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Chowdhury UK, Anderson RH, Spicer DE, Sankhyan LK, George N, Pandey NN, Goja S, Chandhirasekar B. Techniques and pitfalls of coronary arterial reimplantation in anatomical correction of transposition. J Card Surg 2022; 37:3813-3824. [PMID: 36116113 DOI: 10.1111/jocs.16889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/06/2022] [Accepted: 07/23/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM We assessed the anatomical variations in coronary arterial patterns relative to the techniques of reimplantation in the setting of the arterial switch operation, relating the variations to influences on outcomes. METHODS We reviewed pertinent published investigations, assessing events reported following varied surgical techniques for reimplantation of the coronary arteries in the setting of the arterial switch procedure. RESULTS The prevalence of reported adverse events, subsequent to reimplantation, varied from 2% to 11%, with a bimodal presentation of high early and low late incidence. The intramural pattern continues to contribute to mortality, with some reports of 28% fatality. The presence of abnormal course relative to the arterial pedicles in the setting of single sinus origin was associated with a three-fold increase in mortality. Abnormal looping with bisinusal origin of arteries was not associated with increased risk. CONCLUSION The techniques of transfer of the coronary arteries can be individually adapted to cater for the anatomical variations. Cardiac surgeons, therefore, need to be familiar with the myriad creative options available to achieve successful repair when there is challenging anatomy. Long-term follow-up will be required to affirm the superiority of any specific individual technique. Detailed multiplanar computed-tomographic scanning can now reveal all the variants, and elucidate the mechanisms of late complications. Coronary angioplasty or surgical revascularization may be considered in selected cases subsequent to the switch procedure.
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Affiliation(s)
- Ujjwal K Chowdhury
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Robert H Anderson
- Institute of Biomedical Sciences, Newcastle University, Newcastle-upon-Tyne, UK
| | - Diane E Spicer
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Department of Pediatric Cardiology, University of Florida, Gainesville, Florida, USA
| | - Lakshmi K Sankhyan
- Cardiothoracic Centre, All India Institute of Medical Sciences, Bilaspur, India
| | - Niwin George
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Niraj N Pandey
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Shikha Goja
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
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Yang L, Ye L, Yu J, Li J, Zhang Z, Shu Q, Lin R. Lessons learned from ECMO support in pediatric patients with D-transposition of the great arteries: preoperative, intraoperative and postoperative. WORLD JOURNAL OF PEDIATRIC SURGERY 2021; 4:e000273. [PMID: 36475240 PMCID: PMC9716810 DOI: 10.1136/wjps-2021-000273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 09/05/2021] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) support on D-transposition of the great arteries (D-TGA) carries formidable challenges. METHODS A retrospective study was performed on pediatric patients with D-TGA supported by ECMO from July 2007 to December 2019. This study summarized the clinical experience of ECMO support in pediatric patients with D-TGA preoperative, intraoperative, and postoperative. RESULTS Overall, 16 children with D-TGA received ECMO support during this period. Two (2 of 16) were supported before cardiac surgery, 3 (3 of 16) were supported postoperatively in the intensive care unit, and 11 (11 of 16) failed to wean off cardiopulmonary bypass. Two cases of preoperative ECMO support for patients with D-TGA with an intact ventricular septum and restrictive atrial septum due to severe hypoxemia died. In this study, D-TGA with coronary artery malformation and other complicated deformities died (8 of 14), whereas uncomplicated D-TGA without coronary artery malformation all survived (6 of 14). The wean-off rate of ECMO patients supported in D-TGA was 62.5% (10 of 16), while the 30-day survival rate was 44% (7 of 16). CONCLUSION Although a promising ECMO weaning rate was obtained, 30-day survival of this population was frustrating, mainly attributed to the original anatomy of coronary arteries and the concomitant deformities.
