Management of anomalous circumflex coronary artery from the neo-pulmonary artery in an adolescent following neonatal arterial switch operation

Objective: The timing and nature of and risk factors for reoperation after the arterial switch operation in the setting of d-transposition of the great arteries requires further elucidation. Methods: A total of 403 patients who underwent arterial switch operation from 1986 to 2017 were reviewed. Institutional preference was for pulmonary artery reconstruction using a pantaloon patch of fresh autologous pericardium. The targets for coronary artery reimplantation were identified by intermittent root distension. Multivariable analysis was used to identify risk factors for reoperation. Results: Median follow-up was 8.6 years (interquartile range [IQR]: 2-16.9). Pulmonary arterioplasty was the most common reoperation (n = 11, 2.7%) at 3.3 years (IQR: 1.4-11.4) postoperatively. Subvalvar right ventricular outflow tract reconstruction (RVOTR) was required in nine (2.2%) patients at 2.5 years (IQR: 1.1-5.3) postoperatively. Aortic valve repair or replacement (AVR/r) was required in seven (1.7%) patients at 13.6 years (IQR: 10.0-15.8) postoperatively. Aortic root replacement (ARR) and Coronary Artery Bypass Graft/coronary patch arterioplasty were required in five (1.2%) patients each at 13.6 years (IQR: 11.0-15.3) and 11.3 years (IQR: 2.3-13.6) postoperatively, respectively. Taussig-Bing anomaly was a risk factor for any reoperation ( P = .034). Risk factors for specific reoperations included ventricular septal defect for AVR/r ( P = .038), Taussig-Bing anomaly for RVOTR ( P = .004), and pulmonary artery banding for ARR ( P = .028). Conclusions: Pantaloon patch pulmonary artery reconstruction and intermittent neo-aortic root distension during coronary reimplantation have minimized respective outflow tract reoperations. Certain anatomic subsets carry different risks for late reoperation, and pulmonary artery and/or RVOT reinterventions tend to occur sooner than aortic reinterventions. Special attention to these higher risk subpopulations will be critical to optimizing lifelong outcomes.

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Preoperative identification of coronary arterial anatomy in complete transposition, and outcome after the arterial switch operation

Cardiology in the Young ◽

10.1017/s1047951102000537 ◽

2002 ◽

Vol 12 (3) ◽

pp. 240-247 ◽

Cited By ~ 15

Author(s):

Colin J. McMahon ◽

Howaida G. El Said ◽

Timothy F. Feltes ◽

Carmen H. Watrin ◽

Beth A. Hess ◽

...

Keyword(s):

Coronary Artery ◽

Coronary Arteries ◽

Left Coronary Artery ◽

Arterial Switch Operation ◽

Circumflex Coronary Artery ◽

Arterial Switch ◽

Complete Transposition ◽

Switch Operation ◽

The Right ◽

Arterial Anatomy

Background: Perceived correlation between the coronary arterial anatomy in patients with complete transposition, and the outcome of the arterial switch procedure, has made preoperative identification of their patterns standard practice. Purpose: Our purpose was to assess the accuracy of preoperative echocardiographic identification of coronary arterial patterns, to evaluate the necessity of preoperative imaging by angiography, and to determine the impact of the coronary arterial anatomy on outcome. Methods: We reviewed the medical records of all patients referred for an arterial switch operation between August 1995 and January 2000. The anatomy as described at the time of the operation using the Leiden convention was compared to the preoperative echocardiographic and angiographic findings. Results: The procedure had been performed in 67 patients, at a mean age of 9 days, with a range from 3 days to 15 months. In 42 patients, the ventricular septum was intact, while 21 patients had a ventricular septal defect, and the other four had double outlet right ventricle with the aorta anterior and rightward. In 52 patients, the left coronary artery arose from sinus #1, and the right from sinus #2. In 8 patients, the interventricular branch of the left coronary artery arose from sinus #1, with the circumflex coronary artery arising together with the right coronary artery from sinus #2. In three patients, all three coronary arteries arose from sinus #1, while in the remaining individual patients, a large conal branch arose with the left coronary artery from sinus #1, the right coronary and left anterior descending arteries arose from sinus #1, all three coronary arteries took origin from sinus #2, and the left anterior descending and right coronary artery arose from sinus #1 with no circumflex coronary artery identifiable, respectively. In two patients (4%), we identified an intramural coronary arterial course. Echocardiography and angiography were comparable (81% versus 86%) in delineating the coronary arterial anatomy. Patients with a single arterial orifice, or an atypical coronary arterial anatomy, had a slightly longer stay on the intensive care unit, and in the hospital, but showed no difference in mortality. In fact, there was no early mortality (70% confidence limits; 0–2.9%), while two patients died late (2.9%). Conclusion: We conclude that complex coronary arterial anatomy does not preclude a successful arterial switch procedure, although patients with a single coronary artery, or other arterial patterns, had a slightly longer hospital course. Preoperative echocardiographic evaluation is comparable to non-selective coronary angiography. Irrespective of complexity, nonetheless, the coronary arteries can successfully be translocated, obviating the need for preoperative coronary angiography.

