolled North American centers, report better
objective outcomes with the Mustard operation. This
may only reflect schools of training that have historically
favored one operation over the other, leading to in-
creased and improved experience with each respective
surgical procedure. Despite the theoretical advantage of
avoiding foreign material in the Senning operation, one
should ultimately proceed with what works best for each
institution.
The superior results of the double switch or Senning-
Rastelli operation compared with the “classic” or “phys-
iologic” repair make the former the preferred surgical
treatment in patients with CCTGA. Theoretically, even-
tual RV failure or tricuspid valve insufficiency should be
avoided, as the morphologic LV and mitral valve are
restored to the systemic circulation [63]. As the follow-up
of the more modern anatomic repair is still short, atrial
arrhythmias and venous pathway obstructions or leaks
may still be expected [10], although the management of
these problems may relatively be straightforward and
without heavy dire consequences.
In the current era, the Senning operation in patients
with TGA is reserved for those with unfavorable coro-
nary anatomy, for late referral, or for patients with TGA
and pulmonary vascular obstructive disease, even when
referred at an earlier age. These situations and the choice
for a Senning operation may be particularly frequent and
pertinent in developing countries without access to nitric
oxide or ECMO. In patients with CCTGA, the Senning
operation is an integral part of the double switch or
Senning-Rastelli operation, whose long-term follow-up is
still awaited.
References
1. Senning A. Surgical correction of transposition of the great
vessels. Surgery 1959;45:966–80.
2. Kirklin JW, Barrat-Boyes BG. Complete transposition of the
great arteries. In: Kirklin JW, Barrat-Boyes BG, eds. Cardiac
Surgery, 2nd ed. New York: Churchill Livingstone, 1993:
1383–1467.
3. Pacifico AD. Concordant transposition –Senning operation.
In: Stark J, de Leval M, eds. Surgery for Congenital Heart
Defects, 1st ed. London: Grune & Stratton, 1983:345–352.
4. Kirklin JW, Devloo RA, Weidman WH. Open intracardiac
repair for transposition of the great vessels: 11 cases. Surgery
1961;50:58–66.
5. Senning A. Correction of transposition of the great arteries.
Ann Surg 1975;182:287–92.
6. Mustard WT, Keith JD, Trusler GA, Fowler R, Kidd L. The
surgical management of tansposition of the great vessels.
J Thorac Cardiovasc Surg 1964;48:953–70.
7. Quaegebeur JM, Rohmer J, Brom AG, Tinkelenberg J. Re-
vival of the Senning operation in the treatment of transpo-
sition of the great arteries. Thorax 1977;32:517–24.
8. Kirjavainen M, Happonen J-H, Louhimo I. Late results of
Senning operation. J Thorac Cardiovasc Surg 1999;117:488–
95.
9. Preˆtre R, Tamisier D, Bonhoeffer P, et al. Results of the
arterial switch operation in neonates with transposed great
arteries. Lancet 2001;357:1826–30.
10. Ilbawi MN, Ocampo CB, Allen BS, et al. Intermediate results
of the anatomic repair for congenitally corrected transposi-
tion. Ann Thorac Surg 2002;73:594–600.
11. Wells WJ, Blackstone E, and the Congenital Heart Surgeons
Society. Intermediate outcome after Mustard and Senning
procedures: a study by the Congenital Heart Surgeons
Society. In: Williams WG, ed. Pediatric Cardiac Surgery
Annual of the Seminars in Thoracic and Cardiovascular
Surgery (Vol 3). Philadelphia: WB Saunders, 2000:186–97.
12. Sarkar D, Bull C, Yates R, et al. Comparison of long-term
outcomes of atrial repair of simple transposition with impli-
cations for a late arterial switch strategy. Circulation 1999;
100(Suppl):II176–81.
13. Bender HW, Stewart JR, Merrill WH, Hammon JW, Graham
TP. Ten years’ experience with the Senning operation for
transposition of the great arteries: physiological results and
late follow-up. Ann Thorac Surg 1989;47:218–23.
14. Helbing WA, Hansen B, Ottenkamp J, et al. Long-term
results of atrial correction for transposition of the great
arteries. Comparison of Mustard and Senning operations.
J Thorac Cardiovasc Surg 1994;108:363–72.
15. Marx GR, Hougen TJ, Norwood WI, Fyler DC, Castaneda
AR, Nadas AS. Transposition of the great arteries with intact
ventricular septum: results of Mustard and Senning opera-
tions in 123 consecutive patients. J Am Coll Cardiol 1983;1:
476–83.
16. Reddy VM, Sharma S, Cobanoglu A. Atrial switch (Senning
procedure) in the era of the arterial switch operation: Cur-
rent indications and results. Eur J Cardiothorac Surg 1996;
10:546–50.
17. Litwin SB, Bhavani SS. The Senning procedure for repair of
1442 REVIEW DODGE-KHATAMI ET AL Ann Thorac Surg
LONG-TERM ISSUES AND REVIVAL OF THE SENNING OPERATION 2005;79:1433–44
REVIEWS

11. d-transposition of the great arteries. J Cardiac Surg 1987;2:
415–28.
18. Rubay JE, de Halleux C, Jaumin P, et al. Long-term follow-up
of the Senning operation for transposition of the great
arteries in children under 3 months of age. J Thorac Cardio-
vasc Surg 1987;94:75–81.
19. Stark J. Reoperations after Mustard and Senning operations.
In: Stark J, Pacifico AD, eds. Reoperations in Cardiac Sur-
gery. Berlin: Springer-Verlag, 1989:187–207.
20. Douard H, Labbe´ L, Barat JL, Broustet JP, Baudet E, Choussat
A. Cardiorespiratory response to exercise after venous
switch operation for transposition of the great arteries. Chest
1997;111:23–9.
21. Matthys D, De Wolf D, Verhaaren H. Lack of increase in
stroke volume during exercise in asymptomatic adolescents
in sinus rhythm after intraatrial repair for simple transposi-
tion of the great arteries. Am J Cardiol 1996;78:595–6.
22. Gilljam T, Eriksson BO, Sixt R. Cardiac output and pulmo-
nary gas exchange at maximal exercise after atrial redirec-
tion for complete transposition. Eur Heart J 1998;19:1856–64.
23. Buheitel G, Hofbeck M, Gerling S, Koch A, Singer H.
Similarities and differences in the exercise performance of
patients after a modified Fontan procedure compared to
patients with complete transposition following a Senning
operation. Cardiol Young 2000;10:201–7.
24. Lubiszewska B, Gosiewska E, Hoffman P, et al. Myocardial
perfusion and function of the systemic right ventricle in
patients after atrial switch procedure for complete transpo-
sition: long-term follow-up. J Am Coll Cardiol 2000;36:1365–
70.
25. Mee RBB. Arterial switch for right ventricular failure follow-
ing Mustard or Senning operations. In: Stark J, Pacifico AD,
eds. Reoperations in Cardiac Surgery. Berlin: Springer-
Verlag, 1989:217–232.
26. Turina MI, Siebenmann R, von Segesser LK, Scho¨nbeck M,
Senning A. Late functional deterioration after atrial correc-
tion for transposition of the great arteries. Circulation 1989;
80(suppl I):I162–7.
27. Reich O, Voriskova M, Ruth C, et al. Long term ventricular
performance after intra-atrial correction of transposition: left
ventricular filling is the major limitation. Heart 1997;78:376–
81.
28. Cochrane AD, Karl TR, Mee RBB. Staged conversion to
arterial switch for late failure of the systemic right ventricle.
Ann Thorac Surg 1993;56:864–2.
29. Mee RBB. Severe right ventricular failure after Mustard or
Senning operation. Two-stage repair: pulmonary artery
banding and switch. J Thorac Cardiovasc Surg 1986;92:385–
90.
30. Millane T, Bernard EJ, Jaeggi E, et al. Role of ischemia and
infarction in late right ventricular dysfunction after atrial
repair of transposition of the great arteries. J Am Coll
Cardiol 2000;35:1661–8.
31. Labbe´ L, Douard H, Barat J-L, et al. Alte´ration de la viabilite´
myocardique et dysfonction ventriculaire syste´mique apre`s
intervention de Senning. Arch Mal Coeur 1997;90:631–7.
32. Okuda H, Nakazawa M, Imai Y, et al. Comparison of
ventricular function after Senning and Jatene procedures for
complete transposition of the great arteries. Am J Cardiol
1985;55:530–34.
33. Hornung TS, Bernard EJ, Jaeggi ET, Howman-Giles RB,
Celermajer DS, Hawker RE. Myocardial perfusion defects
and associated systemic ventricular dysfunction in congen-
itally corrected transposition of the great arteries. Heart
1998;80:322–6.
34. Tulevski II, Zijta FM, Smeijers AS, Dodge-Khatami A, van
der Wall EE, Mulder BJM. Regional and global right ventric-
ular dysfunction in asymptomatic or minimally symptomatic
patients with congenitally corrected transposition. Cardiol
Young 2004 [in press].
35. Lorenz CH, Walker ES, Graham TP, Powers TA. Right
ventricular performance and mass by use of cine MRI late
after atrial repair of transposition of the great arteries.
Circulation 1995;92(suppl II):II-233–9.
36. Hochreiter C, Snyder MS, Borer JS, Engle MA. Right and left
ventricular performance 10 years after Mustard repair of
transposition of the great arteries. Am J Cardiol 1994;74:478–
82.
37. Turina M, Siebenmann R, Nussbaumer P, Senning A. Long-
term outlook after atrial correction of transposition of the
great arteries. J Thorac Cardiovasc Surg 1988;95:828–35.
38. Graham TP, Burger J, Bender HW, Hammon JW, Boucek RJ,
Appleton S. Improved right ventricular function after atrial
repair of transposition of the great arteries. Circulation
1985;72(suppl II):II-45–51.
39. Graham TP. Hemodynamic residua and sequelae following
intraatrial repair of transposition of the great arteries: a
review. Ped Cardiol 1982;2:203–13.
40. Williams WG, McCrindle BW, Ashburn DA, Jonas RA,
Mavroudis C, Blackstone EH. Outcomes of 829 neonates
with complete transposition of the great arteries 12–17 years
after repair. Eur J Cardiothorac Surg 2003;24:1–10.
41. DeLeon VH, Hougen TJ, Norwood WI, Lang P, Marx GR,
Castaneda A. Results of the Senning operation for transpo-
sition of the great arteries with intact ventricular septum in
neonates. Circulation 1984;70(suppl I):I-21–5.
42. Byrum CJ, Bove EL, Sondheimer HM, Kavey REW, Black-
man MS. Hemodynamic and electrophysiologic results of
the Senning procedure for transposition of the great arteries.
Am J Cardiol 1986;58:138–42.
43. Deanfield J, Camm J, Macartney F, et al. Arrhythmia and late
mortality after Mustard and Senning operation for transpo-
sition of the great arteries. J Thorac Cardiovasc Surg 1988;
96:569–76.
44. Kanter RJ, Papagiannis J, Carboni MP, Ungerleider RM,
Sanders WE, Wharton JM. Radiofrequency catheter ablation
of supraventricular tachycardia substrates after Mustard and
Senning operations for d-transposition of the great arteries.
J Am Coll Cardiol 2000;35:428–41.
45. Van Hare GF, Lesh MD, Ross BA, Perry JC, Dorostkar PC.
Mapping and radiofrequency ablation of intratrial reentrant
tachycardia after the Senning or Mustard procedure for
transposition of the great arteries. Am J Cardiol 1996;77:985–
91.
46. Huhta JC, Edwards WD, Danielson GK, Feldt RH. Abnor-
malities of the tricuspid valve in complete transposition of
the great arteries with ventricular septal defect. J Thorac
Cardiovasc Surg 1982;83:569–76.
47. Poirier NC, Mee RBB. Left ventricular reconditioning and
anatomical correction for systemic right ventricular dysfunc-
tion. In: Williams WG, ed. Pediatric Cardiac Surgery Annual
of the Seminars in Thoracic and Cardiovascular Surgery.
Philadelphia: WB Saunders, 2000:198–215.
48. Chang AC, Wernovsky G, Wessel DL, et al. Surgical man-
agement of late right ventricular failure after Mustard or
Senning repair. Circulation 1992;86(Suppl II):II-140–9.
49. Dunbar-Masterson C, Wypij D, Bellinger DC, et al. General
health status of children with d-transposition of the great
arteries after the arterial switch operation. Circulation 2001;
104(Suppl I):I-138–42.
50. Bellinger DC, Wypij D, Kuban KC, et al. Development and
neurological status of children at 4 years after heart surgery
with hypothermic circulatory arrest or low-flow cardiopul-
monary bypass. Circulation 1999;100:526–32.
51. Bellinger DC, Wypij D, du Plessis AJ, et al. Neurodevelop-
mental status at eight years in children with dextro-
transposition of the great arteries: the Boston Circulatory
Arrest Trial. J Thorac Cardiovasc Surg 2003;126:1385–96.
52. Alde´n B, Gilljam T, Gillberg C. Long-term psychological
outcome of children after surgery for transposition of the
great arteries. Acta Pediatr 1998;87:405–10.
53. Culbert EL, Ashburn DA, Cullen-Dean G, et al. Quality of
life of children after repair of transposition of the great
arteries. Circulation 2003;108:857–62.
54. Ellerbeck KA, Smith ML, Holden EW, et al. Neurodevelop-
1443Ann Thorac Surg REVIEW DODGE-KHATAMI ET AL
2005;79:1433–44 LONG-TERM ISSUES AND REVIVAL OF THE SENNING OPERATION
REVIEWS

12. mental outcomes in children surviving d-transposition of the
great arteries. Dev Behav Pediatr 1998;19:335–41.
55. Morris CD, Menasche VD. 25-year mortality after surgical
repair of congenital heart defect in childhood: a population-
based cohort study. JAMA 1991;266:3447–52.
56. Moons P, Gewillig M, Sluysmans T, et al. Long term outcome
up to 30 years after the Mustard or Senning operation: a
nationwide multicentre study in Belgium. Heart 2004;90:307–
13.
57. Daebritz SH, Tiete AR, Sachweh JS, Engelhardt W, von
Bernuth G, Messmer BJ. Systemic right ventricular failure
after atrial switch operation: Midterm results of conversion
into an arterial switch. Ann Thorac Surg 2001;71:1255–9.
58. Mavroudis C, Backer CL. Arterial switch after failed atrial
baffle procedures for transplantation of the great arteries.
Ann Thorac Surg 2000;69:851–7.
59. Corno AF, Bonnet D, Sekarski N, Sidi D, Vouhe´ D, von
Segesser LK. Remote control of pulmonary blood flow: initial
clinical experience. J Thorac Cardiovasc Surg 2003;126:1775–
80.
60. Amin Z, McElhinney DB, Moore P, Reddy VM, Hanley FL.
Coronary arterial size late after the atrial inversion proce-
dure for transposition of the great arteries: implications for
the arterial switch operation. J Thorac Cardiovasc Surg
2000;120:1047–52.
61. Bove EL. Congenitally corrected transposition of the great
arteries: ventricle to pulmonary artery connection strategies.
Sem Thorac Cardiovasc Surg 1995;7:139–44.
62. Imai Y, Seo K, Aoki M, Shin’oka T, Hiramatsu K, Ohta J.
Double-switch operation for congenitally corrected transpo-
sition. In: Coles JG, Williams WG, eds. Pediatric Cardiac
Surgery Annual of the Seminars in Thoracic and Cardiovas-
cular Surgery. Philadelphia: WB Saunders, 2001:16–33.
63. Karl TR, Weintraub RG, Brizard CP, Cochrane AD, Mee
RBB. Senning plus arterial switch operation for discordant
(congenitally corrected) transposition. Ann Thorac Surg
1997;64:495–502.
64. Langley SM, Winlaw DS, Stumper O, et al. Midterm results
after restoration of the morphologically left ventricle to the
systemic circulation in patients with congenitally corrected
transposition. J Thorac Cardiovasc Surg 2003;125:1229–41.
65. Reddy VM, McElhinney DB, Silverman NH, Hanley FL. The
double switch procedure for anatomical repair of congeni-
tally corrected transposition of the great arteries in infants
and children. Eur Heart J 1998;18:1470–7.
66. Jahangiri M, Redington AN, Elliott MJ, Stark J, Tsang VT, de
Leval MR. A case for anatomic correction in atrioventricular
discordance? Effects of surgery on tricuspid valve function.
J Thorac Cardiovasc Surg 2001;121:1040–5.
67. Dodge-Khatami A, Tulevski II, Bennink GBWE, et al. Com-
parable systemic ventricular function in healthy adults and
patients with unoperated congenitally corrected transposi-
tion using MRI dobutamine stress testing. Ann Thorac Surg
2002;73:1759–64.
68. Sharma R, Choudhary SK, Bhan A, et al. Left ventricle is
better suited as pulmonary ventricle in simple transposition
with severe pulmonary hypertension. Ann Thorac Surg
2002;74:1612–5.
69. Luciani GB, Chang AC, Starnes VA. Surgical repair of
transposition of the great arteries in neonates with persistent
pulmonary hypertension. Ann Thorac Surg 1996;61:800–4.
70. Kang N, de Leval M, Elliott M, et al. Extending the bound-
aries of the primary arterial switch operation in patients with
transposition of the great arteries and intact ventricular
septum. Circulation 2004: In review or read at the American
Heart Association Meeting, Orlando, Florida, 10 November
2003.
1444 REVIEW DODGE-KHATAMI ET AL Ann Thorac Surg
LONG-TERM ISSUES AND REVIVAL OF THE SENNING OPERATION 2005;79:1433–44
REVIEWS