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Affiliation(s)
- Lijun Yang
- Extracorporeal Circulation and Extracorporeal Life Support, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Lifen Ye
- Extracorporeal Circulation and Extracorporeal Life Support, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jiangen Yu
- Cardiac Surgery, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jianhua Li
- Cardiac Surgery, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Zewei Zhang
- Cardiac Surgery, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Qiang Shu
- Cardiac Surgery, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Ru Lin
- Extracorporeal Circulation and Extracorporeal Life Support, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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Moll M, Moll JA, Moll JJ, Łubisz M, Michalak KW. Intramural coronary pattern in patients with transposition: incidence and impact on follow-up. Eur J Cardiothorac Surg 2021; 58:145-152. [PMID: 32057070 DOI: 10.1093/ejcts/ezaa021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/22/2019] [Accepted: 01/04/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Coronary complications are still the main reason for early mortality after an arterial switch operation. The high incidence of coronary anomalies in patients with transposition of the great arteries may increase the difficulty of coronary transfer, and among them, an intramural pattern was shown to be an independent risk factor of early mortality. However, recently published studies have reported that this rare coronary variant has no impact on the survival rate. The aim of this study was to assess the frequency of intramural coronary patterns in patients with transposition and the impact on overall mortality after an arterial switch operation. Additionally, we presented all coronary arrangements associated with intramural patterns in our cohort and the surgical techniques used to manage them successfully. METHODS All arterial switch operations were retrospectively reviewed. In each case, the surgical reports contained detailed graphical representations and coronary anatomy patterns. All operatively confirmed intramural patterns were included in the analysis. RESULTS Among 806 patients, 271 patients had coronary anomalies (33.62%), and 28 patients had an intramural pattern (3.47%), which was frequently associated with other complex coronary anomalies (P < 0.001). Overall survival was significantly higher in patients with intramural coronary artery patterns than in those with other coronary variants (21.34% vs 8.74%, P = 0.024, log-rank test). CONCLUSIONS Intramural patterns associated with transposition remain a surgical challenge and increase overall mortality in our cohort. To reliably confirm or reject the significance of the observed impact of this rare coronary variant, a multicentre data analysis is required.
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Affiliation(s)
- Maciej Moll
- Department of Cardiac Surgery, Polish Mother's Memorial Hospital, Research Institute, Lodz, Poland
| | - Jadwiga A Moll
- Department of Cardiology, Polish Mother's Memorial Hospital, Research Institute, Lodz, Poland
| | - Jacek J Moll
- Department of Cardiac Surgery, Polish Mother's Memorial Hospital, Research Institute, Lodz, Poland
| | - Monika Łubisz
- Department of Cardiology, Polish Mother's Memorial Hospital, Research Institute, Lodz, Poland
| | - Krzysztof W Michalak
- Department of Cardiology, Polish Mother's Memorial Hospital, Research Institute, Lodz, Poland
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Clinical Outcome of Patients with Transposition of the Great Arteries and Intramural Coronary Artery. Pediatr Cardiol 2021; 42:417-424. [PMID: 33591387 DOI: 10.1007/s00246-020-02499-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/07/2020] [Indexed: 10/22/2022]
Abstract
To review the early and intermediate outcomes of patients with transposition of the great arteries (TGA) and intramural coronary artery (IMCA) who underwent arterial switch operation (ASO) at our center. Among 450 patients with TGA who underwent an ASO between 2010 and 2018, 26 (5.8%) patients were identified with IMCA. The left coronary artery was intramural in 21 of 26 patients. We adopted coronary transfer using double coronary buttons with unroofed intramural course for all 26 patients. Early mortality for patients with IMCA was 3 of 26 (11.5%) compared with 10 of 424 (2.4%) for those without IMCA (p = 0.007). Six patients suffered major adverse events, including extracorporeal membrane oxygenation support in 3 patients, delayed sternal closure in 6 patients. The follow-up was available for all 23 survivors, with the mean follow-up period of 73.5 ± 28.7 months. There was no late death and reinterventions, and all patients were asymptomatic at last follow-up. One patient exhibited moderate neopulmonary regurgitation, and 1 patient presented with distal stenosis of the right pulmonary artery. Coronary transfer using double coronary buttons with unroofed intramural course was a good option for patients with TGA and IMCA. With this technique, ASO could be performed with optimal early and intermediate outcomes.
