Skip to main content Accessibility help

Long-term outcomes after the atrial switch for surgical correction of transposition: a meta-analysis comparing the Mustard and Senning procedures

  • Paul Khairy (a1) (a2), Michael J. Landzberg (a1), Jean Lambert (a3) and Clare P. O'Donnell (a1) (a2)


Most adults with regular transposition (the combinations of concordant atrioventricular and discordant ventriculo-arterial connections) have undergone either the Mustard or Senning procedure in childhood. It is unclear whether adverse events differ according to the surgery performed. With this in mind, we conducted a systematic review and meta-analysis to compare long-term outcomes. We searched systematically entries to MEDLINE and EMBASE databases from January 1966 through August 2003, supplementing the search by secondary sources. Comparative studies were required to include at least 10 patients in each cohort of Mustard or Senning procedure, and to report overall survival. Data were extracted by two independent reviewers. We used a component approach to assess quality. On the basis of assessment of heterogeneity, we then used a random-effects model for pooled analyses. In all, we included seven studies, incorporating 885 patients. We found a trend towards lower mortality for the 369 patients undergoing a Mustard procedure when compared to 474 submitted to the Senning operation, with a hazard ratio of 0.63 and 95% confidence intervals between 0.35 and 1.14 (p = 0.13). This trend increased with the size of the sample (p = 0.004). Obstruction in the systemic venous pathway was more common in those having the Mustard procedure, with a risk ratio of 3.5 and 95% confidence intervals from 1.8 to 7.0 (p < 0.001), with a trend towards greater obstruction of the pulmonary venous pathway in those undergoing the Senning procedure, 7.6% vs. 3.8% (p = 0.27). A trend towards fewer residual shunts was observed for those with Mustard baffles, 7.0% vs. 14.1% (p = 0.10). Sinus nodal dysfunction, however, was more common after the Mustard procedure. Data regarding atrial tachydysrhythmias was inconclusive. Systemic cardiac failure and functional capacity, was similar. We conclude that outcomes are not uniform among patients submitted to the Mustard and Senning procedures. Knowledge of such differences may facilitate stratification of risk and follow-up.


Corresponding author

Correspondence to: Dr Paul Khairy, BACH Service, Department of Cardiology, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA. Tel: +1 (617) 355 6508; Fax: +1 (617) 739 8632; E-mail:


