ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Jaggers, J. J.
Right arrow Articles by Ungerleider, R. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Jaggers, J. J.
Right arrow Articles by Ungerleider, R. M.

Ann Thorac Surg 2000;69:S205-S235
© 2000 The Society of Thoracic Surgeons

Congenital Heart Surgery Nomenclature and Database Project: transposition of the great arteries

James J. Jaggers, MDa, Duke E. Cameron, MDb, J. René Herlong, MDc, Ross M. Ungerleider, MDa

a Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
b Division of Pediatric Cardiology, Duke University Medical Center, Durham, North Carolina, USA
c Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA

Address reprint requests to Dr Jaggers, Division of Pediatric Cardiothoracic Surgery, Box 3474, Duke University Medical Center, Durham, NC 27710
e-mail: jagge003{at}mc.duke.edu

Presented at the International Nomenclature and Database Conferences for Pediatric Cardiac Surgery, 1998–1999.

Abstract

The extant nomenclature for transposition of the great arteries (TGA) is reviewed for the purposes of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include relevant nomenclature categories including synonyms where appropriate. The general categories of TGA are: TGA with intact ventricular septum, TGA with ventricular septal defect (VSD) and TGA with VSD and left ventricular outflow tract obstruction (LVOTO). A comprehensive database set is presented which is based on a hierarchical scheme. Data are entered at various levels of complexity and detail that can be determined by the clinician. A detailed hierarchical system is described herein for classification of the coronary artery anatomy associated with TGA. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented which will allow for data sharing and would lend itself to basic interpretation of trends.

I. Background

Transposition of the great arteries (TGA) has been recognized for nearly 300 years. Mathew Baillie of London first described the most common variety of transposition, d-TGA, in 1797. The term transposition of the aorta and pulmonary artery (PA) (trans meaning across, and positio meaning placement) was applied by Farre in 1814, literally meaning that the aorta and pulmonary artery are placed across the ventricular septum. Subsequent attempts to characterize anomalies based upon an embryologic basis resulted in the assignment of the word transposition to any defect in which the aorta was anterior relative to the PA. By the early 1900s, this was extended to any defects with abnormal position of the great vessels regardless of the ventricular origin [1].

Van Praagh has been most influential in clarifying the anatomy related to transposition. He recommends that aberrations in conotruncal development be regarded as malpositions of the great arteries. Transposition is simply one variety of malposition. Other types of malposition include double-outlet right ventricle (DORV), double-outlet left ventricle, and anatomically corrected malposition [2]. This defect is the result of malformation of the infundibulum or conus arteriosus. Typically, there is muscular subaortic conus that widely separates the transposed aortic valve from both atrioventricular valves. Absence of a subpulmonary conal free wall permits direct pulmonary-mitral fibrous continuity. This arrangement has been termed complete transposition. This may be contrasted to incomplete transposition, which is obsolete terminology and refers to what is now termed double-outlet right or left ventricle (LV). All malpositions of the great arteries that we now classify as transposition are complete transpositions. Thus, complete transposition may refer to either physiologically uncorrected transposition, or to physiologically corrected transposition because in both cases the great arteries arise from the wrong ventricle, and thus are completely transposed. Thus, the modifier complete is both redundant and should be avoided. Some have used the term transposition to refer to any heart in which the aorta is anterior to the PA. This definition is imprecise, because the aorta is not anterior in all hearts with transposition, and there are a number of malformations in which the aorta is anterior and that are not transpositions.

II. Analysis: a unified TGA nomenclature system

When we refer to TGA, we are referring to those defects in which there is physiologically uncorrected transposition. This complex always has discordant ventriculoarterial alignment such that the aorta arises entirely or in large part from the right ventricle (RV) and the PA arises entirely or in large part above the LV. Concordant atrioventricular alignment is nearly always present.

For the purposes of this document and the creation of a prospective, comprehensive database, we define TGA as those heart defects in which there is physiologically uncorrected transposition of the great arteries. A diagram featuring the types of TGA is illustrated in Figure 1. This definition will include those hearts in which there is atrial situs solitus, concordant atrioventricular alignment, and discordant ventriculoarterial alignment. This definition will also include those defects in which there is situs inversis, L-looped ventricles, and either d or l transposition. The segmental anatomy is designated {S,D,D} {S,D,A}, and {S,D,L}, as well as {I,L,L} and {I,L,D}. Van Praagh makes the distinction that, in those hearts in which one is not able to define the atrial situs, it is impossible to say whether there is atrioventricular concordance. Yet, these patients ({A,L,L}, and {A,D,D}) behave as physiologically uncorrected TGA. By the strictest definition, if atrial situs is not definable, then one cannot state that there is atrioventricular concordance. However, it is clear that there are many occasions in which hearts that have TGA are treated with arterial switch and therefore will be included in this definition.



View larger version (48K):
[in this window]
[in a new window]
  		Fig 1. Anatomic types of transposition of the great arteries (TGA) as described by Van Praagh and colleagues. The anatomic subtypes that are included in this nomenclature include: 1, TGA {S,D,D/A/L}; 3, TGA {I,L,L/D}; and 5, 6 TGA {A,L,L} {A,D,D}. Those with situs ambiguous technically cannot be TGA as described by Van Praagh, but may be physiologically uncorrected and appropriately treated by existing standard therapies for TGA.

 
Another modifying term that is added to TGA is simple. The term simple TGA has come to be used to denote those patients without associated defects like tricuspid atresia, mitral atresia, common atrioventricular (AV) valve, and single ventricles. This modifying term has occasionally been further restricted to imply only those cases without associated ventricular septal defect (VSD) or left ventricular outflow tract obstruction (LVOTO). There has, thus far, been no consensus on the use of the term simple transposition.

Most surgeons use the terms TGA, d-TGA and complete transposition synonymously, however d-TGA refers to only those hearts in which the aortic valve is rightward to the pulmonary valve. Indeed this is the most common variant found in over 80% of cases reported by Van Praagh. In this variety, the aortic valve lies to the right of the pulmonary valve.

l-TGA and a-TGA refers to different variants of great vessel malpositions (Fig 1). In l-TGA the aortic valve lies to the left of the pulmonic valve and in a-TGA the aortic valve lies directly anterior to the pulmonic valve. Typically l-TGA has been used synonymously with anatomically corrected transposition. However, just as all d-TGA are not physiologic uncorrected TGA, not all l-TGA are physiologic corrected TGA.

In the variety {S,D,L}, the aorta lies to the left of the pulmonic valve, yet it is still aligned with the morphologic right ventricle. Houyel and associates reported a series of 26 cases of {S,D,L} TGA [3]. This arrangement was also present in 6 of 193 cases of physiologically uncorrected TGA with situs solitus (Fig 1). This lesion, like d-TGA is also physiologically uncorrected, and is treated in a similar fashion to {S,D,D}, d-TGA. There are some important associations in patients with {S,D,L} that include VSD, malalignment of the conal septum, right ventricular hypoplasia, LVOTO, and a high incidence of single right coronary. This is thus an unusual variety of GA, but nonetheless should be captured by any prospective database.

a-TGA refers to those hearts in which the aorta lies directly anterior to the PA and occurs in 0.5% [4]. Therefore the terms d-TGA, a-TGA or l-TGA define the spatial arrangements of the great arteries and should not be used to define transposition, but they are important modifiers, because the spatial relationship of the great vessels may closely correlate with coronary artery anatomy.

Proposed nomenclature

TGA is categorized according to the presence or absence of a VSD, and the presence or absence of LVOTO. Nearly 75% of TGA patients have the simple form: isolated ventriculoarterial (VA) discordance, an intact ventricular septum (IVS), a patent foramen ovale (PFO), and patent ductus arteriosus (PDA) (spontaneous or prostaglandin-maintained). In this common form, there is a subaortic conus or infundibulum. The left ventricle rarely has subpulmonary conus, so there is fibrous continuity between pulmonary and mitral valves. The aorta and pulmonary artery are nearly the same diameter, and the aorta is anterior and to the right of the PA. Approximately 50% of patients with TGA have no other significant defects besides a PFO or a PDA. The presence of a VSD is relatively common (40% to 45%), however, nearly a third of these defects will be very small or hemodynamically insignificant. A true secundum atrial septal defect (ASD) may be present in approximately 10% to 20% of patients. LVOTO can occur in patients with or without VSD, although it is quite rare in those with IVS, occurring in less than 5%).

The VSD in patients with TGA is the most common associated anomaly. The VSD may be small, large, multiple, and occur anywhere within the interventricular septum. We propose that when a VSD is present, the nomenclature for VSD described in the VSD article in this supplement will apply. (See VSD article by Jacobs and colleagues in this supplement).

The perimembranous and outlet type is the most common. Some inlet type defects may involve abnormalities of the conduction tissue and the tricuspid valve straddling of the interventricular septum. Outlet-type or malalignment VSD have particular significance because anterior, rightward, malalignment defects are associated with variable degrees of overriding of the pulmonary annulus onto the right ventricle. As the degree of overriding increases, DORV with subpulmonary VSD exists. This complex is also referred to as Taussig-Bing anomaly and is addressed elsewhere in this supplement. (See DORV article by Walters and colleagues in this supplement).

GUEST EDITORS’ NOTE: The difference between DORV with subpulmonary VSD (Taussig-Bing anomaly) and TGA-VSD is described in the DORV article by Walters and colleagues in this supplement as follows:

We define DORV as a type of ventriculoarterial connection in which both great vessels arise entirely or predominantly from the RV. Hearts with DORV and subpulmonary VSD (Taussig-Bing malformation) are considered a subset of DORV until the PA arises predominately from the LV; they are then considered a subset of TGA with VSD.

LVOTO may occur anywhere in the left ventricular outflow tract (LVOT) and occurs in approximately 25% of patients. In some classification systems this associated defect has been referred to as pulmonary stenosis in the uncorrected heart. We prefer to classify this in reference to the morphologic ventricle from which it arises. Approximately 30% of patients with TGA-VSD have LVOTO. Subvalvar LVOTO can be dynamic, fixed membranous, or diffuse tunnel-like obstruction. Dynamic obstruction is rarely noted in the neonate with elevated pulmonary vascular resistance, but may manifest itself as the child gets to be a few weeks old and pulmonary vascular resistance falls. A subvalvar membranous ring or tunnel stenosis is more commonly associated with TGA-VSD patients. Other unusual forms of subvalvar LVOTO result from malattachment of the mitral apparatus on the interventricular septum or redundant or aneurysmal tricuspid valve tissue ballooning through the VSD into the LVOT. Pulmonary valve stenosis and annular hypoplasia are rarely associated with TGA-IVS but can exist with other concomitant LVOTO.

Tricuspid valve abnormalities can also coexist in approximately 4% of surgical patients. The tricuspid valve may have anomalous chordal attachments to the edges of the perimembranous or outlet VSD. Tricuspid valve anomalies are much more common in the TGA-IVS. Both the tricuspid and mitral valves can straddle the interventricular septum. These associated defects can be associated with significantly hypoplastic ventricles and are discussed in the single ventricle article by Jacobs and Mayer in this supplement.

TGA can also be associated with interrupted aortic arch or coarctation of the aorta in approximately 5% of patients. They are much more commonly associated in those patients with malalignment type VSD with some degree of override, ie Taussig-Bing anomaly. This complex often coexists with some degree of right ventricular outflow tract obstruction (RVOTO). Right aortic arch is associated with approximately 4% of patients with TGA-IVS and nearly 20% of those with TGA-VSD.

A universally accepted scheme for describing coronary anomalies has been more elusive. In a thorough review of coronary classification schemes, Amato divided them into pre- and post-Jatene (arterial switch) eras [5]. Post-Jatene classifications concentrated on surgical considerations. Among the earliest pre-Jatene descriptions was by Rowlatt in 1962, in which five patterns were recognized among 59 hearts with TGA-IVS and six patterns in 23 TGA-VSD hearts [6]. This was one of the earliest reports to appreciate the importance of VSD as a marker for unusual coronary patterns. In 1963, Elliott and associates attempted to integrate the spatial relationship of the aorta and PA to the coronary pattern classification [7]. In 1966, Shaher and Pudu proposed a complex alphanumeric classification of coronary artery origin with 9 pattern types and 18 subtypes; this system was too cumbersome for wide acceptance [8].

In 1978, Yacoub and Radley-Smith proposed a simpler surgically oriented system that rode the popular wave of Jatene’s new operation [9]. Five types, identified as A through E, were described: type A being the most common (left anterior descending coronary artery (LAD) and circumflex coronary artery (Cx) from the anterior sinus) and type D the second most common (Cx off the right coronary). Its simplicity made it immediately appealing and easy to embrace, and surgeons were quick to realize that types A and D could account for 90% of coronary patterns.

In 1988, Planche and colleagues tried to describe the initial course, as well as origins of the coronary arteries, by grouping patterns according to the looping of the coronaries in front or in back of the arterial trunks. They proposed that the origin alone was inadequate to determine the optimal method of coronary transfer [10].

In 1983, the Leiden group proposed a convention that remains the most widely accepted today [11]. Not merely descriptive, but rather a method of description, it positions a theoretic observer within the aorta, facing toward the PA. The aortic sinus on his right is sinus 1 while the aortic sinus on his left is sinus 2 (Fig 2). With this classification system, the commonest coronary pattern is denoted as 1LCx-2R. This means that the left coronary artery and the Cx arise from sinus 1, and the right coronary artery (RCA) arises from the sinus 2. The strength of this classification lies in its simplicity and its power to describe greater than 95% of coronary patterns in typical TGA. It has been widely accepted by the surgical community. It is limited by the inability to define epicardial or intramural course of the coronary arteries, origin of additional arteries like sinus node arteries, and the rare instances of coronary origin from the nonfacing sinuses. Smith attempted to expand on the Leiden convention and subdivided patterns according to dual or single sinus origin of the coronary arteries [12].



View larger version (21K):
[in this window]
[in a new window]
  		Fig 2. The proposed method of description of the coronary arteries in transposition of the great arteries (TGA) involves the point of view of the hypothetical observer in sinus 3 (nonfacing sinus), as originally described in the Leiden convention for naming of coronary artery patterns in TGA. (Reproduced, with permission, from Mavroudis C, Backer CL. Pediatric cardiac surgery, 2nd ed. St. Louis: Mosby, 1994:339–66.)

