Preoperative diagnosis of coronary artery anatomy in dextrotransposition of the great arteries

Is Preoperative Delineation of Coronary Artery Pattern a Prerequisite for Arterial Switch Operation?

OBJECTIVE

To determine the effect of preoperative echocardiographic delineation of coronary artery pattern on the immediate postoperative result of arterial switch procedures.

METHODS

A retrospective review of a consecutive series of children who underwent the arterial switch operation at a single institution from February 2001 to December 2004.

RESULTS

Sixty-six children underwent an arterial switch operation. The median age at the time of repair was 1.17 months (range 0.2-96 months). Fifty-five patients (83%) were diagnosed to have dextro-transposition of the great arteries, and 11 patients (17%) had double outlet right ventricle of the Taussig-Bing type. Associated left-sided obstructive lesions were present in 12 cases (18.3%). The dominant coronary pattern was 1 LCX; 2R (60.6%), and followed by 1L; 2RCX (24.2%). The techniques used for coronary transfer were the trapdoor flap, circular buttonhole transfer, or combined technique in all patients except for one case. Preoperatively, the coronary artery anatomy was adequately delineated in only 26 cases (39.4%). Forty patients (60.6%) had either different coronary description or non-documented coronary artery pattern. Myocardial ischemia was not observed in any case postoperatively and no patient in the series required reoperation for coronary revision. There were 10 in-hospital deaths (15%) not related to the coronary pattern. Follow-up is available for 49 of the surviving patients (87.5%) at a mean of 10.1 months. There has been no readmission or reintervention for myocardial ischemia.

CONCLUSIONS

The trapdoor flap and circular buttonhole techniques are the most practical and reproducible maneuvers of coronary transfer during arterial switch operation. Both techniques can compensate for inadequate preoperative echocardiographic delineation of coronary artery pattern.

Clinical implications of short-axis aortopulmonary rotation on juxtacommissural origin of the coronary artery in transposition of the great arteries and surgical strategy

BACKGROUND

The relationship of short-axis aortopulmonary rotation (APR) with juxtacommissural origin of the coronary arteries (JOCA) in transposition of the great arteries (TGA) has never been elucidated. The surgical outcome of arterial switch operation (ASO) is influenced by the presence of JOCA.

METHODS

Fifteen patients with TGA who presented to our institution between 1988 and 1995, and 23 cases from the literature, all with documented JOCA and APR, were analyzed. Each coronary arterial type was assigned to one of five patterns, according to similarities of epicardial configuration. All our patients underwent an ASO with various techniques to deal with JOCA.

RESULTS

JOCA near the facing commissure (FC, 35 cases), were more frequent with anterior TGA (29/31, 94%) except types 5cj and 9j that were seen with posterior and right lateral TGA (4/4, 100%); whereas JOCA near the right-hand nonfacing commissure (RNC, 3 cases) were related with posterior TGA. Eta-square analysis showed significant correlation between various JOCA and short axis APR. Thirteen of our cases had JOCA near FC, two near RNC. Five of the former in whom the coronary artery was excised as a single button had a superior trapdoor; using a two-button technique three of the former had a lateral funnel and one of the latter had a medial trapdoor for the JOCA; all survived although on late noncoronary death was noted. In the remaining six cases without augmentation, only one survived (8/1 vs 1/5, p < 0.02).

CONCLUSION

JOCA in TGA was related to short axis APR, generally near FC in anterior TGA (except types 5cj and 9j), and near the RNC in posterior TGA. A superior (lateral) or medial flap, to augment the coronary button for JOCA near FC or RNC is helpful for a successful ASO.