Risultati a breve termine in neonati affetti da trasposizione delle grandi arterie: un'analisi retrospettiva

Background: Dextro-transposition of the great arteries (d-TGA) is a cyanotic congenital heart disease characterized by ventriculo-arterial discordance. Early postnatal adaptation carries a high risk of acute decompensation, depending on the effectiveness of intercirculatory blood mixing at the atrial and ductal levels. Transition to neonatal circulation is often complicated by persistent pulmonary hypertension of the newborn (PPHN), which exacerbates hypoxemia and hemodynamic instability. Prostaglandin E1 (PGE1) is widely used to maintain ductal patency; however, when atrial-level mixing is inadequate, balloon atrial septostomy (BAS) represents a key intervention before surgery. Objective of the study: To evaluate short-term outcomes in neonates with d-TGA and to identify clinical and echocardiographic predictors of balloon atrial septostomy (BAS). Secondary objectives included assessing the impact of PPHN and outborn status on postnatal adaptation, determinants of PGE1 withdrawal failure, and early mortality. Methods: We conducted a monocentric retrospective study including all neonates with d-TGA admitted to the NICU of Padova between 2020 and 2025. Clinical, echocardiographic and laboratory data were analyzed, and Cox regression was used to identify predictors of BAS. Results: Forty-five neonates with d-TGA were included. Among them, 57.8% underwent BAS. They showed significantly lower oxygen saturation, higher FiO2 requirements, metabolic acidosis and higher lactate levels after NICU admission. Smaller foramen ovale (FO) diameter (HR 0.49, p=0.0002) and the presence of differential cyanosis (HR 3.75, p=0.016) emerged as independent predictors of BAS. PPHN was identified in 58% of patients but was not independently associated with BAS requirement or short-term outcomes. Outborn status was associated with higher early lactate levels and greater need for sedation and inotropes but did not significantly impact postoperative morbidity or mortality. Discontinuation of PGE1 was more frequently unsuccessful in neonates with simple d-TGA. Overall survival after arterial switch operation was 87%, with mortality mainly confined to complex d-TGA. Conclusions: In neonates with d-TGA, a physiology-driven and individualized approach to early postnatal management is required. The main independent predictors of the need for BAS were a small FO diameter and differential cyanosis. FO size may represent a useful anatomical marker of insufficient mixing, guiding timely intervention. Baseline physiological vulnerability plays a central role in determining postnatal adaptation, whereas PPHN and outborn status do not negatively impact short-term outcomes. Anatomical complexity remains a key determinant of PGE1 requirement and surgical outcomes.