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Preoperative Coronary Anatomy Assessment with Echocardiography and Morbidity After Arterial Switch Operation of Transposition of the Great Arteries. Pediatr Cardiol 2018; 39:1620-1626. [PMID: 30003297 PMCID: PMC6244994 DOI: 10.1007/s00246-018-1939-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 07/05/2018] [Indexed: 11/24/2022]
Abstract
In transposition of the great arteries (TGA), certain coronary patterns have been associated with major adverse events early after the arterial switch operation (ASO). We sought to determine the impact of preoperative echocardiographic (ECHO) diagnosis on the intra- and postoperative morbidity. All patients with TGA born between June 2001 and June 2017 and who underwent ASO were reviewed. Data on presumed coronary anatomy (CA) preoperatively were obtained from the preoperative ECHO report. Intraoperative CA was categorized according to Yacoub classification. Major postoperative morbidity included at least one of the following: delayed sternal closure (DSC), prolonged (> 72 h) mechanical ventilation, reintubation, peritoneal dialysis (PD), ECMO, reoperation, and readmission within 30 days after surgery. 240 patients with median age of 5 days (range 1-614) and mean weight at surgery was 3.6 kg (1.8-8.4) were included. Preoperative ECHO assessment of CA was available in 228 patients. Intraoperatively, 181 patients (75%) were found to have type A, 25 patients had type B or C or intramural (B-C-IM; 10%), and 34 patients had type D or E (D-E; 14%). Patients with types B, C, and intramural coronary (B-C-IM) had increased risk for delayed sternum closure (9/25 vs. 20/181 in type A and 8/34 in type D-E; p = 0.04), peritoneal dialysis (4/25 vs. 8/181 and 1/34; p = 0.04), and ECMO (2/25 vs. 1/131 and 1/34; p = 0.02). Within the B-C-IM group, preoperative ECHO raised suspicion of type A in 13 patients (i.e., incorrect diagnosis, ID; 52%), whereas non-A CA was suspected in 12 patients (i.e., correct diagnosis, CD; 48%). With the exception of reoperation, which was seen only in the ID subgroup (4/12 vs. 0/10 in the CD subgroup; p = 0.04), the intraoperative (cardiopulmonary bypass time and cross-clamp time) and postoperative morbidity indices were comparable in both ID and CD subgroups (p > 0.1). Although there is a significant risk for early postoperative morbidity in TGA patients with single, interarterial, and intramural CA, there seems to be relatively limited influence of preoperative ECHO assessment of coronary anatomy on this morbidity burden.
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Clinical guidelines for the management of patients with transposition of the great arteries with intact ventricular septum. Cardiol Young 2017; 27:530-569. [PMID: 28249633 DOI: 10.1017/s1047951117000014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Sarris GE, Balmer C, Bonou P, Comas JV, da Cruz E, Chiara LD, Di Donato RM, Fragata J, Jokinen TE, Kirvassilis G, Lytrivi I, Milojevic M, Sharland G, Siepe M, Stein J, Büchel EV, Vouhé PR. Clinical guidelines for the management of patients with transposition of the great arteries with intact ventricular septum. Eur J Cardiothorac Surg 2017; 51:e1-e32. [DOI: 10.1093/ejcts/ezw360] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Excellent Long-Term Outcomes of the Arterial Switch Operation in Patients With Intramural Coronary Arteries. Ann Thorac Surg 2016; 101:725-9. [DOI: 10.1016/j.athoracsur.2015.08.090] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 08/23/2015] [Accepted: 08/31/2015] [Indexed: 11/23/2022]
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