Utilization of the aortic flap above the facing commissure in arterial switch operations

Transposition of Great Arteries with Complex Coronary Artery Variants: Time-Related Events Following Arterial Switch Operation

Coronary artery anatomy represents a challenging and, often, determining predictor of outcome in an arterial switch operation (ASO). Impact of specific coronary artery variants, such as single, intramural and inverted, on time-related events following ASO, is, yet, to be determined. We sought to compare early and late outcomes within the group of nonstandard coronary artery variants. Patients who underwent ASO from January 1995 to October 2010 were reviewed. Patients with coronary artery variants other than L1Cx1R2 ("standard" by Leiden classification) were included. Patients with single, intramural and inverted coronary artery variants incorporated in group A. All other nonstandard coronary variants incorporated in group B. Demographics, perioperative variables, early and late outcomes were assessed. Of the 123 ASO, 24 patients (19.5%) with nonstandard coronary variant were studied. Thirteen were in group A and 11 in group B. There were two early deaths (1 in group A and 1 in group B) (p > 0.05). There is one death early after hospital discharge (group A). Mean follow-up was 59.4 ± 55.1 months. There was no structural coronary artery failure after hospital discharge following ASO. Freedom from any reintervention at 8 years was (78.3 ± 9.6%) (p 0.55) with no late neo-aortic or mitral valve intervention. ASO with single, intramural or inverted coronary artery course carries no added longitudinal risk for structural or flow impairment within the group of nonstandard coronary artery variants. There is an early hazard period with no late survival attrition. Aortic arch repair as part of staged strategy prior to ASO might influence early and late outcome.

Restoration of Transposed Great Arteries to Nature

Surgical correction of transposition of the great arteries was proposed by many in the past half-century and was claimed as the anatomical correction, but the treatment of choice was ever changing. The current technique usually includes the Lecompte maneuver to bring the pulmonary bifurcation in front of the aorta. Although the ventricular–arterial connection is corrected, it is not “normal.” This review describes an innovative technique to reconstruct the great arteries in spiral fashion, which is the natural relationship of the aorta and pulmonary artery. The surgical principles of nature and even distribution using autologous tissues are emphasized. The structural and functional studies of the spiral great arteries in the last 2 decades are also presented.

The "hinge-twist" technique for anomalous origin of the left coronary artery

A murmur was heard in an asymptomatic boy (age 4), and transthoracic echocardiography revealed anomalous origin of the left main coronary artery (LMCA) from the right sinus of Valsalva (age 6). Confirmed by catheterization and computed tomographic angiography (age 10), the LMCA followed a short interarterial course between the aorta and main pulmonary artery before supplying the anterior descending and circumflex coronary arteries. An intramural segment was not clearly seen. Results of stress testing were normal. Because sudden death was a concern, the patient underwent surgery at age 11. The "hinge-twist" technique was utilized in the absence of an intramural component or ostial stenosis in an effort to avoid the long-term complications of coronary reimplantation, ostial patching, or bypass grafting.

"Bay window" technique for the arterial switch operation of the transposition of the great arteries with complex coronary arteries

BACKGROUND

The success of arterial switch operations for transposition of the great arteries largely depends on faultless coronary translocation and subsequent sufficient myocardial perfusion. However, in patients with complex coronary artery anatomy, coronary translocation is often difficult to perform by conventional surgical techniques alone. Therefore we developed the "bay window" technique as a useful adjunct in patients with complex coronary arteries undergoing concomitant coronary translocation and arterial switch operation. Early and midterm results of this technique are described.

METHODS

Between September 2001 and February 2002, 4 patients with transposition of the great arteries with complex coronary arteries underwent arterial switch operation. The ages of the patients at the time of operation ranged from 8 to 52 days. Great arterial relationships were anteroposterior in 2 patients, right-oblique in 1, and side-by-side in 1. One patient also had ventricular septal defect. Coronary arterial patterns were as follows: absent left main trunk in 1 patient, short left main trunk in 1, and short right main trunk in 1. Both coronary arterial orifices were resected as a tall U-shaped cuff. The inferior half of the coronary cuff was sewn into a J-shaped incision on the pulmonary stump. The superior half of the coronary cuff was folded down inside to form a bay window channel.

RESULTS

No coronary events occurred (ie, inclusive of coronary stenosis, myocardial infarction, and coronary death). Postoperative echocardiogram demonstrated normal ventricular wall motions in all 4 patients.

CONCLUSIONS

The bay window technique is an innovative and simple surgical adjunct for translocating complex coronary arteries.

Modified arterial switch operation by spiral reconstruction of the great arteries in transposition

BACKGROUND

Spiral relationship of the normally related great arteries (SRGA) has never been reconstructed in an arterial switch operation.

METHODS

From March 1998 to April 1999, 9 consecutive cases of transposition of the great arteries (TGA) family (from 2 days to 1.6 years old) underwent arterial switch operations with SRGA at our hospital. Two had a congenitally corrected TGA (plus atrial redirection). Lecompte maneuver was not used in all. The posterior wall of pulmonary trunk was not divided but three were reattached, two of whom had had previous pulmonary trunk banding. Thus the wall was shared between the great arteries facing each other.

RESULTS

All survived the operation. Supraaortic stenosis was balloon-dilated in 2 cases of early series, but technical modifications later were able to avoid it. Angiogram showed smooth flow into SRGA without upward and anterior tilting of the pulmonary bifurcation. All great and coronary arteries were patent. All were doing well on follow-up (16.5 +/- 4.2 months).

CONCLUSIONS

We concluded that the techniques to relocate the coronary arteries using common wall and in situ switch could also be applied to pulmonary arterial reconstruction, so that SRGA can be resumed in TGA.