 
Finally, Amato proposed all-inclusive methods of describing coronary anatomy from the perspective of an observer standing in the PA. Their models also relate the epicardial course of the vessel [5]. The literature on coronary anatomy had led to considerable confusion because of inconsistent use of terms such as facing and left or right handed, and by changing the perspective of hypothetical observers (within the aorta versus within the pulmonary artery). Finally, some terms in the literature are not the province of any single classification. Inverted coronaries describe a rare (< 2%) pattern in which the left and right coronary origins are inverted from the usual [13]. The RCA arises from the anterior and leftward aortic sinus and courses anteriorly and to the right into the right atrioventricular groove, while the left main coronary arise from the posterior and rightward sinus to course leftward behind the pulmonary to the left side of the heart.

While the Leiden convention classification system has the acceptance of the surgical community, most pediatric cardiologists do not favor it because it is based upon the surgeon’s point of view, looking at the heart from the aorta to the PA. Since the anatomy of the coronary arteries is diagnosed most often now by echocardiography, the cardiologist has an opposite point of reference. For the purposes of this nomenclature system, the principles of naming of the sinuses will follow the Leiden convention in which a hypothetical observer is positioned in the nonfacing sinus of the aortic valve, with his feet towards the heart. The facing sinus to the right hand of the hypothetical observer is the sinus 1. Synonyms for this include left facing sinus or right hand sinus. Sinus 2 is defined as the right facing sinus or the left hand sinus. The nonfacing sinus will be referred to as the sinus 3. There are also reports of major coronary artery branches arising from the nonfacing sinus. While in the collective experience of the subcommittee this is extremely rare, it should nonetheless be incorporated into the nomenclature for characterization. The most frequently seen anatomy is the left coronary artery from sinus 1 and the RCA from sinus 2 (62.5%). The second most common type is the RCA and is circumflex from sinus 2 and the LAD from sinus 1 (22%). These two patterns describe over 85% of the coronary artery reported possibilities described for TGA. The most common patterns are seen in Figure 3.



View larger version (24K):
[in this window]
[in a new window]
  		Fig 3. The most common coronary artery patterns in transposition of the great arteries with or without ventricular septal defect in the Boston Children’s Hospital experience. (Reproduced from Sabiston DC, Jr, Spencer FC, eds. Surgery of the chest. 6th ed. Philadelphia: WB Saunders, 1995:1592–604.)

 
This process of defining the nomenclature for the purpose of making an inclusive and interactive computerized database provides a unique opportunity to capture all possible patterns of coronary anatomy with TGA. We envision a descriptive, menu driven database system that will allow coding of anatomic relationship of the great arteries, assignment of the specific coronary arteries to the appropriate sinus and one that also allows for description of the course and branching of the coronary arteries. Each coronary artery that arises from the aorta will be coded in this manner. This will include: the sinus from which the coronary artery arises, the position of the coronary artery within the sinus, the presence of an intramural coronary artery, and the relationship of the intramural coronary to the sinus and commissure (Table 1).


View this table:
[in this window]
[in a new window]
  		Table 1. Coronary Artery Anatomy Descriptorsa

 
For instance, the two most common coronary patterns in TGA (Yacoub types A and D) can be coded by the following hierarchical scheme:

For type A the hierarchical scheme is:

LAD + Cx (Single Orifice), Sinus 1, Central, Not intramural
RCA, Sinus 2, Central, Not intramural

For type D the hierarchical scheme is:

LAD, Sinus 1, Central, Not intramural
RCA + Cx (Single Orifice), Central, Not intramural

Sometimes there are separate orifice origins of the coronaries from the same sinus. Under these conditions the hierarchical scheme will be different, and is represented by the following scheme for Yacoub types A and D, respectively.

For type A, with individual takeoff of the sinus 1 coronaries, the hierarchical scheme is:

LAD, Sinus 1, Central, Not intramural
Cx, Sinus 1, Central, Not intramural
RCA, Sinus 2, Central, Not intramural

For type D, with individual takeoff of the sinus 2 coronaries, the hierarchical scheme is:

LAD, Sinus 1, Central, Not intramural
Cx, Sinus 2, Central, Not intramural
RCA, Sinus 2, Central, Not intramural

We believe that this approach is superior to one in which the person coding the information tries to match the anatomy to one of the existing classification systems. This will also allow different specialties and different centers to communicate about coronary anatomy in a very objective way.

Coronary artery hierarchy nomenclature

Coronary artery hierarchy level 1

LAD
RCA
Cx
LAD + Cx (Single orifice)
RCA + Cx (Single orifice)
LAD + RCA (Single orifice)
LAD + RCA + Cx (Single orifice)
Sinus node artery (Separate orifice)
Conus artery (Separate orifice)

Coronary artery hierarchy level 2

LAD, NOS

LAD, Sinus 1
LAD, Sinus 2
LAD, Sinus 3

RCA, NOS

RCA, Sinus 1
RCA, Sinus 2
RCA, Sinus 3

Cx, NOS

Cx, Sinus 1
Cx, Sinus 2
Cx, Sinus 3

LAD + Cx (Single orifice), NOS

LAD + Cx (Single orifice), Sinus 1
LAD + Cx (Single orifice), Sinus 2
LAD + Cx (Single orifice), Sinus 3

RCA + Cx (Single orifice), NOS

RCA + Cx (Single orifice), Sinus 1
RCA + Cx (Single orifice), Sinus 2
RCA + Cx (Single orifice), Sinus 3

LAD + RCA (Single orifice), NOS

LAD + RCA (Single orifice), Sinus 1
LAD + RCA (Single orifice), Sinus 2
LAD + RCA (Single orifice), Sinus 3

LAD + RCA + Cx (Single orifice), NOS

LAD + RCA + Cx (Single orifice), Sinus 1
LAD + RCA + Cx (Single orifice), Sinus 2
LAD + RCA + Cx (Single orifice), Sinus 3

Sinus node artery (Separate orifice), NOS

Sinus node artery (Separate orifice), Sinus 1
Sinus node artery (Separate orifice), Sinus 2
Sinus node artery (Separate orifice), Sinus 3

Conus artery (Separate orifice), NOS

Conus artery (Separate orifice), Sinus 1
Conus artery (Separate orifice), Sinus 2
Conus artery (Separate orifice), Sinus 3

Coronary artery hierarchy level 3

LAD, NOS
LAD, Sinus 1, NOS

LAD, Sinus 1, Central
LAD, Sinus 1, Right pericommissural
LAD, Sinus 1, Left pericommissural

LAD, Sinus 2, NOS

LAD, Sinus 2, Central
LAD, Sinus 2, Right pericommissural
LAD, Sinus 2, Left pericommissural

LAD, Sinus 3, NOS

LAD, Sinus 3, Central
LAD, Sinus 3, Right pericommissural
LAD, Sinus 3, Left pericommissural

RCA, NOS
RCA, Sinus 1, NOS

RCA, Sinus 1, Central
RCA, Sinus 1, Right pericommissural
RCA, Sinus 1, Left pericommissural

RCA, Sinus 2, NOS

RCA, Sinus 2, Central
RCA, Sinus 2, Right pericommissural
RCA, Sinus 2, Left pericommissural

RCA, Sinus 3, NOS

RCA, Sinus 3, Central
RCA, Sinus 3, Right pericommissural
RCA, Sinus 3, Left pericommissural

Cx, NOS
Cx, Sinus 1, NOS

Cx, Sinus 1, Central
Cx, Sinus 1, Right pericommissural
Cx, Sinus 1, Left pericommissural

Cx, Sinus 2, NOS

Cx, Sinus 2, Central
Cx, Sinus 2, Right pericommissural
Cx, Sinus 2, Left pericommissural

Cx, Sinus 3, NOS

Cx, Sinus 3, Central
Cx, Sinus 3, Right pericommissural
Cx, Sinus 3, Left pericommissural

LAD + Cx (Single orifice), NOS
LAD + Cx (Single orifice), Sinus 1, NOS

LAD + Cx (Single orifice), Sinus 1, Central
LAD + Cx (Single orifice), Sinus 1, Right pericommissural
LAD + Cx (Single orifice), Sinus 1, Left pericommissural

LAD + Cx (Single orifice), Sinus 2, NOS

LAD + Cx (Single orifice), Sinus 2, Central
LAD + Cx (Single orifice), Sinus 2, Right pericommissural
LAD + Cx (Single orifice), Sinus 2, Left pericommissural

LAD + Cx (Single orifice), Sinus 3, NOS

LAD + Cx (Single orifice), Sinus 3, Central
LAD + Cx (Single orifice), Sinus 3, Right pericommissural
LAD + Cx (Single orifice), Sinus 3, Left pericommissural

RCA + Cx (Single orifice), NOS
RCA + Cx (Single orifice), Sinus 1, NOS

RCA + Cx (Single orifice), Sinus 1, Central
RCA + Cx (Single orifice), Sinus 1, Right pericommissural
RCA + Cx (Single orifice), Sinus 1, Left pericommissural

RCA + Cx (Single orifice), Sinus 2, NOS

RCA + Cx (Single orifice), Sinus 2, Central
RCA + Cx (Single orifice), Sinus 2, Right pericommissural
RCA + Cx (Single orifice), Sinus 2, Left pericommissural

RCA + Cx (Single orifice), Sinus 3, NOS

RCA + Cx (Single orifice), Sinus 3, Central
RCA + Cx (Single orifice), Sinus 3, Right pericommissural
RCA + Cx (Single orifice), Sinus 3, Left pericommissural

LAD + RCA (Single orifice), NOS
LAD + RCA (Single orifice), Sinus 1, NOS

LAD + RCA (Single orifice), Sinus 1, Central
LAD + RCA (Single orifice), Sinus 1, Right pericommissural
LAD + RCA (Single orifice), Sinus 1, Left pericommissural

LAD + RCA (Single orifice), Sinus 2, NOS

LAD + RCA (Single orifice), Sinus 2, Central
LAD + RCA (Single orifice), Sinus 2, Right pericommissural
LAD + RCA (Single orifice), Sinus 2, Left pericommissural

LAD + RCA (Single orifice), Sinus 3, NOS

LAD + RCA (Single orifice), Sinus 3, Central
LAD + RCA (Single orifice), Sinus 3, Right pericommissural
LAD + RCA (Single orifice), Sinus 3, Left pericommissural

LAD + RCA + Cx (Single orifice), NOS
LAD + RCA + Cx (Single orifice), Sinus 1, NOS

LAD + RCA + Cx (Single orifice), Sinus 1, Central
LAD + RCA + Cx (Single orifice), Sinus 1, Right pericommissural
LAD + RCA + Cx (Single orifice), Sinus 1, Left pericommissural

LAD + RCA + Cx (Single orifice), Sinus 2, NOS

LAD + RCA + Cx (Single orifice), Sinus 2, Central
LAD + RCA + Cx (Single orifice), Sinus 2, Right pericommissural
LAD + RCA + Cx (Single orifice), Sinus 2, Left pericommissural

LAD + RCA + Cx (Single orifice), Sinus 3, NOS

LAD + RCA + Cx (Single orifice), Sinus 3, Central
LAD + RCA + Cx (Single orifice), Sinus 3, Right pericommissural
LAD + RCA + Cx (Single orifice), Sinus 3, Left pericommissural

Sinus node artery (Separate orifice), NOS
Sinus node artery (Separate orifice), Sinus 1, NOS

Sinus node artery (Separate orifice), Sinus 1, Central
Sinus node artery (Separate orifice), Sinus 1, Right pericommissural
Sinus node artery (Separate orifice), Sinus 1, Left pericommissural

Sinus node artery (Separate orifice), Sinus 2, NOS

Sinus node artery (Separate orifice), Sinus 2, Central
Sinus node artery (Separate orifice), Sinus 2, Right pericommissural
Sinus node artery (Separate orifice), Sinus 2, Left pericommissural

Sinus node artery (Separate orifice), Sinus 3, NOS

Sinus node artery (Separate orifice), Sinus 3, Central
Sinus node artery (Separate orifice), Sinus 3, Right pericommissural
Sinus node artery (Separate orifice), Sinus 3, Left pericommissural

Conus artery (Separate orifice), NOS
Conus artery (Separate orifice), Sinus 1, NOS

Conus artery (Separate orifice), Sinus 1, Central
Conus artery (Separate orifice), Sinus 1, Right pericommissural
Conus artery (Separate orifice), Sinus 1, Left pericommissural

Conus artery (Separate orifice), Sinus 2, NOS

Conus artery (Separate orifice), Sinus 2, Central
Conus artery (Separate orifice), Sinus 2, Right pericommissural
Conus artery (Separate orifice), Sinus 2, Left pericommissural

Conus artery (Separate orifice), Sinus 3, NOS

Conus artery (Separate orifice), Sinus 3, Central
Conus artery (Separate orifice), Sinus 3, Right pericommissural
Conus artery (Separate orifice), Sinus 3, Left pericommissural

Coronary artery hierarchy level 4: presence of intramural artery

LAD, NOS
LAD, Sinus 1, NOS
LAD, Sinus 1, Central, NOS

LAD, Sinus 1, Central, Intramural
LAD, Sinus 1, Central, Not intramural

LAD, Sinus 1, Right pericommissural, NOS

LAD, Sinus 1, Right pericommissural, Intramural
LAD, Sinus 1, Right pericommissural, Not intramural

LAD, Sinus 1, Left pericommissural, NOS

LAD, Sinus 1, Left pericommissural, Intramural
LAD, Sinus 1, Left pericommissural, Not intramural

LAD, Sinus 2, NOS
LAD, Sinus 2, Central, NOS

LAD, Sinus 2, Central, Intramural
LAD, Sinus 2, Central, Not intramural

LAD, Sinus 2, Right pericommissural, NOS

LAD, Sinus 2, Right pericommissural, Intramural
LAD, Sinus 2, Right pericommissural, Not intramural

LAD, Sinus 2, Left pericommissural, NOS

LAD, Sinus 2, Left pericommissural, Intramural
LAD, Sinus 2, Left pericommissural, Not intramural

LAD, Sinus 3, NOS
LAD, Sinus 3, Central, NOS

LAD, Sinus 3, Central, Intramural
LAD, Sinus 3, Central, Not intramural

LAD, Sinus 3, Right pericommissural, NOS

LAD, Sinus 3, Right pericommissural, Intramural
LAD, Sinus 3, Right pericommissural, Not intramural

LAD, Sinus 3, Left pericommissural, NOS

LAD, Sinus 3, Left pericommissural, Intramural
LAD, Sinus 3, Left pericommissural, Not intramural

RCA, NOS
RCA, Sinus 1, NOS
RCA, Sinus 1, Central, NOS

RCA, Sinus 1, Central, Intramural
RCA, Sinus 1, Central, Not intramural

RCA, Sinus 1, Right pericommissural, NOS

RCA, Sinus 1, Right pericommissural, Intramural
RCA, Sinus 1, Right pericommissural, Not intramural

RCA, Sinus 1, Left pericommissural, NOS

RCA, Sinus 1, Left pericommissural, Intramural
RCA, Sinus 1, Left pericommissural, Not intramural

RCA, Sinus 2, NOS
RCA, Sinus 2, Central, NOS

RCA, Sinus 2, Central, Intramural
RCA, Sinus 2, Central, Not intramural

RCA, Sinus 2, Right pericommissural, NOS

RCA, Sinus 2, Right pericommissural, Intramural
RCA, Sinus 2, Right pericommissural, Not intramural

RCA, Sinus 2, Left pericommissural, NOS

RCA, Sinus 2, Left pericommissural, Intramural
RCA, Sinus 2, Left pericommissural, Not intramural

RCA, Sinus 3, NOS
RCA, Sinus 3, Central, NOS

RCA, Sinus 3, Central, Intramural
RCA, Sinus 3, Central, Not intramural

RCA, Sinus 3, Right pericommissural, NOS

RCA, Sinus 3, Right pericommissural, Intramural
RCA, Sinus 3, Right pericommissural, Not intramural

RCA, Sinus 3, Left pericommissural, NOS

RCA, Sinus 3, Left pericommissural, Intramural
RCA, Sinus 3, Left pericommissural, Not intramural

Cx, NOS
Cx, Sinus 1, NOS
Cx, Sinus 1, Central, NOS

Cx, Sinus 1, Central, Intramural
Cx, Sinus 1, Central, Not intramural

Cx, Sinus 1, Right pericommissural, NOS

Cx, Sinus 1, Right pericommissural, Intramural
Cx, Sinus 1, Right pericommissural, Not intramural

Cx, Sinus 1, Left pericommissural, NOS

Cx, Sinus 1, Left pericommissural, Intramural
Cx, Sinus 1, Left pericommissural, Not intramural

Cx, Sinus 2, NOS
Cx, Sinus 2, Central, NOS

Cx, Sinus 2, Central, Intramural
Cx, Sinus 2, Central, Not intramural

Cx, Sinus 2, Right pericommissural, NOS

Cx, Sinus 2, Right pericommissural, Intramural
Cx, Sinus 2, Right pericommissural, Not intramural

Cx, Sinus 2, Left pericommissural, NOS

Cx, Sinus 2, Left pericommissural, Intramural
Cx, Sinus 2, Left pericommissural, Not intramural

Cx, Sinus 3, NOS
Cx, Sinus 3, Central, NOS

Cx, Sinus 3, Central, Intramural
Cx, Sinus 3, Central, Not intramural

Cx, Sinus 3, Right pericommissural, NOS

Cx, Sinus 3, Right pericommissural, Intramural
Cx, Sinus 3, Right pericommissural, Not intramural

Cx, Sinus 3, Left pericommissural, NOS

Cx, Sinus 3, Left pericommissural, Intramural
Cx, Sinus 3, Left pericommissural, Not intramural

LAD + Cx (Single orifice), NOS
LAD + Cx (Single orifice), Sinus 1, NOS
LAD + Cx (Single orifice), Sinus 1, Central, NOS

LAD + Cx (Single orifice), Sinus 1, Central, Intramural
LAD + Cx (Single orifice), Sinus 1, Central, Not intramural

LAD + Cx (Single orifice), Sinus 1, Right pericommissural, NOS

LAD + Cx (Single orifice), Sinus 1, Right pericommissural, Intramural
LAD + Cx (Single orifice), Sinus 1, Right pericommissural, Not intramural

LAD + Cx (Single orifice), Sinus 1, Left pericommissural, NOS

LAD + Cx (Single orifice), Sinus 1, Left pericommissural, Intramural
LAD + Cx (Single orifice), Sinus 1, Left pericommissural, Not intramural

LAD + Cx (Single orifice), Sinus 2, NOS
LAD + Cx (Single orifice), Sinus 2, Central, NOS

LAD + Cx (Single orifice), Sinus 2, Central, Intramural
LAD + Cx (Single orifice), Sinus 2, Central, Not intramural

LAD + Cx (Single orifice), Sinus 2, Right pericommissural, NOS

LAD + Cx (Single orifice), Sinus 2, Right pericommissural, Intramural
LAD + Cx (Single orifice), Sinus 2, Right pericommissural, Not intramural

LAD + Cx (Single orifice), Sinus 2, Left pericommissural, NOS

LAD + Cx (Single orifice), Sinus 2, Left pericommissural, Intramural
LAD + Cx (Single orifice), Sinus 2, Left pericommissural, Not intramural

LAD + Cx (Single orifice), Sinus 3, NOS
LAD + Cx (Single orifice), Sinus 3, Central, NOS

LAD + Cx (Single orifice), Sinus 3, Central, Intramural
LAD + Cx (Single orifice), Sinus 3, Central, Not intramural

LAD + Cx (Single orifice), Sinus 3, Right pericommissural, NOS

LAD + Cx (Single orifice), Sinus 3, Right pericommissural, Intramural
LAD + Cx (Single orifice), Sinus 3, Right pericommissural, Not intramural

LAD + Cx (Single orifice), Sinus 3, Left pericommissural, NOS

LAD + Cx (Single orifice), Sinus 3, Left pericommissural, Intramural
LAD + Cx (Single orifice), Sinus 3, Left pericommissural, Not intramural

RCA + Cx (Single orifice), NOS
RCA + Cx (Single orifice), Sinus 1, NOS
RCA + Cx (Single orifice), Sinus 1, Central, NOS

RCA + Cx (Single orifice), Sinus 1, Central, Intramural
RCA + Cx (Single orifice), Sinus 1, Central, Not intramural

RCA + Cx (Single orifice), Sinus 1, Right pericommissural, NOS

RCA + Cx (Single orifice), Sinus 1, Right pericommissural, Intramural
RCA + Cx (Single orifice), Sinus 1, Right pericommissural, Not intramural

RCA + Cx (Single orifice), Sinus 1, Left pericommissural, NOS

RCA + Cx (Single orifice), Sinus 1, Left pericommissural, Intramural
RCA + Cx (Single orifice), Sinus 1, Left pericommissural, Not intramural

RCA + Cx (Single orifice), Sinus 2, NOS
RCA + Cx (Single orifice), Sinus 2, Central, NOS

RCA + Cx (Single orifice), Sinus 2, Central, Intramural
RCA + Cx (Single orifice), Sinus 2, Central, Not intramural

RCA + Cx (Single orifice), Sinus 2, Right pericommissural, NOS

RCA + Cx (Single orifice), Sinus 2, Right pericommissural, Intramural
RCA + Cx (Single orifice), Sinus 2, Right pericommissural, Not intramural

RCA + Cx (Single orifice), Sinus 2, Left pericommissural, NOS

RCA + Cx (Single orifice), Sinus 2, Left pericommissural, Intramural
RCA + Cx (Single orifice), Sinus 2, Left pericommissural, Not intramural

RCA + Cx (Single orifice), Sinus 3, NOS
RCA + Cx (Single orifice), Sinus 3, Central, NOS

RCA + Cx (Single orifice), Sinus 3, Central, Intramural
RCA + Cx (Single orifice), Sinus 3, Central, Not intramural

RCA + Cx (Single orifice), Sinus 3, Right pericommissural, NOS

RCA + Cx (Single orifice), Sinus 3, Right pericommissural, Intramural
RCA + Cx (Single orifice), Sinus 3, Right pericommissural, Not intramural

RCA + Cx (Single orifice), Sinus 3, Left pericommissural, NOS

RCA + Cx (Single orifice), Sinus 3, Left pericommissural, Intramural
RCA + Cx (Single orifice), Sinus 3, Left pericommissural, Not intramural

LAD + RCA (Single orifice), NOS
LAD + RCA (Single orifice), Sinus 1, NOS
LAD + RCA (Single orifice), Sinus 1, Central, NOS

LAD + RCA (Single orifice), Sinus 1, Central, Intramural
LAD + RCA (Single orifice), Sinus 1, Central, Not intramural

LAD + RCA (Single orifice), Sinus 1, Right pericommissural, NOS

LAD + RCA (Single orifice), Sinus 1, Right pericommissural, Intramural
LAD + RCA (Single orifice), Sinus 1, Right pericommissural, Not intramural

LAD + RCA (Single orifice), Sinus 1, Left pericommissural, NOS

LAD + RCA (Single orifice), Sinus 1, Left pericommissural, Intramural
LAD + RCA (Single orifice), Sinus 1, Left pericommissural, Not intramural

LAD + RCA (Single orifice), Sinus 2, NOS
LAD + RCA (Single orifice), Sinus 2, Central, NOS

LAD + RCA (Single orifice), Sinus 2, Central, Intramural
LAD + RCA (Single orifice), Sinus 2, Central, Not intramural

LAD + RCA (Single orifice), Sinus 2, Right pericommissural, NOS

LAD + RCA (Single orifice), Sinus 2, Right pericommissural, Intramural
LAD + RCA (Single orifice), Sinus 2, Right pericommissural, Not intramural

LAD + RCA (Single orifice), Sinus 2, Left pericommissural, NOS

LAD + RCA (Single orifice), Sinus 2, Left pericommissural, Intramural
LAD + RCA (Single orifice), Sinus 2, Left pericommissural, Not intramural

LAD + RCA (Single orifice), Sinus 3, NOS
LAD + RCA (Single orifice), Sinus 3, Central, NOS

LAD + RCA (Single orifice), Sinus 3, Central, Intramural
LAD + RCA (Single orifice), Sinus 3, Central, Not intramural

LAD + RCA (Single orifice), Sinus 3, Right pericommissural, NOS

LAD + RCA (Single orifice), Sinus 3, Right pericommissural, Intramural
LAD + RCA (Single orifice), Sinus 3, Right pericommissural, Not intramural

LAD + RCA (Single orifice), Sinus 3, Left pericommissural, NOS

LAD + RCA (Single orifice), Sinus 3, Left pericommissural, Intramural
LAD + RCA (Single orifice), Sinus 3, Left pericommissural, Not intramural

LAD + RCA + Cx (Single orifice), NOS
LAD + RCA + Cx (Single orifice), Sinus 1, NOS
LAD + RCA + Cx (Single orifice), Sinus 1, Central, NOS

LAD + RCA + Cx (Single orifice), Sinus 1, Central, Intramural
LAD + RCA + Cx (Single orifice), Sinus 1, Central, Not intramural

LAD + RCA + Cx (Single orifice), Sinus 1, Right pericommissural, NOS

LAD + RCA + Cx (Single orifice), Sinus 1, Right pericommissural, Intramural
LAD + RCA + Cx (Single orifice), Sinus 1, Right pericommissural, Not intramural

LAD + RCA + Cx (Single orifice), Sinus 1, Left pericommissural, NOS

LAD + RCA + Cx (Single orifice), Sinus 1, Left pericommissural, Intramural
LAD + RCA + Cx (Single orifice), Sinus 1, Left pericommissural, Not intramural

LAD + RCA + Cx (Single orifice), Sinus 2, NOS
LAD + RCA + Cx (Single orifice), Sinus 2, Central, NOS

LAD + RCA + Cx (Single orifice), Sinus 2, Central, Intramural
LAD + RCA + Cx (Single orifice), Sinus 2, Central, Not intramural

LAD + RCA + Cx (Single orifice), Sinus 2, Right pericommissural, NOS

LAD + RCA + Cx (Single orifice), Sinus 2, Right pericommissural, Intramural
LAD + RCA + Cx (Single orifice), Sinus 2, Right pericommissural, Not intramural

LAD + RCA + Cx (Single orifice), Sinus 2, Left pericommissural, NOS

LAD + RCA + Cx (Single orifice), Sinus 2, Left pericommissural, Intramural
LAD + RCA + Cx (Single orifice), Sinus 2, Left pericommissural, Not intramural

LAD + RCA + Cx (Single orifice), Sinus 3, NOS
LAD + RCA + Cx (Single orifice), Sinus 3, Central, NOS

LAD + RCA + Cx (Single orifice), Sinus 3, Central, Intramural
LAD + RCA + Cx (Single orifice), Sinus 3, Central, Not intramural

LAD + RCA + Cx (Single orifice), Sinus 3, Right pericommissural, NOS

LAD + RCA + Cx (Single orifice), Sinus 3, Right pericommissural, Intramural
LAD + RCA + Cx (Single orifice), Sinus 3, Right pericommissural, Not intramural

LAD + RCA + Cx (Single orifice), Sinus 3, Left pericommissural, NOS

LAD + RCA + Cx (Single orifice), Sinus 3, Left pericommissural, Intramural
LAD + RCA + Cx (Single orifice), Sinus 3, Left pericommissural, Not intramural

Sinus node artery (Separate orifice), NOS
Sinus node artery (Separate orifice), Sinus 1, NOS
Sinus node artery (Separate orifice), Sinus 1, Central, NOS

Sinus node artery (Separate orifice), Sinus 1, Central, Intramural
Sinus node artery (Separate orifice), Sinus 1, Central, Not intramural

Sinus node artery (Separate orifice), Sinus 1, Right pericommissural, NOS

Sinus node artery (Separate orifice), Sinus 1, Right pericommissural, Intramural
Sinus node artery (Separate orifice), Sinus 1, Right pericommissural, Not intramural

Sinus node artery (Separate orifice), Sinus 1, Left pericommissural, NOS

Sinus node artery (Separate orifice), Sinus 1, Left pericommissural, Intramural
Sinus node artery (Separate orifice), Sinus 1, Left pericommissural, Not intramural