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Acquired origin of the left anterior descending coronary artery from the pulmonary artery: A complication of the arterial switch operation

Annals of Pediatric Cardiology ◽

10.4103/0974-2069.79626 ◽

2011 ◽

Vol 4 (1) ◽

pp. 60

Author(s):

Safa Baris ◽

Isa Ozyilmaz ◽

AyseGüler Eroglu ◽

Levent Saltik

Keyword(s):

Coronary Artery ◽

Pulmonary Artery ◽

Arterial Switch Operation ◽

Arterial Switch ◽

Switch Operation

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Alternative pulmonary artery reconstruction technique in the arterial switch operation

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezab049 ◽

2021 ◽

Author(s):

Hisayuki Hongu ◽

Masaaki Yamagishi ◽

Yoshinobu Maeda ◽

Keiichi Itatani ◽

Masatoshi Shimada ◽

...

Keyword(s):

Pulmonary Artery ◽

Arterial Switch Operation ◽

Late Complication ◽

Late Complications ◽

Reconstruction Technique ◽

Reconstruction Method ◽

Arterial Switch ◽

Switch Operation ◽

Longitudinal Extension

Abstract OBJECTIVES Late complications of arterial switch operations (ASO) for transposition of the great arteries, such as neo-pulmonary artery (PA) stenosis and/or neoaortic regurgitation, have been reported. We developed an alternative reconstruction method called the longitudinal extension (LE) method to prevent PA bifurcation stenosis (PABS). METHODS We identified 48 patients diagnosed with transposition of the great arteries and performed ASO using the Lecompte manoeuvre for neo-PA reconstruction. In 9 consecutive patients (from 2014), the LE method was performed (LE). Before 2014, conventional techniques were performed in 39 patients (C). The median body weight and age in the LE and C groups were 3.0 and 3.1 kg and 12 and 26 days, respectively. In the LE group, 1 patient underwent bilateral PA banding before ASO. In C, PA banding and arch repair were performed in 1 patient each. Patients who received concomitant procedures were included. RESULTS The median follow-up in LE and C groups was 1.9 and 10.1 years, respectively. Early mortality/late death was not found in group LE and in 1 patient in group C. Only 1 case required ascending aorta sliding plasty in LE, and 8 patients needed PA augmentation for PABS in C. The median velocity of right/left PA was measured as 1.6/1.9 m/s in LE and 2.1/2.3 m/s in C, so it showed a lower value in LE. CONCLUSIONS Excellent mid-term results were obtained with the LE method. It was considered a useful procedure in preventing PABS, which is a primary late complication of ASO. Further follow-up and investigations are needed.

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Single coronary artery and neonatal arterial switch operation: early and long-term outcomes†

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezx046 ◽

2017 ◽

Vol 52 (1) ◽

pp. 90-95 ◽

Cited By ~ 7

Author(s):

Sébastien Gerelli ◽

Margaux Pontailler ◽

Bruno Rochas ◽

Emanuela Angeli ◽

Mathieu Van Steenberghe ◽

...

Keyword(s):

Coronary Artery ◽

Arterial Switch Operation ◽

Single Coronary Artery ◽

Long Term Outcomes ◽

Arterial Switch ◽

Switch Operation

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Coronary artery pattern and age impact exercise performance late after the arterial switch operation

Journal of Thoracic and Cardiovascular Surgery ◽

10.1016/j.jtcvs.2007.06.022 ◽

2007 ◽

Vol 134 (5) ◽

pp. 1207-1212 ◽

Cited By ~ 23

Author(s):

Sara K. Pasquali ◽

Bradley S. Marino ◽

Michael G. McBride ◽

Gil Wernovsky ◽

Stephen M. Paridon

Keyword(s):

Coronary Artery ◽

Exercise Performance ◽

Arterial Switch Operation ◽

Arterial Switch ◽

Switch Operation ◽

Impact Exercise

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Left coronary artery stenosis with post-stenotic aneurysm after arterial switch operation before and after coronary revascularisation surgery

Cardiology in the Young ◽

10.1017/s1047951111000394 ◽

2011 ◽

Vol 21 (4) ◽

pp. 456-457 ◽

Cited By ~ 2

Author(s):

Davide Marini ◽

Claudio Defilippi ◽

Gabriella Agnoletti

Keyword(s):

Coronary Artery ◽

Left Coronary Artery ◽

Left Main Coronary Artery ◽

Coronary Artery Stenosis ◽

Arterial Switch Operation ◽

Cardiac Computed Tomography ◽

Left Main ◽

Arterial Switch ◽

Switch Operation ◽

Before And After

AbstractWe report the case of a child with severe and atypical stenosis of the left main coronary artery, which occurred late after arterial switch operation for transposition of the great arteries. Cardiac computed tomography accurately defined the lesion, showing the presence of post-stenotic dilation, guided the surgical approach and assessed coronary patency after revascularisation surgery.

