Ann Thorac Surg 1998;66:2087-2089
© 1998 The Society of Thoracic Surgeons
Case Reports
Transposition of the great arteries and isolated origin of the sinus node artery
Massimo A. Mariani, MD, PhDa,
Tjalling W. Waterbolk, MDa,
Tjark Ebels, MD, PhDa
a Thorax Center, University Hospital Groningen, Groningen, the Netherlands
Accepted for publication May 19, 1998.
Address reprint requests to Dr Ebels, Thorax Center, University Hospital Groningen, Hanzeplein, 1, Postbus 30.001, 9700RB Groningen, the Netherlands
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Abstract
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We report the cases of 2 newborns who underwent at 7 days of age an arterial switch operation for transposition of the great arteries with a rare coronary anomaly: the left and right coronary arteries originated with a single ostium from sinus 1 and the sinus node artery had an isolated origin from sinus 2. The sinus node artery was reimplanted into the new aorta in both patients. Both babies were discharged in sinus rhythm. Preserving the vascularization of the sinus node may avoid the occurrence of postoperative atrial rhythm disturbances.
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Introduction
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We report the cases of 2 newborns who underwent at 7 days of age an arterial switch operation for D-transposition of the great arteries with an unusual coronary artery pattern: the left and right coronary arteries originated with a single ostium from sinus 1 and the sinus node artery had an isolated origin from sinus 2 [1, 2]. One of the 2 newborns also had a bilateral arterial duct. Unexpectedly, an isolated sinus node artery originating from sinus 2 was identified during the operation. The isolated sinus node artery was reimplanted to prevent postoperative supraventricular arrhythmias.
Two newborns were diagnosed with transposition of the great arteries by means of echocardiography. At echocardiography a single coronary ostium was identified. No preoperative angiography was performed. In patient 1 the foramen ovale was patent and the aorta was situated in a position oblique and anterior to the pulmonary artery. Preoperatively, a prostaglandin infusion was used to keep the arterial duct open in both newborns. At the operation, a right-sided arterial duct was found during surgical preparation of the vessels in patient 1. This right duct (Fig 1 ) arose from the right pulmonary artery and was connected to the right subclavian artery. In addition, a left arterial duct larger than the right ductus was found in the usual position in both patients. Cardiopulmonary bypass was established by means of bicaval cannulation in both newborns. In patient 1 both arterial ducts were ligated with 1-0 silk sutures and divided to mobilize the pulmonary artery bifurcation. Cardiopulmonary bypass was maintained in moderate hypothermia (28°C) and cardiac arrest was induced by infusing cold crystalloid cardioplegic solution into the aortic root in both newborns. The deep hypothermia circulatory arrest was not used. The common coronary ostium leading to both the right coronary artery, the left anterior descending artery, and the circumflex artery, was identified in sinus 1 after transection of the aorta. An additional small coronary ostium (<1 mm in diameter) leading to the sinus node artery was identified in sinus 2 (Fig 2 ). Both coronary ostia were excised together with a wide button of tissue of Valsalva sinus and the first tract of both arteries was mobilized to avoid kinking after reimplantation. Then the coronary ostia were reimplanted into the neoaorta with running 8-0 polypropylene sutures, according to the "trap-door" technique [3, 4]. The remaining holes on the pulmonary artery were closed by means of two glutaraldehyde-fixed autologous pericardial patches with running 7-0 polypropylene sutures. The aorta and the pulmonary artery were then anastomosed end-to-end to the respective roots with 7-0 polypropylene sutures. In patient 1 the foramen ovale was then closed directly with a running 6-0 polypropylene suture. The newborns were then weaned from cardiopulmonary bypass. The hearts of both newborns restarted in sinus rhythm and no electrocardiographic disturbances occurred. Intraoperative epicardial echocardiography showed good ventricular function and the absence of transvalvular gradients in both newborns. Both newborns were discharged in sinus rhythm after an uneventful postoperative course of 21 and 13 days, respectively.
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Fig 1. The intraoperative photograph (patient 1) shows the right ductus arteriosus (white arrowhead). The aorta is retracted toward the left by means of a silastic vessel loop.
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Fig 2. The intraoperative photograph (patient 1) shows the isolated origin of the sinus node artery from the sinus 2 (white arrowhead), after the aorta has been transected and widely opened.
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Comment
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We identified an isolated origin of the sinus node artery in 2 newborns with D-transposition of the great arteries.
In their report of postmortem examination of the coronary arteries in transposition, Rossi and colleagues [1] found that the sinus node artery always was a branch of either the right or the left coronary artery. The anatomic pattern of a common coronary ostium originating from sinus 1, associated with the isolated origin of the sinus node artery from sinus 2, has been described previously only in 3 patients (2% of cases) in another morphologic study by Smith and associates [2]. However, in those cases the left and right coronary arteries originated separately from sinus 1, instead of having a common ostium as in our 2 patients.
The considerable variation described in the anatomy of coronary arteries in transposition of the great arteries, including the arterial supply to the sinus node, emphasizes that it is worthwhile to assess the complex pattern of coronary vascularization in each patient. In fact, coronary anatomy is the main determinant of operative survival and can influence surgical management and postoperative outcome of the neonates [5, 6]. Previous studies [1, 2] have focused on the importance of avoiding surgical injury to the sinus node artery, as such an injury can result in atrial standstill or sinoatrial block. Atrial rhythm disturbances have a negative impact on the outcome of patients with transposition of the great arteries [7]. In the 2 above described neonates, our main concern was to preserve the vascularization of the sinus node by reimplanting the sinus node artery. The absence of postoperative atrial rhythm disturbances justified this policy in our opinion. In particular, we emphasize the importance of excising wide buttons of tissue of the Valsalva sinuses around the coronary ostia and of using the trap-door technique [3, 4] to facilitate the reimplantation in the neoaorta without tension on the anastomosis.
Transposition of the great arteries associated with bilateral arterial ducts (in left aortic arch), single coronary ostium, and isolated origin of the sinus node artery has not been described previously. Previous studies have not described bilateral arterial duct in transposition of the great arteries with left aortic arch, whereas only 1 patient with bilateral ducts was described in a transposition of the great arteries with right aortic arch [8]. The practical surgical significance of bilateral arterial duct is limited to the need of ligating and dividing both ducts.
In conclusion we are convinced of the importance of preserving the vascularization of the sinus node in patients with transposition of the great arteries undergoing a switch operation to avoid the occurrence of postoperative atrial rhythm disturbances.
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References
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Rossi M.B., Ho S.Y., Anderson R.H., Rossi-Filho R.I., Lincoln C. Coronary arteries in complete transposition: the significance of sinus node artery. Ann Thorac Surg 1986;42:573-577.[Abstract]
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Smith A., Arnold R., Wilkinson J.L., Hamilton D.I., McKay R., Anderson R.H. An anatomical study of the patterns of the coronary arteries and sinus nodal artery in complete transposition. Int J Cardiol 1986;12:295-304.[Medline]
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Kirklin JW, Barratt-Boyes BG. Complete transposition of the great arteries. In: Cardiac surgery, 2nd ed. New York: Churchill Livingstone, 1415–7.
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Mee R. The arterial switch operation. In: Stark J., de Leval M., eds. Surgery for congenital heart defects. Philadelphia: WB Saunders, 1994:483-500.
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Day R.W., Laks H., Drinkwater D.C. The influence of coronary anatomy on the arterial switch operation in neonates. J Thorac Cardiovasc Surg 1992;104:706-712.[Abstract]
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Mayer J.E., Jr, Sanders S.P., Jonas R.A., Castañeda A.R., Wernovski G. Coronary artery pattern and outcome of arterial switch operation for transposition of the great arteries. Circulation 1990;82:IV139-IV45.
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Rhodes L.A., Wernovski G., Keane J.F., et al. Arrhythmias and and intracardiac conduction defect after the arterial switch operation. J Thorac Cardiovasc Surg 1995;109:303-310.[Abstract/Free Full Text]
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Abstract
Introduction