Sinus node artery (Separate orifice), Sinus 2, NOS
Sinus node artery (Separate orifice), Sinus 2, Central, NOS

Sinus node artery (Separate orifice), Sinus 2, Central, Intramural
Sinus node artery (Separate orifice), Sinus 2, Central, Not intramural

Sinus node artery (Separate orifice), Sinus 2, Right pericommissural, NOS

Sinus node artery (Separate orifice), Sinus 2, Right pericommissural, Intramural
Sinus node artery (Separate orifice), Sinus 2, Right pericommissural, Not intramural

Sinus node artery (Separate orifice), Sinus 2, Left pericommissural, NOS

Sinus node artery (Separate orifice), Sinus 2, Left pericommissural, Intramural
Sinus node artery (Separate orifice), Sinus 2, Left pericommissural, Not intramural

Sinus node artery (Separate orifice), Sinus 3, NOS
Sinus node artery (Separate orifice), Sinus 3, Central, NOS

Sinus node artery (Separate orifice), Sinus 3, Central, Intramural
Sinus node artery (Separate orifice), Sinus 3, Central, Not intramural

Sinus node artery (Separate orifice), Sinus 3, Right pericommissural, NOS

Sinus node artery (Separate orifice), Sinus 3, Right pericommissural, Intramural
Sinus node artery (Separate orifice), Sinus 3, Right pericommissural, Not intramural

Sinus node artery (Separate orifice), Sinus 3, Left pericommissural, NOS

Sinus node artery (Separate orifice), Sinus 3, Left pericommissural, Intramural
Sinus node artery (Separate orifice), Sinus 3, Left pericommissural, Not intramural

Conus artery (Separate orifice), NOS
Conus artery (Separate orifice), Sinus 1, NOS
Conus artery (Separate orifice), Sinus 1, Central, NOS

Conus artery (Separate orifice), Sinus 1, Central, Intramural
Conus artery (Separate orifice), Sinus 1, Central, Not Intramural

Conus artery (Separate orifice), Sinus 1, Right pericommissural, NOS

Conus artery (Separate orifice), Sinus 1, Right pericommissural, Intramural
Conus artery (Separate orifice), Sinus 1, Right pericommissural, Not intramural

Conus artery (Separate orifice), Sinus 1, Left pericommissural, NOS

Conus artery (Separate orifice), Sinus 1, Left pericommissural, Intramural
Conus artery (Separate orifice), Sinus 1, Left pericommissural, Not intramural

Conus artery (Separate orifice), Sinus 2, NOS
Conus artery (Separate orifice), Sinus 2, Central, NOS

Conus artery (Separate orifice), Sinus 2, Central, Intramural
Conus artery (Separate orifice), Sinus 2, Central, Not intramural

Conus artery (Separate orifice), Sinus 2, Right pericommissural, NOS

Conus artery (Separate orifice), Sinus 2, Right pericommissural, Intramural
Conus artery (Separate orifice), Sinus 2, Right pericommissural, Not intramural

Conus artery (Separate orifice), Sinus 2, Left pericommissural, NOS

Conus artery (Separate orifice), Sinus 2, Left pericommissural, Intramural
Conus artery (Separate orifice), Sinus 2, Left pericommissural, Not intramural

Conus artery (Separate orifice), Sinus 3, NOS
Conus artery (Separate orifice), Sinus 3, Central, NOS

Conus artery (Separate orifice), Sinus 3, Central, Intramural
Conus artery (Separate orifice), Sinus 3, Central, Not intramural

Conus artery (Separate orifice), Sinus 3, Right pericommissural, NOS

Conus artery (Separate orifice), Sinus 3, Right pericommissural, Intramural
Conus artery (Separate orifice), Sinus 3, Right pericommissural, Not intramural

Conus artery (Separate orifice), Sinus 3, Left pericommissural, NOS

Conus artery (Separate orifice), Sinus 3, Left pericommissural, Intramural
Conus artery (Separate orifice), Sinus 3, Left pericommissural, Not intramural

Coronary artery hierarchy level 5: position of intramural artery

LAD, NOS
LAD, Sinus 1, NOS
LAD, Sinus 1, Central, NOS
LAD, Sinus 1, Central, Intramural, NOS

LAD, Sinus 1, Central, Intramural, Within sinus
LAD, Sinus 1, Central, Intramural, Across commissure
LAD, Sinus 1, Central, Intramural, Above sinus

LAD, Sinus 1, Central, Not Intramural
LAD, Sinus 1, Central, Right pericommissural, NOS
LAD, Sinus 1, Central, Right pericommissural, Intramural, NOS

LAD, Sinus 1, Right pericommissural, Intramural, Within sinus
LAD, Sinus 1, Right pericommissural, Intramural, Across commissure
LAD, Sinus 1, Right pericommissural, Intramural, Above sinus

LAD, Sinus 1, Right pericommissural, Not intramural
LAD, Sinus 1, Left pericommissural, NOS
LAD, Sinus 1, Left pericommissural, Intramural, NOS

LAD, Sinus 1, Left pericommissural, Intramural, Within sinus
LAD, Sinus 1, Left pericommissural, Intramural, Across commissure
LAD, Sinus 1, Left pericommissural, Intramural, Above sinus

LAD, Sinus 1, Left pericommissural, Not intramural
LAD, Sinus 2, NOS
LAD, Sinus 2, Central NOS
LAD, Sinus 2, Central, Intramural, NOS

LAD, Sinus 2, Central, Intramural, Within sinus
LAD, Sinus 2, Central, Intramural, Across commissure
LAD, Sinus 2, Central, Intramural, Above sinus

LAD, Sinus 2, Central, Not intramural
LAD, Sinus 2, Right pericommissural, NOS
LAD, Sinus 2, Right pericommissural, Intramural, NOS

LAD, Sinus 2, Right pericommissural, Intramural, Within sinus
LAD, Sinus 2, Right pericommissural, Intramural, Across commissure
LAD, Sinus 2, Right pericommissural, Intramural, Above sinus

LAD, Sinus 2, Right pericommissural, Not intramural
LAD, Sinus 2, Left pericommissural, NOS
LAD, Sinus 2, Left pericommissural, Intramural, NOS

LAD, Sinus 2, Left pericommissural, Intramural, Within sinus
LAD, Sinus 2, Left pericommissural, Intramural, Across commissure
LAD, Sinus 2, Left pericommissural, Intramural, Above sinus

LAD, Sinus 2, Left pericommissural, Not intramural
LAD, Sinus 3, NOS
LAD, Sinus 3, Central, NOS
LAD, Sinus 3, Central, Intramural, NOS

LAD, Sinus 3, Central, Intramural, Within sinus
LAD, Sinus 3, Central, Intramural, Across commissure
LAD, Sinus 3, Central, Intramural, Above sinus

LAD, Sinus 3, Central, Not intramural
LAD, Sinus 3, Right pericommissural, NOS
LAD, Sinus 3, Right pericommissural, Intramural, NOS

LAD, Sinus 3, Right pericommissural, Intramural, Within sinus
LAD, Sinus 3, Right pericommissural, Intramural, Across commissure
LAD, Sinus 3, Right pericommissural, Intramural, Above sinus

LAD, Sinus 3, Right pericommissural, Not intramural
LAD, Sinus 3, Left pericommissural, NOS
LAD, Sinus 3, Left pericommissural, Intramural, NOS

LAD, Sinus 3, Left pericommissural, Intramural, Within sinus
LAD, Sinus 3, Left pericommissural, Intramural, Across commissure
LAD, Sinus 3, Left pericommissural, Intramural, Above sinus

LAD, Sinus 3, Left pericommissural, Not intramural
RCA, NOS
RCA, Sinus 1, NOS
RCA, Sinus 1, Central, NOS
RCA, Sinus 1, Central, Intramural, NOS

RCA, Sinus 1, Central, Intramural, Within sinus
RCA, Sinus 1, Central, Intramural, Across commissure
RCA, Sinus 1, Central, Intramural, Above sinus

RCA, Sinus 1, Central, Not intramural
RCA, Sinus 1, Right pericommissural, NOS
RCA, Sinus 1, Right pericommissural, Intramural, NOS

RCA, Sinus 1, Right pericommissural, Intramural, Within sinus
RCA, Sinus 1, Right pericommissural, Intramural, Across commissure
RCA, Sinus 1, Right pericommissural, Intramural, Above sinus

RCA, Sinus 1, Right pericommissural, Not intramural
RCA, Sinus 1, Left pericommissural, NOS
RCA, Sinus 1, Left pericommissural, Intramural, NOS

RCA, Sinus 1, Left pericommissural, Intramural, Within sinus
RCA, Sinus 1, Left pericommissural, Intramural, Across commissure
RCA, Sinus 1, Left pericommissural, Intramural, Above sinus

RCA, Sinus 1, Left pericommissural, Not intramural
RCA, Sinus 2, NOS
RCA, Sinus 2, Central, NOS
RCA, Sinus 2, Central, Intramural, NOS

RCA, Sinus 2, Central, Intramural, Within sinus
RCA, Sinus 2, Central, Intramural, Across commissure
RCA, Sinus 2, Central, Intramural, Above sinus

RCA, Sinus 2, Central, Not intramural
RCA, Sinus 2, Right pericommissural, NOS
RCA, Sinus 2, Right pericommissural, Intramural, NOS

RCA, Sinus 1, Right pericommissural, Intramural, Within sinus
RCA, Sinus 2, Right pericommissural, Intramural, Across commissure
RCA, Sinus 2, Right pericommissural, Intramural, Above sinus

RCA, Sinus 2, Right pericommissural, Not intramural
RCA, Sinus 2, Left pericommissural, NOS
RCA, Sinus 2, Left pericommissural, Intramural, NOS

RCA, Sinus 2, Left pericommissural, Intramural, Within sinus
RCA, Sinus 2, Left pericommissural, Intramural, Across commissure
RCA, Sinus 2, Left pericommissural, Intramural, Above sinus

RCA, Sinus 2, Left pericommissural, Not intramural
RCA, Sinus 3, NOS
RCA, Sinus 3, Central, NOS
RCA, Sinus 3, Central, Intramural, NOS

RCA, Sinus 3, Central, Intramural, Within sinus
RCA, Sinus 3, Central, Intramural, Across commissure
RCA, Sinus 3, Central, Intramural, Above sinus

RCA, Sinus 3, Central, Not intramural
RCA, Sinus 3, Right pericommissural, NOS
RCA, Sinus 3, Right pericommissural, Intramural, NOS

RCA, Sinus 3, Right pericommissural, Intramural, Within sinus
RCA, Sinus 3, Right pericommissural, Intramural, Across commissure
RCA, Sinus 3, Right pericommissural, Intramural, Above sinus

RCA, Sinus 3, Right pericommissural, Not intramural
RCA, Sinus 3, Left pericommissural, NOS
RCA, Sinus 3, Left pericommissural, Intramural, NOS

RCA, Sinus 3, Left pericommissural, Intramural, Within sinus
RCA, Sinus 3, Left pericommissural, Intramural, Across commissure
RCA, Sinus 3, Left pericommissural, Intramural, Above sinus

RCA, Sinus 3, Left pericommissural, Not intramural
CX, NOS
CX, Sinus 1, NOS
CX, Sinus 1, Central, NOS
CX, Sinus 1, Central, Intramural, NOS

CX, Sinus 1, Central, Intramural, Within sinus
CX, Sinus 1, Central, Intramural, Across commissure
CX, Sinus 1, Central, Intramural, Above sinus

CX, Sinus 1, Central, Not intramural
CX, Sinus 1, Right pericommissural, NOS
CX, Sinus 1, Right pericommissural, Intramural, NOS

CX, Sinus 1, Right pericommissural, Intramural, Within sinus
CX, Sinus 1, Right pericommissural, Intramural, Across commissure
CX, Sinus 1, Right pericommissural, Intramural, Above sinus

CX, Sinus 1, Right pericommissural, Not intramural
CX, Sinus 1, Left pericommissural, NOS
CX, Sinus 1, Left pericommissural, Intramural, NOS

CX, Sinus 1, Left pericommissural, Intramural, Within sinus
CX, Sinus 1, Left pericommissural, Intramural, Across commissure
CX, Sinus 1, Left pericommissural, Intramural, Above sinus

CX, Sinus 1, Left pericommissural, Not intramural
CX, Sinus 2, NOS
CX, Sinus 2, Central, NOS
CX, Sinus 2, Central, Intramural, NOS

CX, Sinus 2, Central, Intramural, Within sinus
CX, Sinus 2, Central, Intramural, Across commissure
CX, Sinus 2, Central, Intramural, Above sinus

CX, Sinus 2, Central, Not intramural
CX, Sinus 2, Right pericommissural, NOS
CX, Sinus 2, Right pericommissural, Intramural, NOS

CX, Sinus 2, Right pericommissural, Intramural, Within sinus
CX, Sinus 2, Right pericommissural, Intramural, Across commissure
CX, Sinus 2, Right pericommissural, Intramural, Above sinus

CX, Sinus 2, Right pericommissural, Not intramural
CX, Sinus 2, Left pericommissural, NOS
CX, Sinus 2, Left pericommissural, Intramural, NOS

CX, Sinus 2, Left pericommissural, Intramural, Within sinus
CX, Sinus 2, Left pericommissural, Intramural, Across commissure
CX, Sinus 2, Left pericommissural, Intramural, Above sinus

CX, Sinus 2, Left pericommissural, Not intramural
CX, Sinus 3, NOS
CX, Sinus 3, Central, NOS
CX, Sinus 3, Central, Intramural, NOS

CX, Sinus 3, Central, Intramural, Within sinus
CX, Sinus 3, Central, Intramural, Across commissure
CX, Sinus 3, Central, Intramural, Above sinus

CX, Sinus 3, Central, Not intramural
CX, Sinus 3, Right pericommissural, NOS
CX, Sinus 3, Right pericommissural, Intramural, NOS

CX, Sinus 3, Right pericommissural, Intramural, Within sinus
CX, Sinus 3, Right pericommissural, Intramural, Across commissure
CX, Sinus 3, Right pericommissural, Intramural, Above sinus

CX, Sinus 3, Right pericommissural, Not intramural
CX, Sinus 3, Left pericommissural, NOS
CX, Sinus 3, Left pericommissural, Intramural, NOS

