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Ann Thorac Surg 1996;62:586-588
© 1996 The Society of Thoracic Surgeons

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Case Report

Arterial Switch Operation: Myocardial Ischemia Reversed by Internal Mammary Artery Graft

Department of Cardiac Surgery, Ospedali Riuniti di Bergamo, Bergamo, Italy

Accepted for publication March 5, 1996.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
We report a case in which an internal mammary artery graft to the left anterior descending coronary artery was successfully used in a newborn boy to reverse life-threatening myocardial ischemia 24 hours after arterial switch operation. One year later, angiography showed patency of both the graft and the transposed coronary ostium with normal left ventricular function. A brief review of the literature shows encouraging results of internal mammary artery grafts in pediatric patients.

	Introduction

Top Footnotes Abstract Introduction Comment References

 
Weaning from cardiopulmonary bypass after arterial switch operation (ASO) is usually impossible in the presence of acute ischemia related to impeded coronary flow. In this situation an internal mammary artery (IMA) graft has already proved feasible and successful [1–4]. We report a case in which slowly evolving myocardial ischemia was reversed by left IMA to left anterior descending artery (LAD) bypass graft 24 hours after ASO. Twelve months later the patient was asymptomatic in good clinical condition, and angiography revealed patency of both the graft and the transposed left coronary ostium with normal left ventricular (LV) function.

A 4-kg male baby aged 12 hours was referred to the neonatal department of our hospital for cyanosis, polypnea, and bradycardia. Echocardiography showed transposition of great arteries with nonrestrictive ventricular septal defect. Prostaglandin E₁ infusion was started, and 2 days later a Rashkind procedure was performed. An aortic root injection revealed a Yacoub type A coronary distribution. At the age of 40 days (weight, 4.7 kg) the baby underwent anatomic correction. Operative findings were (1) anteroposterior relationship of aorta and pulmonary artery, (2) Yacoub type A coronary anatomy, and (3) large perimembranous outlet ventricular septal defect. The common trunk of the left coronary artery appeared to be longer than usual, and the circumflex branch arose at an acute angle from it. The coronary ostia were translocated into two medially hinged trap doors created in the neo-aortic root.

After cross-clamp removal, reperfusion of the myocardium appeared to be unsatisfactory in the anterior wall of the LV. We reasoned that an excessively medial relocation of the left coronary button (performed to avoid kinking of the circumflex branch) caused stretching of the LAD. To obviate this problem an oval pericardial patch was inserted between the two coronary ostia to enlarge the neo-aortic root and to relieve the tension on the LAD. The operation was completed by transatrial closure of the ventricular septal defect and reconstruction of pulmonary artery. Eventually the perfusion of the LV seemed to be adequate and the hemodynamic status was good enough to allow weaning from cardiopulmonary bypass. The sternum was left open.

Left ventricular function initially appeared acceptable with dopamine, nitroglycerin, and nitroprusside infusion, but deteriorated progressively in the next 24 hours despite increasing pharmacologic support. Left atrial pressure rose to 15 mm Hg with a mean arterial pressure of about 40 mm Hg. Sequential pacing was started after a period of sinus bradycardia and junctional rhythm. Transthoracic echocardiography revealed poor LV function with akinesia of both interventricular septum and the anterolateral wall, and diskinesia of the apex.

The baby was returned to the operating room, and to avoid a complex redo of the left coronary anastomosis a left IMA graft to the LAD was performed. The IMA was dissected free and found to have a diameter of 1 mm. Cardiopulmonary bypass was instituted with a single right atrial cannula, and the patient was cooled to a nasopharyngeal temperature of 28°C. The aorta was cross-clamped and crystalloid cardioplegia was administered through the aortic root. An end-to-side anastomosis between the IMA and the middle portion of the LAD was constructed using 5.5x magnifying loupes and 8/0 monofilament running suture. The aortic cross-clamp was removed after 10 minutes and the heart started beating spontaneously with evidence of good perfusion of the LV. Weaning from cardiopulmonary bypass was easily achieved after rewarming, the chest was closed, and the patient was returned to the intensive care unit in sinus rhythm receiving 5 µg•kg^-1•min^-1 of dopamine.

The subsequent postoperative course was uneventful. Echocardiography performed on the first, third, seventh, and fourteenth postoperative days revealed good LV function, and thallium scintigraphy performed on the eleventh postoperative day showed only a small perfusion defect in the middle portion of the LV anterior wall. An angiogram performed 1 year later showed a patent IMA graft as well as patency of the translocated left coronary ostium (Fig 1).

View larger version (39K): [in this window] [in a new window]   Fig 1. . Injection into the left subclavian artery shows opacification of left internal mammary artery (IMA) and left anterior descending artery (LAD); retrograde contrast filling of the aortic root demonstrates patency of translocated coronary ostium (CO).

	Comment

Top Footnotes Abstract Introduction Comment References

An IMA graft in ASO should be considered in case of severe injury to the coronary artery during dissection, or failure to obtain enough tissue for the flap around the ostium. We believe it may also play a role when the mechanism of impeded coronary flow is not clearly understood or taking down of multiple suture lines would be technically very difficult and would require an extended ischemic period.

Several authors have reported successful use of IMA graft in pediatric patients after ASO [1–4] with angiographic proof of patency as late as 8 months postoperatively. Grabitz and coworkers [3] described a right IMA bypass graft performed by Dr Messmer in a 7-day-old newborn baby operated on for ASO, with regular function of the graft after more than 30 months of follow-up.

Reports of IMA grafts in pediatric patients with Kawasaki disease [6–8] show that the graft is a live conduit with potential for growth and adaptation, and excellent long-term patency. All the IMA grafts became longer as body surface area increased, and the anastomotic junction did grow. Moreover, body development was normal, including sternum and chest in patients who underwent myocardial revascularization with bilateral mammary artery grafts. In a 1991 multicenter follow-up study by Kitamura and colleagues [9] actuarial analysis showed that the IMA graft patency rate was 77.7% 85 months after operation in 140 patients with Kawasaki disease. Review of the literature reporting the use of IMA grafting for treatment of congenital coronary malformations shows encouraging results in all patients, even though long-term patency of the graft has not yet been assessed [10–12].

The long-term fate of a neonatal IMA graft after ASO is still unknown; nonetheless, favorable results like those in children with Kawasaki disease or anomalies of the coronary arteries can probably also be expected in this group of patients.

	Footnotes

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Address reprint requests to Dr Merlo, Cardiochirurgia, Ospedali Riuniti di Bergamo, Bergamo 24100, Italy.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Ebel T, Meuzelaar K, Gallandat Huet RCG, et al. Neonatal arterial switch operation complicated by intramural left coronary artery and treated by left internal mammary artery bypass graft. J Thorac Cardiovasc Surg 1989;97:473–5.[Medline]
2. Rheuban KS, Kron IL, Bulatovic A. Internal mammary artery bypass after the arterial switch operation. Ann Thorac Surg 1990;50:125–6.[Abstract/Free Full Text]
3. Grabitz RG, Messmer BJ, Seghaye MC, Engelhardt W, Muhler E, von Bernuth G. Internal mammary artery bypass graft for impaired coronary perfusion after neonatal arterial switch operation. Eur J Cardiothorac Surg 1992;6:388–90.[Abstract/Free Full Text]
4. Balasundaram S, Kumar N, Al Halees Z, Wilson N. Left internal thoracic artery bypass graft in arterial switch with coronary transfer for transposition of the great arteries. Int J Cardiol 1992;36:121–3.[Medline]
5. Mayer JE Jr, Sanders SP, Jonas RA, Castañeda AR, Wernovsky G. Coronary artery pattern and outcome of arterial switch operation for transposition of the great arteries. Circulation 1990;82(Suppl 4):139–45.
6. Hirose H, Kawashima Y, Nakano S, et al. Long-term result in surgical treatment of children 4 years old or younger with coronary involvement due to Kawasaki disease. Circulation 1986;74(Suppl 1):77–81.
7. Kitamura S, Seki T, Kawachi K, et al. Excellent patency and growth potential of internal mammary artery graft in pediatric coronary artery bypass surgery. Circulation 1988;78(Suppl 1):129–39.
8. Kitamura S, Kawachi K, Seki T, et al. Bilateral internal mammary artery graft for coronary artery bypass operations in children. J Thorac Cardiovasc Surg 1990;99:708–15.[Abstract]
9. Kitamura S, Kameda Y, Seki T, et al. Long-term outcome of myocardial revascularization in patients with Kawasaki coronary artery disease. J Thorac Cardiovasc Surg 1994;107: 663–74.[Abstract/Free Full Text]
10. Kitamura S, Kawachi K, Nishii T, et al. Internal thoracic artery grafting for congenital coronary malformations. Ann Thorac Surg 1992;53:513–6.[Abstract/Free Full Text]
11. Fortune RL, Baron PJ, Fitzgerald JW. Atresia of the left main coronary artery: repair with left internal mammary bypass. J Thorac Cardiovasc Surg 1987;94:150–1.[Abstract]
12. Cohen AJ, Grishkin BA, Helsel RA, Head HD. Surgical therapy in the management of coronary anomalies: emphasis on utility of internal mammary artery grafts. Ann Thorac Surg 1989;47:630–7.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Francesco P. Annecchino Giancarlo Crupi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Merlo, M. Articles by Ziolkowska, L. Search for Related Content PubMed PubMed Citation Articles by Merlo, M. Articles by Ziolkowska, L.