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Ann Thorac Surg 2000;69:949-951
© 2000 The Society of Thoracic Surgeons

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Case Reports

Arterial switch operation: successful bilateral internal thoracic artery grafting

^a Departments of Cardiac Surgery and Cardiology, Glenfield Hospital, Leicester, United Kingdom

Address reprint requests to Dr Hickey, Department of Cardiothoracic Surgery, Glenfield Hospital, Groby Rd, Leicester LE3 9QP, United Kingdom

	Abstract

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Internal thoracic artery grafting in arterial switch operations for transposition of great arteries has been reported for salvage of myocardial ischemia after initial coronary transfer. We report a situation where we opted for primary coronary bypass grafting to avoid an obviously difficult coronary transfer, with successful outcome.

	Introduction

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Survival after arterial switch correction of transposition of the great arteries (TGA) depends, in large measure, on the avoidance of myocardial ischemia. This is usually achieved by coronary translocation to the neoaorta, and this is the surgical goal in all cases. Occasionally, because of unfavorable coronary anatomy, technical failure, or a combination of both, serious myocardial ischemia ensues. In this setting, coronary artery bypass (CAB) using the internal thoracic artery (ITA) has been reported [1, 2]. We report medium term survival in a patient where the entire coronary circulation is supplied by ITA grafts, and promote awareness of this technique as a salvage procedure.

A 23-week-old, 6.4 kg infant with complex complete TGA was accepted for arterial switch operation (ASO). The patient presented on the ninth day of life with cyanosis. The diagnosis of complete TGA with multiple muscular ventricular septal defects (VSD) was confirmed by echocardiography. Balloon atrial septostomy was performed on the ninth postnatal day, and on the 26th postnatal day, a pulmonary artery (PA) band was applied. When accepted for ASO, the PA band was in place with a gradient of 60 mm Hg across it. The left ventricle (LV) was globular. There was no significant mitral or tricuspid regurgitation. Two midmuscular VSDs were seen. The right ventricular (RV) and LV pressures were equal. There was no outflow tract obstruction. The pulmonary annulus was 0.95 cm in diameter, and the aortic annulus was 1.15 cm. Preoperative catheterization and angiography revealed no left superior vena cava. LV angiography showed the PA arising from a normal sided LV. The PA band was identified just proximal to the PA bifurcation. The PAs appeared normal, with no areas of stenosis or distortion. A moderate sized midmuscular VSD was identified with one orifice on the left side, and 2 exit points on the RV aspect. No other VSDs were seen. Aortography revealed a left-sided aorta arising from the RV, with normal arch vessel anatomy. It was felt that the coronary arteries arose in the usual position for transposition, with the right coronary artery (RCA) arising from the right posterior facing sinus, and the left coronary artery (LCA) from the left posterior facing sinus. The LCA gave rise to the circumflex and left anterior descending (LAD) branches. There was a small aortopulmonary collateral artery to the right lung arising from the mid thoracic descending aorta. Because of progressive cyanosis (oxygen saturation of 55% to 60% on air) and with the LV being adequately prepared, the patient was referred for corrective operation.

	Surgical technique

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After exposure of the heart, the great vessels were mobilized, and the ductal remnant ligated and divided. After total body heparinization, aortic cannulation and bicaval venous cannulation were established. CPB was instituted, and core cooling to 15°C initiated. A LV vent was placed through the right superior pulmonary vein. The aorta was cross-clamped, and antegrade cold cardioplegic arrest was attained. An oblique right atriotomy was made and the atrial septal defect was sutured directly with 4-0 Prolene (Johnson & Johnson). The tricuspid valve was then retracted, and the muscular VSDs were identified and closed directly with 4-0 Tycron pledgeted, interrupted mattressed sutures (Davis & Geck). The right atrium was closed, and the aorta transected at an appropriate level and the coronaries were inspected. It then became apparent that there was a single coronary orifice straddling the commissure between the right and left posterior facing cusps. However, the RCA and LCA took off on their separate courses, immediately downstream to the single ostium. Both had proximal intramural segments. It was felt that an attempt to transfer the coronaries, under the circumstances, would contribute to torsion and kinking. A decision to harvest both ITAs was taken with a view to constructing coronary artery bypass grafts. The left and then the right ITA pedicles were dissected out, and good flow was confirmed from both pedicles. The right ITA was anastomosed to the proximal RCA, and the left ITA was anastomosed to the proximal LAD. Both native coronary arteries were more than 1.5 mm in size at the site of anastomosis. Long anastomoses were constructed using 8-0 Prolene continuous suture. The single coronary ostium was then sutured closed within the aortic root. The Le Compte maneuver was done after excision of the PA band. Without the necessity for coronary transfer, completion of the switch operation was straightforward. After rewarming, the patient was taken off CPB without problems and decannulated. A short while later, ST depression on the electrocardiogram followed by hypotension, and progressing to ventricular fibrillation, necessitated going back on CPB with aortic cannulation and a single venous cannula. However, the patient was cardioverted and, after a period of rest for the heart, the operation was completed uneventfully. The patient was transferred to intensive care in a stable hemodynamic condition with minimal doses of dopamine and adrenaline.

Postoperative ventilation was maintained for 5 days because of concern about the possibility of coronary supply and demand mismatch, and worries about ITA reactivity/spasm. This was the presumed cause of difficulty immediately after bypass. An echocardiogram done 8 days postoperatively showed well contracting ventricles. Two small residual shunts, in relation to the VSDs were identified. There was no obvious segmental dyskinesis. The patient was discharged to home on the tenth postoperative day. One year after operation, the child was healthy with no clinical, electrocardiogram or echocardiogram evidence of heart failure.

	Comment

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With relevance to ASO, the recognition and appropriate management of variable coronary artery anatomy in complete TGA is crucial for a successful outcome. Of the anatomical variations in the coronaries, the presence of an intramural segment or juxtacommissural origin of coronary arteries (JOCA) remains a major challenge for the surgeon. It has been pointed out that an intramural coronary artery should be strongly suspected in the presence of JOCA, and high take-off of the coronary arteries. A new classification of the coronary arterial pattern has been proposed recently based on short axis aortopulmonary rotation in transposition [3]. The situation encountered in the present patient could be classified as "1j" according to the above classification. Coronary artery translocation is the most important step in achieving a successful result in ASO, and ingenious methods have been reported. Although a few centers have reported excellent results, coronary artery transfer requires a high technical expertise. Techniques of performing the ASO without coronary translocation have also been reported. Those reported include creation of flaps in the proximal great arteries, the coronaries being transferred in the process to the neoaorta, without distortion of their original anatomic position. The Aubert modification of the ASO has also been employed to avoid coronary translocation. [4]

Use of a single ITA for coronary reperfusion has been reported in the situation of salvaging ischemic myocardium after suboptimal coronary perfusion following ASO with initial translocation of coronary ostia [1, 2]. In this case we report the clinical situation where a decision was taken in which standard coronary translocation was not feasible, and therefore an attempt should be made to reperfuse the entire coronary artery system using both ITAs, with the coronary ostium being sutured off from within the aorta. The flow through both ITAs was excellent. The ascending aorta having been transected at a prior stage of the operation, retraction, probing and exposure of the proximal RCA and LCA was rendered easy, and good quality anastomoses were ensured. The coronary anastomoses having been completed, the remainder of the ASO with a Le Compte maneuver was straightforward. Prior experience with a single ITA in salvage situations, after suboptimal coronary perfusion following ASO in babies, have documented the suitability of the ITA as a reliable conduit, even in babies [1, 2]. We are unaware of other reports of bilateral ITA grafting in the setting of ASO. We do not propose this technique as one of first choice, but report it as yet another method of getting out of difficulty. The long-term fate of neonatal ITA grafting for ASO is yet to be assessed, however, reports of ITA grafts in pediatric patients with Kawasaki disease have shown excellent long-term patency and the potential for growth of the conduit and anastomosis [5, 6]

	References

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1. Ebels T., Meuzelaar K., Gallendat Huet R.C., 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;97:473-475.
2. Brackenbury E., Gardiner H., Chan K., Hickey M. Internal mammary artery to coronary artery bypass in paediatric cardiac surgery. Eur J Cardiothorac Surg 1998;14:639-642.[Abstract/Free Full Text]
3. Chiu I.S., Mei-Hwan W., Chung-I C., et al. Clinical implications of short axis aortopulmonary rotation on juxtacommissural origin of the coronary artery in transposition of the great arteries and surgical strategy. J Card Surg 1997;12:23-31.[Medline]
4. Aubert J., Pannetier A., Couvelly J.P., Unal D., Ronault F., Delarue A. Transposition of the great arteries. New technique for anatomical correction. Br Health J 1978;40:204-208.
5. Kitamura S., Seki T., Kawachi K., et al. Excellent patency and growth potential of internal mammary artery grafts in pediatric coronary bypass surgery. New evidence for "live" conduit. Circulation 1988;78(Suppl 1):129-139.
6. Kitamura S., Kawachi K., Seki T., et al. Bilateral internal mammary artery grafts for coronary artery bypass operations in children. J Thorac Cardiovasc Surg 1990;99:708-715.[Abstract]

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