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Abstract 16754: Novel Characterization of Pulmonary Artery Bending, Rather Than Stenosis, Detects Increased Right Ventricular Afterload and is Associated With Increased Right Ventricular Mass in the Post-Arterial Switch Operation Heart

Circulation ◽

10.1161/circ.142.suppl_3.16754 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Marc A Delaney ◽

Paige Mass ◽

Francesco Capuano ◽

Yue-hin Loke ◽

Laura Olivieri

Keyword(s):

Pulmonary Artery ◽

Right Ventricular ◽

Surface Area ◽

Body Surface Area ◽

Body Surface ◽

Arterial Switch Operation ◽

Radius Of Curvature ◽

Transposition Of Great Arteries ◽

Arterial Switch ◽

Switch Operation

Introduction: Surgical treatment of transposition of great arteries involves the Arterial Switch Operation (ASO) and the LeCompte maneuver, where the pulmonary artery (PA) and its bifurcation are translocated anterior to the neoaortic root, creating relative PA stenosis and exaggerated PA bending. Assessment of branch PA dimensions can identify stenosis, however complex 3-dimensional bending without clear stenosis may contribute to elevated right ventricular (RV) afterload. Initial data suggest elevated RV afterload and RV mass are prevalent in these patients but the etiology and associated risk factors remain unclear. Hypothesis: In post-ASO patients, more extreme PA bending, as described by radius of curvature, will be associated with elevated RV afterload and RV mass independently of relative PA stenosis. Methods: Retrospective single-center analysis of 22 post-ASO patients was performed, representing native anatomy of D-TGA with (15, 68%) and without (7, 32%) intact ventricular septum, excluding those with PA stent, pulmonary hypertension, or other anatomical confounders. RV systolic pressure (RVSP) was recorded from echocardiography (11, 50%) or catheterization (11, 50%) and correlated to cardiac magnetic resonance (CMR) imaging measurements including: radius of curvature (Rcw) weighted to differential pulmonary blood flow and RV mass indexed to body surface area. Results: In ASO patients, receiver operating characteristic curve demonstrated Rcw, but not PA stenosis, moderately detected presence of elevated RVSP (>40 mmHg) (respectively: AUC 0.84, p = 0.03 and AUC 0.49, p =0.60). Patients with elevated RV Mass had more extreme Rcw (when normalized to body surface area), but no difference in PA stenosis via Nakata index (respectively: p = 0.10, p = 0.02). Conclusions: Abnormal PA bending as described by Rcw is associated with increased RV afterload and RV Mass. Rcw may serve as a promising future clinical proxy to RV afterload.

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Can we predict potentially dangerous coronary patterns in patients with transposition of the great arteries after an arterial switch operation?

Cardiology in the Young ◽

10.1017/s104795111900204x ◽

2019 ◽

Vol 29 (11) ◽

pp. 1350-1355 ◽

Cited By ~ 1

Author(s):

Krzysztof W. Michalak ◽

Katarzyna Sobczak-Budlewska ◽

Jacek J. Moll ◽

Konrad Szymczyk ◽

Jadwiga A. Moll ◽

...

Keyword(s):

Coronary Artery ◽

Ct Angiography ◽

Coronary Ct Angiography ◽

Arterial Switch Operation ◽

Arterial Switch ◽

Coronary Ct ◽

Coronary Abnormalities ◽

Asymptomatic Patients ◽

Switch Operation

AbstractIntroduction:Coronary artery complications are the main reason for early mortality after an arterial switch operation. Late complications are relatively rare, and there is no consensus regarding the need or indications for routine follow-up coronary artery evaluations or the best first-line assessment modality. The aim of this study was to present the long-term post-operative frequency of coronary abnormalities in asymptomatic patients with transposition of the great arteries discovered by coronary CT angiography and potential “red flags” revealed by other examinations.Patients and methods:A group of 50 consecutive asymptomatic patients who underwent routine long-term coronary artery evaluation after an arterial switch operation according to our institutional protocol were qualified for this study. This routine in-hospital visit included a detailed medical interview, electrocardiography, echocardiography, Holter electrocardiography examinations, and laboratory and cardiopulmonary exercise tests. Patients who showed significant abnormalities were qualified for perfusion scintigraphy.Results:Unfavourable coronary abnormalities were detected in 30 patients (60%) and included ostial stenosis, muscular bridge, coronary fistula, interarterial course, proximal kinking, high ellipticity index, proximal acute angulation (<30 degree) of the left coronary artery, and proximal acute angulation of the right coronary artery. These features could not be predicted based on the medical interviews, surgical reports, or non-invasive screening test results.Conclusion:Complex coronary configurations with potentially dangerous coronary features are common in patients with transposition after an arterial switch operation. Such high-risk patients cannot be identified indirectly, and coronary CT angiography provides accurate information that is useful for post-operative management.

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