CX, Sinus 3, Left pericommissural, Intramural, Within sinus
CX, Sinus 3, Left pericommissural, Intramural, Across commissure
CX, Sinus 3, Left pericommissural, Intramural, Above sinus

CX, Sinus 3, Left pericommissural, Not intramural
LAD + Cx (Single orifice), NOS
LAD + Cx (Single orifice), Sinus 1, NOS
LAD + Cx (Single orifice), Sinus 1, Central, NOS
LAD + Cx (Single orifice), Sinus 1, Central, Intramural, NOS

LAD + Cx (Single orifice), Sinus 1, Central, Intramural, Within sinus
LAD + Cx (Single orifice), Sinus 1, Central, Intramural, Across commissure
LAD + Cx (Single orifice), Sinus 1, Central, Intramural, Above sinus

LAD + Cx (Single orifice), Sinus 1, Central, Not intramural
LAD + Cx (Single orifice), Sinus 1, Right pericommissural, NOS
LAD + Cx (Single orifice), Sinus 1, Right pericommissural, Intramural, NOS

LAD + Cx (Single orifice), Sinus 1, Right pericommissural, Intramural, Within sinus
LAD + Cx (Single orifice), Sinus 1, Right pericommissural, Intramural, Across commissure
LAD + Cx (Single orifice), Sinus 1, Right pericommissural, Intramural, Above sinus

LAD + Cx (Single orifice), Sinus 1, Right pericommissural, Not intramural
LAD + Cx (Single orifice), Left pericommissural, NOS
LAD + Cx (Single orifice), Left pericommissural, Intramural, NOS

LAD + Cx (Single orifice), Sinus 1, Left pericommissural, Intramural, Within sinus
LAD + Cx (Single orifice), Sinus 1, Left pericommissural, Intramural, Across commissure
LAD + Cx (Single orifice), Sinus 1, Left pericommissural, Intramural, Above sinus

LAD + Cx (Single orifice), Sinus 1, Left pericommissural, Not intramural
LAD + Cx (Single orifice), Sinus 2, NOS
LAD + Cx (Single orifice), Sinus 2, Central, NOS
LAD + Cx (Single orifice), Sinus 2, Central, Intramural, NOS

LAD + Cx (Single orifice), Sinus 2, Central, Intramural, Within sinus
LAD + Cx (Single orifice), Sinus 2, Central, Intramural, Across commissure
LAD + Cx (Single orifice), Sinus 2, Central, Intramural, Above sinus

LAD + Cx (Single orifice), Sinus 2, Central, Not intramural
LAD + Cx (Single orifice), Sinus 2, Right pericommissural, NOS
LAD + Cx (Single orifice), Sinus 2, Right pericommissural, Intramural, NOS

LAD + Cx (Single orifice), Sinus 2, Right pericommissural, Intramural, Within sinus
LAD + Cx (Single orifice), Sinus 2, Right pericommissural, Intramural, Across commissure
LAD + Cx (Single orifice), Sinus 2, Right pericommissural, Intramural, Above sinus

LAD + Cx (Single orifice), Sinus 2, Right pericommissural, Not intramural
LAD + Cx (Single orifice), Sinus 2, Left pericommissural, NOS
LAD + Cx (Single orifice), Sinus 2, Left pericommissural, Intramural, NOS

LAD + Cx (Single orifice), Sinus 2, Left pericommissural, Intramural, Within sinus
LAD + Cx (Single orifice), Sinus 2, Left pericommissural, Intramural, Across commissure
LAD + Cx (Single orifice), Sinus 2, Left pericommissural, Intramural, Above sinus

LAD + Cx (Single orifice), Sinus 2, Left pericommissural, Not intramural
LAD + Cx (Single orifice), Sinus 3, NOS
LAD + Cx (Single orifice), Sinus 3, Central, NOS
LAD + Cx (Single orifice), Sinus 3, Central, Intramural, NOS

LAD + Cx (Single orifice), Sinus 3, Central, Intramural, Within sinus
LAD + Cx (Single orifice), Sinus 3, Central, Intramural, Across commissure
LAD + Cx (Single orifice), Sinus 3, Central, Intramural, Above sinus

LAD + Cx (Single orifice), Sinus 3, Central, Not intramural
LAD + Cx (Single orifice), Sinus 3, Right pericommissural, NOS
LAD + Cx (Single orifice), Sinus 3, Right pericommissural, Intramural, NOS

LAD + Cx (Single orifice), Sinus 3, Right pericommissural, Intramural, Within sinus
LAD + Cx (Single orifice), Sinus 3, Right pericommissural, Intramural, Across commissure
LAD + Cx (Single orifice), Sinus 3, Right pericommissural, Intramural, Above sinus

LAD + Cx (Single orifice), Sinus 3, Right pericommissural, Not intramural
LAD + Cx (Single orifice), Sinus 3, Left pericommissural, NOS
LAD + Cx (Single orifice), Sinus 3, Left pericommissural, Intramural, NOS

LAD + Cx (Single orifice), Sinus 3, Left pericommissural, Intramural, Within sinus
LAD + Cx (Single orifice), Sinus 3, Left pericommissural, Intramural, Across commissure
LAD + Cx (Single orifice), Sinus 3, Left pericommissural, Intramural, Above sinus

LAD + Cx (Single orifice), Sinus 3, Left pericommissural, Not intramural
RCA + Cx (Single orifice), NOS
RCA + Cx (Single orifice), Sinus 1, NOS
RCA + Cx (Single orifice), Sinus 1, Central, NOS
RCA + Cx (Single orifice), Sinus 1, Central, Intramural, NOS

RCA + Cx (Single orifice), Sinus 1, Central, Intramural, Within sinus
RCA + Cx (Single orifice), Sinus 1, Central, Intramural, Across commissure
RCA + Cx (Single orifice), Sinus 1, Central, Intramural, Above sinus

RCA + Cx (Single orifice), Sinus 1, Central, Not intramural
RCA + Cx (Single orifice), Sinus 1, Right pericommissural, NOS
RCA + Cx (Single orifice), Sinus 1, Right pericommissural, Intramural, NOS

RCA + Cx (Single orifice), Sinus 1, Right pericommissural, Intramural, Within sinus
RCA + Cx (Single orifice), Sinus 1, Right pericommissural, Intramural, Across commissure
RCA + Cx (Single orifice), Sinus 1, Right pericommissural, Intramural, Above sinus

RCA + Cx (Single orifice), Sinus 1, Right pericommissural, Not intramural
RCA + Cx (Single orifice), Sinus 1, Left pericommissural, NOS
RCA + Cx (Single orifice), Sinus 1, Left pericommissural, Intramural, NOS

RCA + Cx (Single orifice), Sinus 1, Left pericommissural, Intramural, Within sinus
RCA + Cx (Single orifice), Sinus 1, Left pericommissural, Intramural, Across commissure
RCA + Cx (Single orifice), Sinus 1, Left pericommissural, Intramural, Above sinus

RCA + Cx (Single orifice), Sinus 1, Left pericommissural, Not intramural
RCA + Cx (Single orifice), Sinus 2, NOS
RCA + Cx (Single orifice), Sinus 2, Central, NOS
RCA + Cx (Single orifice), Sinus 2, Central, Intramural, NOS

RCA + Cx (Single orifice), Sinus 2, Central, Intramural, Within sinus
RCA + Cx (Single orifice), Sinus 2, Central, Intramural, Across commissure
RCA + Cx (Single orifice), Sinus 2, Central, Intramural, Above sinus

RCA + Cx (Single orifice), Sinus 2, Central, Not intramural
RCA + Cx (Single orifice), Sinus 2, Right pericommissural, NOS
RCA + Cx (Single orifice), Sinus 2, Right pericommissural, Intramural, NOS

RCA + Cx (Single orifice), Sinus 2, Right pericommissural, Intramural, Within sinus
RCA + Cx (Single orifice), Sinus 2, Right pericommissural, Intramural, Across commissure
RCA + Cx (Single orifice), Sinus 2, Right pericommissural, Intramural, Above sinus

RCA + Cx (Single orifice), Sinus 2, Right pericommissural, Not intramural
RCA + Cx (Single orifice), Sinus 2, Left pericommissural, NOS
RCA + Cx (Single orifice), Sinus 2, Left pericommissural, Intramural, NOS

RCA + Cx (Single orifice), Sinus 2, Left pericommissural, Intramural, Within sinus
RCA + Cx (Single orifice), Sinus 2, Left pericommissural, Intramural, Across commissure
RCA + Cx (Single orifice), Sinus 2, Left pericommissural, Intramural, Above sinus

RCA + Cx (Single orifice), Sinus 2, Left pericommissural, Not intramural
RCA + Cx (Single orifice), Sinus 3, NOS
RCA + Cx (Single orifice), Sinus 3, Central, NOS
RCA + Cx (Single orifice), Sinus 3, Central, Intramural, NOS

RCA + Cx (Single orifice), Sinus 3, Central, Intramural, Within sinus
RCA + Cx (Single orifice), Sinus 3, Central, Intramural, Across commissure
RCA + Cx (Single orifice), Sinus 3, Central, Intramural, Above sinus

RCA + Cx (Single orifice), Sinus 3, Central, Not intramural
RCA + Cx (Single orifice), Sinus 3, Right pericommissural, NOS
RCA + Cx (Single orifice), Sinus 3, Right pericommissural, Intramural, NOS

RCA + Cx (Single orifice), Sinus 3, Right pericommissural, Intramural, Within sinus
RCA + Cx (Single orifice), Sinus 3, Right pericommissural, Intramural, Across commissure
RCA + Cx (Single orifice), Sinus 3, Right pericommissural, Intramural, Above sinus

RCA + Cx (Single orifice), Sinus 3, Right pericommissural, Not intramural
RCA + Cx (Single orifice), Sinus 3, Left pericommissural, NOS
RCA + Cx (Single orifice), Sinus 3, Left pericommissural, Intramural, NOS

RCA + Cx (Single orifice), Sinus 3, Left pericommissural, Intramural, Within sinus
RCA + Cx (Single orifice), Sinus 3, Left pericommissural, Intramural, Across commissure
RCA + Cx (Single orifice), Sinus 3, Left pericommissural, Intramural, Above sinus

RCA + Cx (Single orifice), Sinus 3, Left pericommissural, Not intramural
LAD + RCA (Single orifice), NOS
LAD + RCA (Single orifice), Sinus 1, NOS
LAD + RCA (Single orifice), Sinus 1, Central, NOS
LAD + RCA (Single orifice), Sinus 1, Central, Intramural, NOS

LAD + RCA (Single orifice), Sinus 1, Central, Intramural, Within sinus
LAD + RCA (Single orifice), Sinus 1, Central, Intramural, Across commissure
LAD + RCA (Single orifice), Sinus 1, Central, Intramural, Above sinus

LAD + RCA (Single orifice), Sinus 1, Central, Not intramural
LAD + RCA (Single orifice), Sinus 1, Right pericommissural, NOS
LAD + RCA (Single orifice), Sinus 1, Right pericommissural, Intramural, NOS

LAD + RCA (Single orifice), Sinus 1, Right pericommissural, Intramural, Within sinus
LAD + RCA (Single orifice), Sinus 1, Right pericommissural, Intramural, Across commissure
LAD + RCA (Single orifice), Sinus 1, Right pericommissural, Intramural, Above sinus

LAD + RCA (Single orifice), Sinus 1, Right pericommissural, Not intramural
LAD + RCA (Single orifice), Sinus 1, Left pericommissural, NOS
LAD + RCA (Single orifice), Sinus 1, Left pericommissural, Intramural, NOS

LAD + RCA (Single orifice), Sinus 1, Left pericommissural, Intramural, Within sinus
LAD + RCA (Single orifice), Sinus 1, Left pericommissural, Intramural, Across commissure
LAD + RCA (Single orifice), Sinus 1, Left pericommissural, Intramural, Above sinus

LAD + RCA (Single orifice), Sinus 1, Left pericommissural, Not intramural
LAD + RCA (Single orifice), Sinus 2, NOS
LAD + RCA (Single orifice), Sinus 2, Central, NOS
LAD + RCA (Single orifice), Sinus 2, Central, Intramural, NOS

LAD + RCA (Single orifice), Sinus 2, Central, Intramural, Within sinus
LAD + RCA (Single orifice), Sinus 2, Central, Intramural, Across commissure
LAD + RCA (Single orifice), Sinus 2, Central, Intramural, Above sinus

LAD + RCA (Single orifice), Sinus 2, Central, Not intramural
LAD + RCA (Single orifice), Sinus 2, Right pericommissural, NOS
LAD + RCA (Single orifice), Sinus 2, Right pericommissural, Intramural, NOS

LAD + RCA (Single orifice), Sinus 2, Right pericommissural, Intramural, Within sinus
LAD + RCA (Single orifice), Sinus 2, Right pericommissural, Intramural, Across commissure
LAD + RCA (Single orifice), Sinus 2, Right pericommissural, Intramural, Above sinus

LAD + RCA (Single orifice), Sinus 2, Right pericommissural, Not intramural
LAD + RCA (Single orifice), Sinus 2, Left pericommissural, NOS
LAD + RCA (Single orifice), Sinus 2, Left pericommissural, Intramural, NOS

LAD + RCA (Single orifice), Sinus 2, Left pericommissural, Intramural, Within sinus
LAD + RCA (Single orifice), Sinus 2, Left pericommissural, Intramural, Across commissure
LAD + RCA (Single orifice), Sinus 2, Left pericommissural, Intramural, Above sinus

LAD + RCA (Single orifice), Sinus 2, Left pericommissural, Not intramural
LAD + RCA (Single orifice), Sinus 3, NOS
LAD + RCA (Single orifice), Sinus 3, Central, NOS
LAD + RCA (Single orifice), Sinus 3, Central, Intramural, NOS

LAD + RCA (Single orifice), Sinus 3, Central, Intramural, Within sinus
LAD + RCA (Single orifice), Sinus 3, Central, Intramural, Across commissure
LAD + RCA (Single orifice), Sinus 3, Central, Intramural, Above sinus

LAD + RCA (Single orifice), Sinus 3, Central, Not intramural
LAD + RCA (Single orifice), Sinus 3, Right pericommissural, NOS
LAD + RCA (Single orifice), Sinus 3, Right pericommissural, Intramural, NOS

LAD + RCA (Single orifice), Sinus 3, Right pericommissural, Intramural, Within sinus
LAD + RCA (Single orifice), Sinus 3, Right pericommissural, Intramural, Across commissure
LAD + RCA (Single orifice), Sinus 3, Right pericommissural, Intramural, Above sinus

LAD + RCA (Single orifice), Sinus 3, Right pericommissural, Not intramural
LAD + RCA (Single orifice), Sinus 3, Left pericommissural, NOS
LAD + RCA (Single orifice), Sinus 3, Left pericommissural, Intramural, NOS

LAD + RCA (Single orifice), Sinus 3, Left pericommissural, Intramural, Within sinus
LAD + RCA (Single orifice), Sinus 3, Left pericommissural, Intramural, Across commissure
LAD + RCA (Single orifice), Sinus 3, Left pericommissural, Intramural, Above sinus

LAD + RCA (Single orifice), Sinus 3, Left pericommissural, Not intramural
LAD + RCA + Cx (Single orifice), NOS
LAD + RCA + Cx (Single orifice), Sinus 1, NOS
LAD + RCA + Cx (Single orifice), Sinus 1, Central, NOS
LAD + RCA + Cx (Single orifice), Sinus 1, Central, Intramural, NOS

LAD + RCA + Cx (Single orifice), Sinus 1, Central, Intramural, Within sinus
LAD + RCA + Cx (Single orifice), Sinus 1, Central, Intramural, Across commissure
LAD + RCA + Cx (Single orifice), Sinus 1, Central, Intramural, Above sinus

LAD + RCA + Cx (Single orifice), Sinus 1, Central, Not intramural
LAD + RCA + Cx (Single orifice), Sinus 1, Right pericommissural, NOS
LAD + RCA + Cx (Single orifice), Sinus 1, Right pericommissural, Intramural, NOS

LAD + RCA + Cx (Single orifice), Sinus 1, Right pericommissural, Intramural, Within sinus
LAD + RCA + Cx (Single orifice), Sinus 1, Right pericommissural, Intramural, Across commissure
LAD + RCA + Cx (Single orifice), Sinus 1, Right pericommissural, Intramural, Above sinus

LAD + RCA + Cx (Single orifice), Sinus 1, Right pericommissural, Not intramural
LAD + RCA + Cx (Single orifice), Sinus 1, Left pericommissural, NOS
LAD + RCA + Cx (Single orifice), Sinus 1, Left pericommissural, Intramural, NOS

LAD + RCA + Cx (Single orifice), Sinus 1, Left pericommissural, Intramural, Within sinus
LAD + RCA + Cx (Single orifice), Sinus 1, Left pericommissural, Intramural, Across commissure
LAD + RCA + Cx (Single orifice), Sinus 1, Left pericommissural, Intramural, Above sinus

LAD + RCA + Cx (Single orifice), Sinus 1, Left pericommissural, Not intramural
LAD + RCA + Cx (Single orifice), Sinus 2, NOS
LAD + RCA + Cx (Single orifice), Sinus 2, Central, NOS
LAD + RCA + Cx (Single orifice), Sinus 2, Central, Intramural, NOS

LAD + RCA + Cx (Single orifice), Sinus 2, Central, Intramural, Within sinus
LAD + RCA + Cx (Single orifice), Sinus 2, Central, Intramural, Across commissure
LAD + RCA + Cx (Single orifice), Sinus 2, Central, Intramural, Above sinus

LAD + RCA + Cx (Single orifice), Sinus 2, Central, Not intramural
LAD + RCA + Cx (Single orifice), Sinus 2, Right pericommissural, NOS
LAD + RCA + Cx (Single orifice), Sinus 2, Right pericommissural, Intramural, NOS

LAD + RCA + Cx (Single orifice), Sinus 2, Right pericommissural, Intramural, Within sinus
LAD + RCA + Cx (Single orifice), Sinus 2, Right pericommissural, Intramural, Across commissure
LAD + RCA + Cx (Single orifice), Sinus 2, Right pericommissural, Intramural, Above sinus

LAD + RCA + Cx (Single orifice), Sinus 2, Right pericommissural, Not intramural
LAD + RCA + Cx (Single orifice), Sinus 2, Left pericommissural, NOS
LAD + RCA + Cx (Single orifice), Sinus 2, Left pericommissural, Intramural, NOS

LAD + RCA + Cx (Single orifice), Sinus 2, Left pericommissural, Intramural, Within sinus
LAD + RCA + Cx (Single orifice), Sinus 2, Left pericommissural, Intramural, Across commissure
LAD + RCA + Cx (Single orifice), Sinus 2, Left pericommissural, Intramural, Above sinus

LAD + RCA + Cx (Single orifice), Sinus 2, Left pericommissural, Not intramural
LAD + RCA + Cx (Single orifice), Sinus 3, NOS
LAD + RCA + Cx (Single orifice), Sinus 3, Central, NOS
LAD + RCA + Cx (Single orifice), Sinus 3, Central, Intramural, NOS

LAD + RCA + Cx (Single orifice), Sinus 3, Central, Intramural, Within sinus
LAD + RCA + Cx (Single orifice), Sinus 3, Central, Intramural, Across commissure
LAD + RCA + Cx (Single orifice), Sinus 3, Central, Intramural, Above sinus

LAD + RCA + Cx (Single orifice), Sinus 3, Central, Not intramural
LAD + RCA + Cx (Single orifice), Sinus 3, Right pericommissural, NOS
LAD + RCA + Cx (Single orifice), Sinus 3, Right pericommissural, Intramural, NOS

LAD + RCA + Cx (Single orifice), Sinus 3, Right pericommissural, Intramural, Within sinus
LAD + RCA + Cx (Single orifice), Sinus 3, Right pericommissural, Intramural, Across commissure
LAD + RCA + Cx (Single orifice), Sinus 3, Right pericommissural, Intramural, Above sinus

LAD + RCA + Cx (Single orifice), Sinus 3, Right pericommissural, Not intramural
LAD + RCA + Cx (Single orifice), Sinus 3, Left pericommissural, NOS
LAD + RCA + Cx (Single orifice), Sinus 3, Left pericommissural, Intramural, NOS

LAD + RCA + Cx (Single orifice), Sinus 3, Left pericommissural, Intramural, Within sinus
LAD + RCA + Cx (Single orifice), Sinus 3, Left pericommissural, Intramural, Across commissure
LAD + RCA + Cx (Single orifice), Sinus 3, Left pericommissural, Intramural, Above sinus

LAD + RCA + Cx (Single orifice), Sinus 3, Left pericommissural, Not intramural
Sinus node artery (Separate orifice), NOS
Sinus node artery (Separate orifice), Sinus 1, NOS
Sinus node artery (Separate orifice), Sinus 1, Central, NOS
Sinus node artery (Separate orifice), Sinus 1, Central, Intramural, NOS

Sinus node artery (Separate orifice), Sinus 1, Central, Intramural, Within sinus
Sinus node artery (Separate orifice), Sinus 1, Central, Intramural, Across commissure
Sinus node artery (Separate orifice), Sinus 1, Central, Intramural, Above sinus

Sinus node artery (Separate orifice), Sinus 1, Central, Not intramural
Sinus node artery (Separate orifice), Sinus 1, Right pericommissural, NOS
Sinus node artery (Separate orifice), Sinus 1, Right pericommissural, Intramural, NOS

Sinus node artery (Separate orifice), Sinus 1, Right pericommissural, Intramural, Within sinus
Sinus node artery (Separate orifice), Sinus 1, Right pericommissural, Intramural, Across commissure
Sinus node artery (Separate orifice), Sinus 1, Right pericommissural, Intramural, Above sinus

Sinus node artery (Separate orifice), Sinus 1, Right pericommissural, Not intramural
Sinus node artery (Separate orifice), Sinus 1, Left pericommissural, NOS
Sinus node artery (Separate orifice), Sinus 1, Left pericommissural, Intramural, NOS

Sinus node artery (Separate orifice), Sinus 1, Left pericommissural, Intramural, Within sinus
Sinus node artery (Separate orifice), Sinus 1, Left pericommissural, Intramural, Across commissure
Sinus node artery (Separate orifice), Sinus 1, Left pericommissural, Intramural, Above sinus

Sinus node artery (Separate orifice), Sinus 1, Left pericommissural, Not intramural
Sinus node artery (Separate orifice), Sinus 2, NOS
Sinus node artery (Separate orifice), Sinus 2, Central, NOS
Sinus node artery (Separate orifice), Sinus 2, Central, Intramural, NOS

Sinus node artery (Separate orifice), Sinus 2, Central, Intramural, Within sinus
Sinus node artery (Separate orifice), Sinus 2, Central, Intramural, Across commissure
Sinus node artery (Separate orifice), Sinus 2, Central, Intramural, Above sinus

Sinus node artery (Separate orifice), Sinus 2, Central, Not intramural
Sinus node artery (Separate orifice), Sinus 2, Right pericommissural, NOS
Sinus node artery (Separate orifice), Sinus 2, Right pericommissural, Intramural, NOS

Sinus node artery (Separate orifice), Sinus 2, Right pericommissural, Intramural, Within sinus
Sinus node artery (Separate orifice), Sinus 2, Right pericommissural, Intramural, Across commissure
Sinus node artery (Separate orifice), Sinus 2, Right pericommissural, Intramural, Above sinus

Sinus node artery (Separate orifice), Sinus 2, Right pericommissural, Not intramural
Sinus node artery (Separate orifice), Sinus 2, Left pericommissural, NOS
Sinus node artery (Separate orifice), Sinus 2, Left pericommissural, Intramural, NOS

Sinus node artery (Separate orifice), Sinus 2, Left pericommissural, Intramural, Within sinus
Sinus node artery (Separate orifice), Sinus 2, Left pericommissural, Intramural, Across commissure
Sinus node artery (Separate orifice), Sinus 2, Left pericommissural, Intramural, Above sinus

Sinus node artery (Separate orifice), Sinus 2, Left pericommissural, Not intramural
Sinus node artery (Separate orifice), Sinus 3, NOS
Sinus node artery (Separate orifice), Sinus 3, Central, NOS
Sinus node artery (Separate orifice), Sinus 3, Central, Intramural, NOS

Sinus node artery (Separate orifice), Sinus 3, Central, Intramural, Within sinus
Sinus node artery (Separate orifice), Sinus 3, Central, Intramural, Across commissure
Sinus node artery (Separate orifice), Sinus 3, Central, Intramural, Above sinus

Sinus node artery (Separate orifice), Sinus 3, Central, Not intramural
Sinus node artery (Separate orifice), Sinus 3, Right pericommissural, NOS
Sinus node artery (Separate orifice), Sinus 3, Right pericommissural, Intramural, NOS

Sinus node artery (Separate orifice), Sinus 3, Right pericommissural, Intramural, Within sinus
Sinus node artery (Separate orifice), Sinus 3, Right pericommissural, Intramural, Across commissure
Sinus node artery (Separate orifice), Sinus 3, Right pericommissural, Intramural, Above sinus

Sinus node artery (Separate orifice), Sinus 3, Right pericommissural, Not intramural
Sinus node artery (Separate orifice), Sinus 3, Left pericommissural, NOS
Sinus node artery (Separate orifice), Sinus 3, Left pericommissural, Intramural, NOS

Sinus node artery (Separate orifice), Sinus 3, Left pericommissural, Intramural, Within sinus
Sinus node artery (Separate orifice), Sinus 3, Left pericommissural, Intramural, Across commissure
Sinus node artery (Separate orifice), Sinus 3, Left pericommissural, Intramural, Above sinus

Sinus node artery (Separate orifice), Sinus 3, Left pericommissural, Not intramural
Conus artery (Separate orifice), NOS
Conus artery (Separate orifice), Sinus 1, NOS
Conus artery (Separate orifice), Sinus 1, Central, NOS
Conus artery (Separate orifice), Sinus 1, Central, Intramural, NOS

Conus artery (Separate orifice), Sinus 1, Central, Intramural, Within sinus
Conus artery (Separate orifice), Sinus 1, Central, Intramural, Across commissure
Conus artery (Separate orifice), Sinus 1, Central, Intramural, Above sinus

Conus artery (Separate orifice), Sinus 1, Central, Not intramural
Conus artery (Separate orifice), Sinus 1, Right pericommissural, NOS
Conus artery (Separate orifice), Sinus 1, Right pericommissural, Intramural, NOS

Conus artery (Separate orifice), Sinus 1, Right pericommissural, Intramural, Within sinus
Conus artery (Separate orifice), Sinus 1, Right pericommissural, Intramural, Across commissure
Conus artery (Separate orifice), Sinus 1, Right pericommissural, Intramural, Above sinus

Conus artery (Separate orifice), Sinus 1, Right pericommissural, Not intramural
Conus artery (Separate orifice), Sinus 1, Left pericommissural, NOS
Conus artery (Separate orifice), Sinus 1, Left pericommissural, Intramural, NOS

Conus artery (Separate orifice), Sinus 1, Left pericommissural, Intramural, Within sinus
Conus artery (Separate orifice), Sinus 1, Left pericommissural, Intramural, Across commissure
Conus artery (Separate orifice), Sinus 1, Left pericommissural, Intramural, Above sinus

Conus artery (Separate orifice), Sinus 1, Left pericommissural, Not intramural
Conus artery (Separate orifice), Sinus 2, NOS
Conus artery (Separate orifice), Sinus 2, Central, NOS
Conus artery (Separate orifice), Sinus 2, Central, Intramural, NOS

Conus artery (Separate orifice), Sinus 2, Central, Intramural, Within sinus
Conus artery (Separate orifice), Sinus 2, Central, Intramural, Across commissure
Conus artery (Separate orifice), Sinus 2, Central, Intramural, Above sinus

Conus artery (Separate orifice), Sinus 2, Central, Not intramural
Conus artery (Separate orifice), Sinus 2, Right pericommissural, NOS
Conus artery (Separate orifice), Sinus 2, Right pericommissural, Intramural, NOS

Conus artery (Separate orifice), Sinus 2, Right pericommissural, Intramural, Within sinus
Conus artery (Separate orifice), Sinus 2, Right pericommissural, Intramural, Across commissure
Conus artery (Separate orifice), Sinus 2, Right pericommissural, Intramural, Above sinus

Conus artery (Separate orifice), Sinus 2, Right pericommissural, Not intramural
Conus artery (Separate orifice), Sinus 2, Left pericommissural, NOS
Conus artery (Separate orifice), Sinus 2, Left pericommissural, Intramural, NOS

Conus artery (Separate orifice), Sinus 2, Left pericommissural, Intramural, Within sinus
Conus artery (Separate orifice), Sinus 2, Left pericommissural, Intramural, Across commissure
Conus artery (Separate orifice), Sinus 2, Left pericommissural, Intramural, Above sinus

Conus artery (Separate orifice), Sinus 2, Left pericommissural, Not intramural
Conus artery (Separate orifice), Sinus 3, NOS
Conus artery (Separate orifice), Sinus 3, Central, NOS
Conus artery (Separate orifice), Sinus 3, Central, Intramural, NOS

Conus artery (Separate orifice), Sinus 3, Central, Intramural, Within sinus
Conus artery (Separate orifice), Sinus 3, Central, Intramural, Across commissure
Conus artery (Separate orifice), Sinus 3, Central, Intramural, Above sinus

Conus artery (Separate orifice), Sinus 3, Central, Not intramural
Conus artery (Separate orifice), Sinus 3, Right pericommissural, NOS
Conus artery (Separate orifice), Sinus 3, Right pericommissural, Intramural, NOS

Conus artery (Separate orifice), Sinus 3, Right pericommissural, Intramural, Within sinus
Conus artery (Separate orifice), Sinus 3, Right pericommissural, Intramural, Across commissure
Conus artery (Separate orifice), Sinus 3, Right pericommissural, Intramural, Above sinus

Conus artery (Separate orifice), Sinus 3, Right pericommissural, Not intramural
Conus artery (Separate orifice), Sinus 3, Left pericommissural, NOS
Conus artery (Separate orifice), Sinus 3, Left pericommissural, Intramural, NOS

Conus artery (Separate orifice), Sinus 3, Left pericommissural, Intramural, Within sinus
Conus artery (Separate orifice), Sinus 3, Left pericommissural, Intramural, Across commissure
Conus artery (Separate orifice), Sinus 3, Left pericommissural, Intramural, Above sinus

Conus artery (Separate orifice), Sinus 3, Left pericommissural, Not intramural

Definitions for coronary artery hierarchy

Coronary arteries
LAD:
Left anterior descending artery.

RCA
Right coronary artery.

Cx
Circumflex artery.

LAD + Cx (single orifice)
The LAD and circumflex arise from the aorta as a single orifice.

RCA + Cx (single orifice)
The LAD and RCA arise from the aorta as a single orifice.

LAD + RCA (single orifice)
The RCA and Cx arise from the aorta as a single orifice.

LAD + RCA + Cx (single orifice)
The LAD Cx and RCA arise from the aorta from a single orifice.

Sinus node artery (separate orifice)
Sinus node artery arises from a separate orifice in the sinus of the aorta and not from one of the above major arteries.

Conus artery (separate orifice)
Conal artery arises from a separate orifice in the sinus of the aorta and not from one of the above major arteries.

Sinus

Sinus 1
That sinus that corresponds to the sinus 1 of the Leiden classification, synonyms include left facing sinus, right hand sinus, and anterior sinus.

Sinus 2
That sinus that corresponds to the sinus 2 of the Leiden classification, synonyms include right facing sinus, left hand sinus and posterior sinus.

Sinus 3
That sinus that corresponds to the nonfacing sinus of the Leiden classification.

Position in sinus

Central
Within the central two-thirds of the sinus as viewed by a hypothetical observer from within the lumen of the aorta.

Right pericommissural
Within approximately 1 millimeter of the commissure on the right hand side of the sinus as viewed by a hypothetical observer from within the lumen of the aorta standing with his/her feet towards the heart.

Left pericommissural
Within approximately 1 millimeter of the commissure on the left hand side of the sinus as viewed by a hypothetical observer from within the lumen of the aorta with his feet towards the heart.

Intramural

Intramural
When all or part of the coronary artery courses within the wall of the aorta from orifice within the aorta to the point at which it leaves the aorta and emerges on the epicardium of the heart.

Position of intramural coronary artery

Within the sinus
The situation in which the intramural coronary artery arises, courses within the aortic wall, and exits within the same sinus of Valsalva.

Across the commissure
The situation in which the intramural coronary artery arises from one sinus and courses within the aortic wall across a commissure and exits from an adjacent sinus.

Above the sinus
The situation in which the intramural artery arises and exits from above the level of the commissures (sinotubular junction) and does not cross a commissure.

TGA Nomenclature Short List
TGA, NOS
TGA-IVS
TGA-IVS-LVOTO
TGA-VSD
TGA-VSD-LVOTO

Definitions

TGA
Those defects in which the predominant anomaly is that of physiologic uncorrected ventriculoarterial discordant alignment. TGA synonyms include, d-TGA, atrioventricular concordant ventriculoarterial discordant alignment, simple transposition, complete transposition, {S,D,D}, physiologically uncorrected transposition.

IVS
Intact ventricular septum.

VSD
Ventricular septal defect.

LVOTO
Left ventricular outflow tract obstruction. A synonym is pulmonary stenosis.

TGA nomenclature hierarchical scheme

Hierarchy level 1

TGA

Hierarchy level 2

TGA, NOS

TGA-IVS
TGA-IVS-LVOTO
TGA-VSD
TGA-VSD-LVOTO

Modifiers for TGA nomenclature
A list of important modifiers to the hierarchical nomenclature of TGA:

Patent ductus arteriosus
Coarctation of the aorta
Interrupted aortic arch
Anomalies of systemic venous return
Anomalies of pulmonary venous return
With dextrocardia (right sided ventricular mass/apex)
With levocardia (left sided ventricular mass/apex)
With mesocardia (central/midline ventricular mass/apex)
Straddling AV valves
Hypoplastic right ventricle
Hypoplastic left ventricle
Bicuspid pulmonary valve
Bicuspid aortic valve
Right aortic arch

III. Therapy for TGA

History of therapy for D-TGA
Before the 1950s, descriptions and reports of transposition were directed toward definition and morphologic characterization, as there was no effective therapy. It became clear early on, that transposition was associated with a very high mortality in the first year of life. Prior to the advent of effective therapy, TGA was responsible for 16% of all deaths from congenital cardiac disease, and 90% of infants with TGA are dead by one year of age [14, 15]. In patients with a VSD the early survival rate is higher, 91% at one month and 33% at one year [14].

The surgical therapy for transposition began with palliative procedures in 1950 (Table 2) when Blalock and Hanlon, at Johns Hopkins, described a method of atrial septectomy [16]. This operation was designed to improve the mixing of systemic and pulmonary venous return at the atrial level. Others modified this concept by anastomosing the right pulmonary veins to the right atrium and reclosing the atrial septum [17]. In 1953, Lillehei and Varco described a partial physiologic correction, that consisted of anastomosis of the right pulmonary veins to the right atrium and the inferior vena cava to the left atrium [18]. Baffes went on to modify this approach by using an allograft to connect the inferior vena cava to the left atrium [19]. In 1966, Rashkind significantly impacted on the management of infants with TGA by the introduction of balloon atrial septostomy [20]. For the first time, TGA could be effectively palliated without open operation.


View this table:
[in this window]
[in a new window]
  		Table 2. Chronological History of the Surgical Therapy for Transposition of the Great Arteries

 
Complete repairs were attempted throughout the 1950s and 1960s. Early attempts by both Mustard and Bailey were frustrated by the inability to maintain coronary perfusion and adequate oxygen delivery to the myocardium because the coronary circulation was either partially or completely RV dependent. Senning first accomplished the atrial level switch in 1959, using an ingenious technique transposing the walls of the left and right atrium without the use of prosthetic material. Success was limited because the first atrial switch operations were on patients that were 1 to 2 years of age, and already had significant pulmonary vascular obstructive changes. This failure was especially marked in those patients with TGA-VSD [21]. In 1964, Mustard devised an alternate technique for atrial level switch that involved excising the interatrial septum and creating a prosthetic baffle to redirect the systemic and pulmonary venous return [22]. This operation effectively resulted in significantly larger atria, and was thought to result in improved cardiac output [23]. Results with the Mustard operation were significantly improved over the earlier Senning patients. This was most likely due to the fact that these patients had undergone early and successful Blalock-Hanlon operations, and that they had received their atrial switch operations often within the first year of life. The Mustard operation became the mainstay of repair for TGA through the 1960s, but as the complications of baffle obstruction and arrhythmias appeared, the Senning operation reemerged as the favored operation because of fewer complications. Despite very good results with the atrial switch operations in the patients with TGA-IVS, results in the patients with VSD were universally poor, and this provided continued stimulus for an arterial level repair. Through the 1950s and 1960s there were many attempts to repair TGA at the arterial level, but it was not until 1975 that Jatene reported successful arterial switch procedures in infants with TGA-VSD [24].

Simultaneously, Yacoub also successfully performed anatomic repair on infants with TGA-VSD [25]. The one stage arterial switch had not been successful in older children because the left ventricle had not been prepared for the systemic pressures it would have to pump against. Yacoub successfully solved this problem by preparing the left ventricle with a PA band as a first stage with the arterial switch procedure to follow [26]. As the success of the arterial switch operation increased, several groups were reporting good results with one-stage arterial switch procedure in neonates with TGA-IVS [27, 28, 29].

Significant LVOTO occurs primarily in patients with TGA-VSD. In patients with TGA-VSD and LVOTO, atrial switch operations combined with attempts to resect the septal muscle to relieve LVOTO, carried a high mortality. In 1969, Rastelli reported on his experience with an intraventricular tunnel repair to close the VSD, direct left ventricular blood flow across an interventricular baffle to the aorta. The pulmonary artery is then oversewn, and the right ventricular outflow is reconstructed with a homograft valve conduit [30]. The therapeutic principles defined by Rastelli have applications in many other defects as well.

Therapeutic nomenclature for TGA

Therapy for TGA is one of the true success stories of congenital cardiac operation. Therapeutic options for all forms of TGA include palliative therapy, physiologic correction, and anatomic and physiologic correction. A list of potential surgical operations is shown in Table 3. Nomenclature will also include the repair of the associated defects like repair of VSD, LVOTO, RVOTO, and aortic arch anomalies. Physiologic and anatomic correction (arterial switch procedure) is the current state of the art, the treatment of most forms of TGA. Most commonly, balloon atrial septostomy is performed in the first few days of life to improve mixing. This is followed by arterial switch procedure within the first 2 weeks of life. Since the advent of the balloon atrial septostomy, the use of the Blalock-Hanlon operation has essentially disappeared. There may be an occasional infant with associated defects that has a thickened atrial septum, and is either not a candidate for, or has failed balloon atrial septostomy. This child may require an atrial septectomy, but this is likely to be done open with the aid of cardiopulmonary bypass (CPB).


View this table:
[in this window]
[in a new window]
  		Table 3. Possible Surgical Procedures That May Be Used in the Treatment of Transposition of the Great Arteries

 
Despite the excellent results of the atrial switch operation in some centers, late complications of the atrial switch operations, and excellent results of the arterial switch operation has resulted in arterial switch becoming the procedure of choice for TGA. The Le Compte maneuver has been a major advance in the prevention of late complications related to neopulmonary stenosis following the arterial switch procedure.

While this situation is quite unusual, TGA and IVS may occasionally coexist with a significant anatomic LVOTO. In this case, if there is a fixed membranous obstruction, it may be resected and the arterial switch procedure can be performed as usual. If, however, there is diffuse LVOTO, and it cannot be adequately resected, then an atrial switch procedure and a conduit from the left ventricle to the pulmonary artery may be necessary. Another strategy is an inferior vena caval baffle to the left atrium combined with a bidirectional Glenn shunt that can unload the left ventricle and lower the pressure [31].

Although never preferred, palliative procedures may be necessary in some situations. PA banding has been used in young infants with TGA-VSD and intractable heart failure. Because of the poor results with atrial level repair and the improved results with the arterial switch procedure and VSD closure in infancy, there are very few indications for PA banding with this defect. There may be an occasional patient that either presents late (> 3 to 4 weeks of age), or has coexistent medical or congenital defects which may necessitate a staged approach to arterial level repair. This involves training of the left ventricle with a pulmonary artery band to increase the afterload of the left ventricle. This same approach may be taken with the patient who has failed an atrial repair because of right (systemic) ventricular failure. A PA band is placed for left ventricular training, which is followed by atrial baffle taken down and arterial switch. Cardiac transplantation may be required if the LV does not respond to training, or if biventricular failure ensues.

In patients with TGA-VSD and significant LVOTO, the Rastelli operation is most often utilized. When this operation is performed in the very young, there is significant risk of obstruction of the intraventricular baffle. LeCompte modified the Rastelli with an operation called the reparation a l’étage ventriculaire (REV) procedure. In this operation a more extensive resection of the subaortic conus is carried out to just below the neopulmonary valve annulus. In addition, resection of a short portion of the ascending aorta and repositioning the aorta more posterior, allows direct connection of the main pulmonary artery bifurcation to the RVOT, thereby avoiding the necessity of a valved conduit [32].

In TGA-VSD patients with associated defects like interrupted aortic arch and coarctation, there is a very high likelihood of associated subvalvar RVOTO. This obstruction may not be apparent preoperatively, when less than a full cardiac output is crossing the RVOT, as in the case of a VSD or a PDA. However, once an arterial switch procedure has been performed, the RVOTO may be unmasked. In some situations in which there is aortic arch, valvar, and subvalvar obstruction with TGA-VSD, a Damus-Kaye-Stansel operation or a Nikaidoh operation may be indicated [33, 34].