Hide All


Brickner ME, Hillis LD, Lange RA. Congenital heart disease in adults. Second of two parts. N Engl J Med 2000; 342: 334342.
Liebman J, Cullum L, Belloc NB. Natural history of transpostion of the great arteries: anatomy and birth and death characteristics. Circulation 1969; 40: 237262.
Senning A. Surgical correction of transposition of the great vessels. Surgery 1959; 45: 966979.
Mustard WT. Successful two stage correction of transposition of the great vessels. Surgery 1964; 55: 469472.
Jatene AD, Fontes VF, Paulista PP, et al. Anatomic correction of transposition of the great vessels. J Thorac Cardiovasc Surg 1976; 72: 364370.
Wilson NJ, Clarkson PM, Barratt-Boyes BG, et al. Long-term outcome after the mustard repair for simple transposition of the great arteries. 28-year follow-up. J Am Coll Cardiol 1998; 32: 758765.
Gatzoulis MA, Walters J, McLaughlin PR, Merchant N, Webb GD, Liu P. Late arrhythmia in adults with the mustard procedure for transposition of great arteries: a surrogate marker for right ventricular dysfunction? Heart 2000; 84: 409415.
Gelatt M, Hamilton RM, McCrindle BW, et al. Arrhythmia and mortality after the Mustard procedure: a 30-year single-center experience. J Am Coll Cardiol 1997; 29: 194201.
Silka MJ, Hardy BG, Menashe VD, Morris CD. A population-based prospective evaluation of risk of sudden cardiac death after operation for common congenital heart defects. J Am Coll Cardiol 1998; 32: 245251.
Stark J, Tynan MJ, Ashcraft KW, Aberdeen E, Waterston DJ. Obstruction of pulmonary veins and superior vena cava after the Mustard operation for transposition of the great arteries. Circulation 1972; 45: I116I120.
Benatar A, Tanke R, Roef M, Meyboom EJ, Van de Wal HJ. Mid-term results of the modified Senning operation for cavopulmonary connection with autologous tissue. Eur J Cardiothorac Surg 1995; 9: 320324.
Kirjavainen M, Happonen JM, Louhimo I. Late results of Senning operation. J Thorac Cardiovasc Surg 1999; 117: 488495.
Deanfield J, Camm J, Macartney F, et al. Arrhythmia and late mortality after Mustard and Senning operation for transposition of the great arteries. An eight-year prospective study. J Thorac Cardiovasc Surg 1988; 96: 569576.
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 operations in 123 consecutive patients. J Am Coll Cardiol 1983; 1: 476483.
Meisner H, Feder E, Struck E, Silva AZ Jr, Sebening F. Transposition of great arteries: atrial inversion – the Senning versus the Mustard procedure. Arq Bras Cardiol 1982; 38: 385388.
Bender HW Jr, Graham TP Jr, Boucek RJ Jr, Walker WE, Boerth RG. Comparative operative results of the Senning and Mustard procedures for transposition of the great arteries. Circulation 1980; 62: I197I203.
Mahony L, Turley K, Ebert P, Heymann MA. Long-term results after atrial repair of transposition of the great arteries in early infancy. Circulation 1982; 66: 253258.
Parmar MK, Torri V, Stewart L. Extracting summary statistics to perform meta-analyses of the published literature for survival endpoints. Stat Med 1998; 17: 28152834.
Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002; 21: 15391558.
DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177188.
Jüni P, Altman DG, Egger M. Assessing the quality of randomised controlled trials. In: Egger M, Smith GD, Altman DG (eds). Systematic Review in Health Care: Meta-analysis in Context. BMJ Publishing Group, London, 2001, pp 87108.
Meisner H, Feder E, Struck E, Yueh HH, Paek SU, Sebening F. Mustard vs. Senning procedure: a comparison of primary atrial inversion procedures in 108 patients with transposition of the great arteries. Herz 1982; 7: 259266.
Feder E, Meisner H, Buhlmeyer K, Struck E, Sebening F. Operative treatment of TGA: comparison of Senning’s and Mustard’s operation in patients under 2 years. Thorac Cardiovasc Surg 1980; 28: 712.
Dupuis C, Vliers A, Binet JP, Chalant C, Breviere GM, Stijns M. Medium- and long-term results of Mustard and Senning operations in isolated transposition of great vessels. Ann Cardiol Angeiol (Paris) 1985; 34: 3337.
Weidinger F, Schlemmer M, Schmidinger H, Weber H, Domanig E, Wimmer M. Dysrhythmias following the Mustard and Senning operation for transposition of the great arteries. Padiatr Padol 1987; 22: 259266.
Wells WJ, Blackstone E. Intermediate outcomes after Mustard and Senning procedures: a study by the congenital heart surgeons society. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2000; 3: 186197.
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: 363372.
Kugler JD. Sinus node dysfunction. In: Garson A Jr, Bricker JT, McNamara DG (eds). The Science and Practice of Pediatric Cardiology. Lea & Febiger, Philadelphia, 1990, pp 17511785.
Smallhorn JF, Gow R, Freedom RM, et al. Pulsed Doppler echocardiographic assessment of the pulmonary venous pathway after the Mustard or Senning procedure for transposition of the great arteries. Circulation 1986; 73: 765774.
Bender HW Jr, Stewart JR, Merrill WH, Hammon JW Jr, Graham TP Jr. Ten years' experience with the Senning operation for transposition of the great arteries: physiological results and late follow-up. Ann Thorac Surg 1989; 47: 218223.
Chin AJ, Sanders SP, Williams RG, Lang P, Norwood WI, Castaneda AR. Two-dimensional echocardiographic assessment of caval and pulmonary venous pathways after the senning operation. Am J Cardiol 1983; 52: 118126.
Breckenridge IM, Stark J, Bonham-Carter RE, Oelert H, Graham GR, Waterston DJ. Mustard’s operation for transposition of the great arteries. Review of 200 cases. Lancet 1972; 1: 11401142.
Rodriguez-Fernandez HL, Kelly DT, Collado A, Haller JA Jr, Krovetz LJ, Rowe RD. Hemodynamic data and angiographic findings after Mustard repair for complete transposition of the great arteries. Circulation 1972; 46: 799808.
Arciniegas E, Farooki ZQ, Hakimi M, Perry BL, Green EW. Results of the Mustard operation for dextro-transposition of the great arteries. J Thorac Cardiovasc Surg 1981; 81: 580587.
Meijboom F, Szatmari A, Deckers JW, et al. Long-term follow-up (10 to 17 years) after Mustard repair for transposition of the great arteries. J Thorac Cardiovasc Surg 1996; 111: 11581168.
Janousek J, Paul T, Luhmer I, Wilken M, Hruda J, Kallfelz HC. Atrial baffle procedures for complete transposition of the great arteries: natural course of sinus node dysfunction and risk factors for dysrhythmias and sudden death. Z Kardiol 1994; 83: 933938.
Levinsky L, Srinivasan V, Gingell RL, et al. Senning repair with ductal decompression: palliative approach to d-TGA and irreversible pulmonary vascular disease. Am Heart J 1983; 106: 409412.
Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. J Am Med Assoc 2000; 283: 20082012.



Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed