Unveiling ccTGA Complexity: CMR and 3D Modeling for Surgical Planning - A Case Series

Abstract Background Congenitally corrected transposition of the great arteries (ccTGA) is a rare congenital heart defect characterized by atrioventricular and ventriculoarterial discordance and frequently associated with heterogeneous anatomical anomalies. This variability makes surgical indication and strategy particularly complex, requiring accurate preoperative anatomical and functional assessment. Case series We report four pediatric patients with complex ccTGA who underwent anatomical repair at our institution between July 2022 and March 2024. Associated findings included dextrocardia, situs inversus, ventricular septal defects, pulmonary outflow tract obstruction, and atrioventricular valve abnormalities. Imaging and methods All patients underwent stepwise multimodal imaging. Transthoracic echocardiography was complemented by cardiovascular magnetic resonance (CMR) to assess ventricular volumes and function, septal defects, outflow tract relationships, systemic and pulmonary venous return. CMR datasets were processed to generate patient-specific virtual and 3D-printed models through dedicated segmentation, preserving real anatomical dimensions. These models were used for surgical simulation and multidisciplinary planning. Findings Integration of CMR and 3D modeling directly influenced operative strategy in all cases. Three-dimensional reconstructions refined ventricular septal defect tunneling toward the aorta, optimized ventriculotomy site selection, clarified atrial switch configuration, and anticipated the need for pulmonary root translocation. Anatomical repair was successfully achieved in all four patients, with no early mortality and preserved biventricular function at short follow-up. Conclusions Structured integration of CMR and patient-specific 3D modeling enhances spatial understanding and supports individualized surgical planning in complex ccTGA. Incorporating advanced imaging into routine clinical workflow represents a valuable strategy to improve precision and decision-making in anatomically challenging congenital heart disease.