TGA Surgical Procedure Short List
TGA repair, NOS
TGA repair, Arterial switch procedure
TGA repair, Arterial switch procedure with VSD repair
TGA repair, Senning procedure
TGA repair, Mustard procedure
TGA repair, Rastelli procedure
TGA repair, REV procedure
TGA repair, Other procedures (Nikaido, Kawashima, LV to PA conduit, Other)

TGA therapeutic nomenclature hierarchical scheme

TGA hierarchy level 1

TGA repair
TGA palliation

TGA hierarchy level 2

TGA repair, NOS

TGA repair, Arterial switch procedure
TGA repair, Arterial switch procedure with VSD repair
TGA repair, Senning procedure
TGA repair, Mustard procedure
TGA repair, Rastelli procedure
TGA repair, REV procedure
TGA repair, Nikaido procedure
TGA repair, Kawashima procedure
TGA repair, LV to PA conduit
TGA repair, Damus-Kaye-Stansel procedure
TGA repair, Other procedures

TGA Palliation, NOS

TGA Palliation, PA banding
TGA Palliation, Systemic-to-pulmonary artery shunt
TGA Palliation, PA banding and systemic-to-pulmonary artery shunt
TGA Palliation, Balloon atrial septostomy
TGA Palliation, Blade atrial septostomy
TGA Palliation, Surgical septectomy

The various modifications of the systemic-to-pulmonary artery shunt procedures are described in detail in the single ventricle manuscript of this supplement by Jacobs and colleagues, and are not represented in detail in this manuscript. Obviously, the hierarchical description of these procedures described in detail in the single ventricle manuscript may be applied to certain forms of TGA.

TGA hierarchy level 3

TGA repair, NOS
TGA repair, Arterial switch procedure, NOS

TGA repair, Arterial switch procedure, With aortic arch repair
TGA repair, Arterial switch procedure, Staged procedure

TGA repair, Arterial switch procedure with VSD repair, NOS

TGA repair, Arterial switch procedure with VSD repair, With aortic arch repair
TGA repair, Arterial switch procedure with VSD repair, Staged procedure

TGA repair, Senning procedure
TGA repair, Mustard procedure
TGA repair, Rastelli procedure
TGA repair, REV procedure
TGA repair, Nikaido procedure
TGA repair, Kawashima procedure
TGA repair, LV to PA conduit
TGA repair, Damus-Kaye-Stansel procedure
TGA repair, Other procedures
TGA palliation, NOS
PA banding
Systemic-to-pulmonary artery shunt
PA banding and systemic-to-pulmonary artery shunt
Balloon atrial septostomy
Blade atrial septostomy
Surgical septectomy, NOS

Surgical septectomy, Closed techniques (no CPB)
Surgical septectomy, Open techniques (CPB)

TGA hierarchy level 4

TGA repair, NOS
TGA repair, Arterial switch procedure, NOS
TGA repair, Arterial switch procedure, With aortic arch repair
TGA repair, Arterial switch procedure, Staged procedure, NOS

TGA repair, Arterial switch procedure, Staged procedure, With preceding PA band
TGA repair, Arterial switch procedure, Staged procedure, With preceding PA band and systemic-to-pulmonary artery shunt
TGA repair, Arterial switch procedure, Staged procedure, With atrial switch takedown with preceding PA banding
TGA repair, Arterial switch procedure, Staged procedure, With atrial switch takedown without preceding PA banding

TGA repair, Arterial switch procedure with VSD repair, NOS
TGA repair, Arterial switch procedure with VSD repair, With aortic arch repair
TGA repair, Arterial switch procedure with VSD repair, Staged procedure, NOS

TGA repair, Arterial switch procedure with VSD repair, Staged procedure, With preceding PA banding
TGA repair, Arterial switch procedure with VSD repair, Staged procedure, With atrial switch takedown with preceding PA banding
TGA repair, Arterial switch procedure with VSD repair, Staged procedure, With atrial switch takedown without preceding PA banding

TGA repair, Senning procedure
TGA repair, Mustard procedure
TGA repair, Rastelli procedure
TGA repair, REV procedure
TGA repair, Nikaido procedure
TGA repair, Kawashima procedure
TGA repair, LV to PA conduit
TGA repair, Damus-Kaye-Stansel procedure
TGA repair, Other procedures
TGA palliation, NOS
PA banding
Systemic-to-pulmonary artery shunt
PA banding and systemic-to-pulmonary artery shunt
Balloon atrial septostomy
Blade atrial septostomy
Surgical septectomy, NOS
Surgical septectomy, Closed techniques (no CPB)
Surgical septectomy, Open techniques (CPB)

TGA repair, Arterial switch procedure, With Le Compte maneuver
TGA repair, Arterial switch procedure, Without Le Compte maneuver

Additional comments regarding therapeutics
In addition to the above basic treatment options, several other therapeutic issues must be addressed and coded in other areas of the database. First, a separate part of the database must allow for coding of incisions, for this and all other diagnoses (median sternotomy, submammary incision, right thoracotomy, left thoracotomy, minimally invasive incisions, including partial sternotomy, parasternal incision, mini-thoracotomy, etc). Second, a separate part of the database must allow for coding of cardiac incisions for this and all other diagnoses (aortotomy, pulmonary arteriotomy, right atriotomy, right ventriculotomy, left ventriculotomy, etc). Third, a separate module of the database must permit coding of patch materials (Dacron, Gore-Tex, bovine pericardium, autologous pericardium (free autologous pericardium and in situ autologous pericardium), glutaraldehyde fixated autologous pericardium, atrial wall patch, ie atrial wall used to patch a stenotic pulmonary vein, homograft patch, etc). Finally, if additional procedures were performed during one of those procedures, these additional procedures would be coded in detail separately. (For example, if one performs an ASD repair during an arterial switch procedure, the ASD repair would also be coded as a secondary procedure and the type of ASD repair done (primary closure versus patch repair) would be coded in detail as part of this secondary procedure coding).

IV. Outcome reports

The following continuous and discrete variables are considered appropriate for entry into a comprehensive database for patients with TGA. The relevance of each item to a given anatomic subset, or type of operation, will vary. Most importantly, the outcome of the coronary circulation and the fates of the neoaortic valve and the neopulmonary outflow tracts will be crucial to verifying the success of the arterial switch procedure. Many of the variables could be used as either independent or dependent variables for a multivariate logistic regression analysis. A list of potentially important outcome variables relevant to TGA:

Preoperative variables
Age at repair
Preoperative atrial septostomy
Need for Prostaglandin E2 (PGE2)
Preoperative inotropic support
Pulmonary hypertension
Straddling AV valve (none/mitral/tricuspid)
Ventricular position: dextrocardia/levocardia/mesocardia

Procedure variables
Coronary artery anatomy
Circulatory arrest duration
Associated defects
Coarctation/Interrupted Aortic Arch (IAA)
Tricuspid or mitral anomalies
Juxtaposition of atrial appendages
VSD
LVOTO
RVOTO
Hypoplastic ventricle (right/left)

Open sternum
Myocardial ischemia
Post cardiotomy support
Arrhythmia
Single vs multidose cardioplegia
LeCompte maneuver

Postoperative Variables
Arrhythmia
Pulmonary stenosis
Intratrial baffle obstruction
Systemic ventricular failure
Coronary artery stenosis with ischemia
Intraventricular baffle obstruction
Baffle leak
AV valve insufficiency
Neoaortic insufficiency

Summary

For surgeons, the classification of TGA on the surface may seem very straightforward. Indeed it is for the vast majority of patients. There are, however, variations of the pathologic anatomy that a proper nomenclature system must identify. Many of these will be treated with the standard arterial switch procedure even though the anatomy may be other than the standard, {S,D,D} TGA. While there are many classifications systems for the coronary artery patterns associated with TGA, all of them have certain failings. A purely descriptive nomenclature will be the most likely to capture all of the possible patterns that exist and hopefully to help risk stratify the coronary artery anatomy. The surgical options for treatment of TGA are well described and entrenched in the surgical literature. The nomenclature for more recent concepts such as staged arterial switch procedures are provided for in this nomenclature system.

References

  1. Abbott M.E. Congenital cardiac diseases. In: Ossler W., McCrae T., eds. Modern Medicine. Philadelphia: Lea and Feibiger, 1927:4.
  2. Van Praagh R., Perez-Trevino C., Lopez-Cuellar M., et al. Transposition of the great arteries with posterior aorta, anterior pulmonary artery, subpulmonary conus, and fibrous continuity between aortic and atrioventricular valves. Am J Cardiol 1971;28:621-631.[Medline]
  3. Houyel L., Van Praagh R., Lacour-Gayet F., et al. Transposition of the great arteries {S,D,L} Pathologic anatomy, diagnosis, and surgical management of a newly recognized complex. J Thorac Cardiovasc Surg 1995;110:613-624.[Abstract/Free Full Text]
  4. Van Praagh R., Weinberg P.M., et al. The transposition complexes, how many are there?. Henry Ford Hospital International Symposium on Cardiac Surgery 1975:207-213.
  5. Amato J.J., Zelen J., et al. Coronary arterial patterns in complete transposition-classification in relation to the arterial switch procedure. Cardiol Young 1994;4:329-339.
  6. Rowlatt U.F. Coronary artery distribution in complete transposition. JAMA 1962;179:109-118.
  7. Elliot L.P., Neufeld H.N., et al. Complete transposition of the great vessels; and anatomic study of sixty cases. Circulation 1963;27:1105-1117.[Abstract/Free Full Text]
  8. Shaher R.M., Puddu G.C. Coronary arterial anatomy in complete transposition of the great vessels. Am J Cardiol 1966;17:355-361.[Medline]
  9. Yacoub M.H., Radley-Smith R. Anatomy of the coronary arteries in transposition of the great arteries and methods for their transfer in anatomic correction. Thorax 1978;33:418-424.[Abstract/Free Full Text]
  10. Planche C., Bruniaux J., Lacour-Gayet F., et al. Switch operation for transposition of the great arteries in neonates. A study of 120 patients. J Thorac Cardiovasc Surg 1988;96:354-363.[Abstract]
  11. Gittenburger de Groot A., Sauer U., et al. Coronary arterial anatomy in transposition of the great arteries; a morphologic study. Pediatr Cardiol 1983;4(Suppl 1):15-24.
  12. 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 model artery in complete transposition. Int J Cardiol 1986;12:295-304.[Medline]
  13. Wernovsky G., Sanders S.P. Coronary artery anatomy and transposition of the great arteries. Coronary Artery Disease 1993;4:148-157.[Medline]
  14. Leibman J., Cullum L., et al. Natural history of transposition of the great arteries, anatomy and birth and death characteristics. Circulation 1969;40:247.
  15. Miller R. Complete transposition of the great arteries. Philadelphia: FA Davis.
  16. Blalock A.H. The surgical treatment of complete transposition of the aorta and pulmonary artery. Surg Gynecol Obstet 1950;90:1.
  17. Edwards W.S., Bangeron L.M., et al. Reposition of the right pulmonary veins in transposition of the great vessels. JAMA 1964;188:522.
  18. Lillehei C.W. Certain physiologic, pathologic and surgical features of complete transposition of the great vessels. Surgery 1953;34:376.
  19. Baffes T.G. A new method for surgical correction of transposition of the aorta and pulmonary artery. Surg Gynecol Obstet 1956;102:227.[Medline]
  20. Rashkind W.J., Miller W.W. Creation of an atrial septal defect without thoracotomy. A palliative approach to complete transposition of the great arteries. JAMA 1966;196:991.[Abstract/Free Full Text]
  21. Kirklin J.W., Devloo R.A., et al. Open intra-cardiac repair for transposition of the great vessels. Surgery 1961;50:58.[Medline]
  22. Mustard W.T. Successful two stage correction of transposition of the great vessels. Surgery 1964;55:469.[Medline]
  23. Trusler G.A., Bull R.C., et al. The effect on cardiac output of reduction of the atrial volume. J Thorac Cardiovasc Surg 1963;46:109.
  24. Jatene A.D., Fontes V.F., Paulista P.P., et al. Anatomic correction of transposition of the great arteries. J Thorac Cardiovasc Surg 1976;72:364-370.[Abstract]
  25. Yacoub M.H., Radley-Smith R., Hilton C.J. Anatomical correction of complete transposition of the great arteries and ventricular septal defect in infancy. Br Med J 1976;1:1112-1114.
  26. Yacoub M.H., Radley-Smith R., Maclaurin R. Two-stage operation for anatomic correction of transposition of the great arteries with intact ventricular septum. Lancet 1977;1:1275-1278.[Medline]
  27. Casteñada A.R., Norwood W.I., Jonas R.A., et al. Transposition of the great arteries and intact ventricular septum. Ann Thor Surg 1984;38:438-443.[Abstract]
  28. Radley-Smith R., Y M.H. One-stage anatomic correction of simple complete transposition of the great arteries in neonates. Br Heart J 1984;51:685.
  29. Quaegebeur J.M., Rohmer J., et al. The arterial switch operation. An eight year experience. J Thorac Cardiovasc Surg 1986;92:361.[Abstract]
  30. Rastelli G.C., Wallace R.B., et al. Complete repair of transposition of the great arteries with pulmonary stenosis. A review and report of a case corrected by using a new surgical technique. Circulation 1969;39:83.[Abstract/Free Full Text]
  31. Mavroudis C., Backer C.L., Kohr L.M., et al. Bidirectional Glenn shunt in association with congenital heart repairs. Ann Thorac Surg 1999;68:976-982.[Abstract/Free Full Text]
  32. Le Compte Y. Reparation a l’etage ventriculaire—the REV procedure. J Cardiol Young 1991;1:63.
  33. Stansel H.C., Jr A new operation for D-loop transposition of the great vessels. Ann Thorac Surg 1975;19:565.[Abstract]
  34. Nikaidoh H. Aortic translocation and biventricular outflow tract reconstruction. A new surgical repair for transposition of the great arteries associated with ventricular septal defect and pulmonary stenosis. J Thorac Cardiovasc Surg 1984;88:365.[Abstract]



This article has been cited by other articles:


Home page
 Am. J. Roentgenol.Home page
T. C. Demos, H. V. Posniak, K. L. Pierce, M. C. Olson, and M. Muscato
Venous Anomalies of the Thorax
Am. J. Roentgenol., May 1, 2004; 182(5): 1139 - 1150.
[Full Text] [PDF]

Home page
 Circ. Res.Home page
P. J. Gruber and J. A. Epstein
Development Gone Awry: Congenital Heart Disease
Circ. Res., February 20, 2004; 94(3): 273 - 283.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Jaggers, J. J.
Right arrow Articles by Ungerleider, R. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Jaggers, J. J.
Right arrow Articles by Ungerleider, R. M.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS