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Transposition of the Great Arteries

(TGA)

By Jeanne Marie Baffa, MD, Associate Professor of Pediatrics;Director of Echocardiography, Thomas Jefferson University School of Medicine;Nemours/Afred I. duPont Hospital for Children

Transposition of the great arteries is a reversal of the normal connections of the aorta and the pulmonary artery with the heart.

  • The aorta and pulmonary artery are reversed, which causes oxygen-poor blood to be circulated to the body and oxygen-rich blood to be circulated between the lungs and the heart and not to the body.

  • Symptoms are apparent at birth and include severe cyanosis (a bluish discoloration of the lips and skin) and difficulty breathing.

  • The diagnosis is based on echocardiography.

  • Surgery is done during the first few days of life.

Oxygen-poor blood returning from the body flows from the right atrium to the right ventricle as usual, but then flows to the aorta and the body, bypassing the lungs. Oxygenated blood travels back and forth between the heart and lungs (from the lungs to the pulmonary vein, then left atrium and ventricle, then the pulmonary artery) but is not transported to the body.

The body cannot survive without oxygen. However, infants with this defect may survive briefly after birth because the foramen ovale (a hole between the right and left atria) and the ductus arteriosus (a blood vessel connecting the pulmonary artery with the aorta—see Normal Fetal Circulation) are still open at birth. These openings allow oxygen-rich blood to mix with oxygen-poor blood, sometimes supplying enough oxygen to the body to keep the infant alive. Once the ductus closes, as it normally does after birth, very little blood flows to the lungs in infants with this defect and if the defect is not repaired immediately, the infant will die.

Transposition of the great arteries can also be accompanied by another heart defect, ventricular septal defect (a hole in the wall separating the two lower heart chambers), which may actually be helpful by allowing more mixing of oxygen-rich and oxygen-poor blood.

Transposition of the Great Arteries

The normal connections of the aorta and the pulmonary artery with the heart are reversed.

Symptoms

Transposition of the great arteries usually results in severe cyanosis (bluish discoloration of the lips and skin) and difficulty breathing beginning at birth.

Diagnosis

  • Echocardiography

Doctors suspect the diagnosis when they detect very low levels of oxygen in the blood of a newborn, often but not always accompanied by a heart murmur. A heart murmur is a sound created by turbulent blood flow through narrowed or leaking heart valves or through abnormal heart structures.

Echocardiography (ultrasonography of the heart) confirms the diagnosis.

Electrocardiography (ECG) and chest x-rays are typically done. The ECG is usually normal. The chest x-ray often shows an enlarged or abnormally shaped heart.

Treatment

  • Sometimes a drug, such as a prostaglandin, to keep the ductus arteriosus open

  • Surgery

  • Balloon atrial septostomy

Usually, surgery is done within the first few days of life. However, other procedures may be done first to keep the infant alive until surgery can be done.

In some infants, doctors give a prostaglandin by vein to keep the ductus arteriosus open. Keeping the ductus arteriosus open may help by increasing blood flow in the lungs and raising oxygen levels in the blood. Doctors closely monitor infants receiving this drug because they occasionally become less stable when receiving prostaglandin.

If infants have severe symptoms and do not respond to the prostaglandin, doctors may do a balloon atrial septostomy procedure. For balloon septostomy, a thin tube (catheter) with a balloon at its tip is passed through a blood vessel in the arm or leg into the heart. The tip is placed in the opening between the atria (foramen ovale) and the balloon is inflated. This widens the foramen and thus enables oxygen-rich blood to reach the body.

Surgery consists of attaching the aorta and pulmonary artery to the appropriate ventricles and reimplanting the heart's coronary arteries in the aorta after the aorta is repositioned.

Some children need to take antibiotics before visits to the dentist and before certain surgeries (such as on the bowel or bladder). These antibiotics are used to prevent serious heart infections called endocarditis.

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