Ann Thorac Surg 2005;80:636-641
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
Arterial Switch Operation for Transposition of the Great Arteries With Coronary Arteries From a Single Aortic Sinus
Si Chan Sung, MD
a
,
Yun Hee Chang, MD
a
,
*
,
Hyoung Doo Lee, MD
b
,
Siho Kim, MD
c
,
Jong Soo Woo, MD
c
,
Young Seok Lee, MD
d
a Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Busan, Korea
b Department of Pediatrics, Pusan National University Hospital, Busan, Korea
c Department of Thoracic and Cardiovascular Surgery, DongA University Hospital, Busan, Korea
d Department of Pediatrics, DongA University Hospital, Busan, Korea
Accepted for publication February 9, 2005.
* Address reprint requests to Dr Chang, Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, 1-10, Ami-dong, Seo-gu, Busan, 602-061, Korea (South) (Email: drcrista{at}empal.com).
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Abstract
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BACKGROUND: The reimplantation of the coronary arteries from a single aortic sinus (single sinus coronary artery) in an arterial switch operation remains a technically challenging procedure. The technique of coronary transfer in this situation should be individualized depending on coronary ostial anatomy. We reviewed our techniques of coronary reimplantation with early and midterm results.
METHODS: Among 103 patients who underwent arterial switch operations from March 1994 to June 2004, 16 (15.5%) had single sinus coronary artery (median age, 9 days; mean body weight, 3.5 kg). Fourteen patients (14/16, 87.5%) had coronary arteries from right facing sinus (sinus 2). Of these 14 patients, 11 had separate ostia including intramural course of the left coronary artery (n = 9) and 3 had single ostium. Two patients (2/16, 12.5%) had coronary arteries from left facing sinus (sinus 1) with single ostium. Aortic arch obstruction was associated in 5 patients.
RESULTS: All 5 single sinus coronary arteries with single ostium were reimplanted with the trap-door technique. Of the 11 patients with separate ostia, 8 underwent coronary transfer with the aortocoronary flap technique and 3 with the double-button technique. Two of the 3 patients who underwent the double-button technique required left coronary artery bypass using left subclavian artery free graft as the salvaging procedure. There was one early death (1/16, 6.3%), which occurred during our earlier experience, in a patient who had arch anomaly and intramural left coronary artery. There was no late death. All but one patient had good ventricular function.
CONCLUSIONS: All single sinus coronary artery with single ostium can be transferred with the trap-door technique with excellent results. The aortocoronary flap technique in those with separate ostia with or without intramural left coronary artery may be a good option. However, reimplantation of the intramural left coronary artery using separate coronary buttons should be performed with great care.
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Introduction
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Coronary arteries arising from a single aortic sinus, termed "single sinus coronary artery" (SSCA) in this article, have been known as an important risk factor in the arterial switch operation (ASO) even though various surgical techniques have been developed to tackle this anatomic anomaly [1–8]. The SSCA can have single, double, or, very rarely, triple ostia. Additionally, they frequently have various unusual epicardial courses, such as one coronary branch posterior to the pulmonary artery, anterior to the aorta, or between the great arteries. In these situations, reimplantation using a conventional coronary transfer technique can cause kinking or overstretching of one of both coronary arteries at their origin while rotating the coronary button. Also, it is technically demanding or sometimes even impossible to make sizable coronary cuffs. High incidence of intramural course of the left coronary artery adds to these difficulties. We have managed these complex coronary arteries with individualized techniques such as the trap-door technique for SSCA with single ostium, and the aortocoronary flap or double-button technique for those with separate coronary ostia. We evaluated the early and midterm results of the arterial switch operation for the patient with SSCA.
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Material and Methods
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From March 1994 to June 2004, 103 patients underwent ASO by one surgeon at two institutions. Sixteen patients (16/103, 15.5%) had coronary arteries arising from a single aortic sinus. There were 13 males and 3 females. The age at operation ranged from 5 to 39 days (median age, 9 days) and body weight ranged from 2.9 to 4.7 kg (mean weight, 3.5 ± 0.3 kg). Of these patients, transposition of the great arteries (TGA) with intact ventricular septum was diagnosed in 8 patients, TGA with ventricular septal defect (VSD) in 4, and Taussig-Bing (TB) anomaly in 4. Aortic arch anomaly was found in 5 patients (1 in TGA with VSD, 4 in TB anomaly). As the preoperative management, balloon atrial septostomy was performed in 9 patients, infusion of prostaglandin E1 in 13, and mechanical ventilation in 5.
Coronary Artery Anatomy
The coronary artery anatomy is shown in Figure 1. Fourteen patients (14/16, 87.5%) had coronary arteries from right facing sinus (sinus 2) and 2 (2/16, 12.5%) from left facing sinus (sinus 1). Eleven of 14 patients with coronary arteries from sinus 2 had separate coronary ostia. All these patients had a coronary artery between the two great vessels (left coronary artery in 8 patients, left anterior descending artery in 2, and right coronary artery in 1) with intramural course in 9 patients. Of the three patients who had single ostium at sinus 2, two had left coronary artery anterior to the aorta and the other had it posterior to the main pulmonary artery (MPA). The two patients with coronary arteries from sinus 1 had single ostium. One had the right coronary artery between the great vessels and the other had it anterior to the aorta.
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Fig 1. The relations of great arteries and the patterns of coronary artery distribution in single sinus coronary artery. (Cx = left circumflex artery; L = left anterior descending artery; R = right coronary artery.)
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Surgical Technique
Before the heart was arrested, the great arteries were dissected and the right and left pulmonary arteries were widely mobilized for the later Lecompte maneuver. The trap-door technique was applied in coronary relocation for all 5 patients with a single coronary ostium (Fig 2A). After transection of both great arteries, the single coronary artery was removed from its aortic sinus in the U-shaped button. The proximal MPA stump was anastomosed to the transected distal aorta after the Lecompte maneuver. While the aorta was distended by releasing the aorta cross-clamp, a marking suture was placed at the point to which the coronary artery will be transferred. The trap-door incision was made at the marked point and then the coronary button was transferred. In three earlier cases, the single coronary artery was transferred to the MPA using the open trap-door technique before neoaortic reconstruction. The neopulmonary artery was then reconstructed using rectangular-shaped fresh autologous pericardium. In 8 patients with separate ostia, the aortocoronary flap technique was applied for coronary transfer (Fig 2B). After transecting the aorta, we first partially detached the posterior commissure of the aorta if necessary (n = 6) and then removed the sufficient aortic wall including the separate ostia from their aortic sinus as a single disc. The MPA was transected and the anterior wall of the MPA was excised into the small rectangular shape at the corresponding level of the superior border of the coronary disc. To avoid torsion or excessive rotation, the aortocoronary flap was left in situ and was sutured along its cephalic border to a counterborder in the anterior wall of the proximal neoaorta. The aortocoronary flap was roofed with bovine pericardium (n = 2), fresh autologous pericardium (n = 4), or glutaraldehyde-fixed autologous pericardium (n = 2), which was then sutured to the distal ascending aorta to render coronary blood flow. The neopulmonary artery was then reconstructed in the usual manner after reapproximation of the detached commissure. We did not manipulate the ostium of the intramural coronary artery in any patient.
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Fig 2. Coronary transfer techniques for single sinus coronary artery: (A) trap-door technique; (B) aortocoronary flap technique; (C) double-button technique.
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In 3 patients with separate ostia and intramural left coronary artery, we attempted the double-button technique generally used in the usual coronary artery pattern (Fig. 2C). The posterior commissure of the aortic valve was partially detached and then the separate ostia were excised as a single disc, which was divided into two coronary buttons. Afterwards, the coronary artery buttons were then translocated to the reconstructed neoaorta using the trap-door technique after the Lecompte maneuver.
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Results
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All 5 patients with single ostium were successfully managed with the trap-door technique, irrespective of the epicardial courses of coronary arteries. Six of 8 patients who had separate ostia underwent the aortocoronary flap technique without any intraoperative event. One patient required intraoperative revision of an aortocoronary flap due to bleeding. Another patient, the first case of our series, had an injury of the intramural left coronary artery during mobilization, which was repaired. Two of 3 patients who underwent the double-button technique required bypass grafting to the left coronary artery using left subclavian artery free graft due to technical failure (Fig. 3). One of these 2 patients had inadvertent injury of the intramural left coronary artery during its mobilization and underwent left main coronary artery bypass after reimplantation of the right coronary artery. For the other patient, we had judged that the division of separate ostia was possible and attempted the trap-door technique for coronary transfer. However, bypass weaning was very difficult and progressive deterioration of left ventricle contractility was observed. We detected acute angle of the left coronary artery at the transferred site and bypassed it using left subclavian artery free graft (Fig. 4).
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Fig 4. Postoperative outcomes. (LCA = left coronary artery; LSCA = left subclavian artery; SSCA = single sinus coronary artery.)
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Postoperative Outcome
The postoperative outcome is shown in Figure 4. There was one early death in the patients managed by the aortocoronary flap technique (1/16, 6.3%). This patient (the first case of our study), who was diagnosed as TGA with VSD and coarctation of aorta, had an intramural left coronary artery and a very small aortic annulus. This patient required enlargement of the aortic annulus using a small bovine pericardial patch to prevent neopulmonary valvular stenosis. However, the patient could not be weaned from bypass due to myocardial failure. We suspected the cause was left coronary artery injury during its mobilization related to inexperience. During the same period, our overall operative mortality of ASO was 16.5% (17/103). The most important risk factor as evaluated by multivariate logistic regression analysis was the combination of aortic arch anomaly. Eight of 17 patients with aortic arch anomaly (47.1%) died at the early postoperative period. The mortality of the patients with SSCA was lower than the overall mortality (6.3% vs 16.5%).
Follow-up was completed for all operative survivors. Median follow-up duration was 39.6 months (range, 4.6 months to 9.6 years). Interval echocardiogram was the follow-up study of choice and coronary angiography was not routinely performed. Postoperative coronary angiography was performed in 4 patients; in a patient with ventricular dysfunction, in two patients who underwent left coronary bypass using left subclavian artery free graft, and in a remaining patient with successful coronary transfer using the double-button technique. All of these patients had patent coronary arteries (Figs 5A-5D). There was no development of new wall motion abnormality. Two patients required reintervention. A patient with Taussig-Bing anomaly and interrupted aortic arch, and who underwent coronary artery transfer using the aortocoronary flap technique, had decreased ventricle function. At coronary angiography coronary artery perfusion was normal, but arch stenosis at the anastomotic site was detected. Despite successful balloon angioplasty, ventricular function was not completely restored. The other patient who underwent bypass grafting to the left coronary artery using left subclavian artery free graft required cardiac catheterization for balloon angioplasty of the right pulmonary artery. His coronary angiography also revealed intact left coronary artery system. There was one reoperation for relief of distal MPA stenosis in a patient who had successful coronary transfer using the double-button technique.
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Fig 5. Postoperative coronary angiogram of four patients showed patent both coronary artery systems: (A) aortocoronary flap technique; (B) and (C) left coronary bypass using left subclavian free graft; (D) double-button technique.
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There was no electrocardiographic evidence suggesting myocardial ischemia in any of the surviving patients. At the latest echocardiograms, ventricular wall motion abnormalities were detected in only the one patient described earlier. There was no aortic regurgitation greater than mild. Among the patients who underwent the aortocoronary flap technique, a mild pressure gradient (23 mm Hg) across the pulmonary valve was detected in only one patient diagnosed as TGA with VSD and coarctation of aorta. No significant pulmonary valvular regurgitation was observed in any patient and there was no late death.
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Comment
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The most critical step in ASO is the reimplantation of coronary arteries. When the coronary arteries originate from a single aortic sinus, with or without multiple ostia, most of them have unusual epicardial or intramural courses making the technique of coronary transfer even more challenging. In the past, some surgeons suggested that ASO was not the procedure of choice in patients with single coronary artery or intramural course between two great arteries [9, 10]. However, in the current era, it has been generally accepted that all coronary artery patterns in TGA can be translocated.
The reported incidence of single coronary artery varied from 4.5% to 13.3%. Our series has a somewhat higher incidence of 15.5%. One reason for the widely varied reported incidence of single coronary artery is its confusing definition in the literature. Some authors included all coronary arteries from a single aortic sinus regardless of the number of ostium [4, 8, 11], while others included only those with a single ostium [[3, 12]. To avoid this confusion, we used the term "single sinus coronary artery" instead of "single coronary artery" in this article. In the literature [4, 12–14], the SSCA from right facing sinus was reported to be three times more common than the SSCA from left facing sinus (sinus 2). However, it was seven times more common in our series. Eleven of our 16 SSCA had separate ostia, and 9 of these 11 had intramural left coronary arteries. Six of 9 patients with intramural left coronary arteries had anterior and posterior great artery relations. The incidence of intramural course of the SSCA in our study was quite high compared to other reports [11–14]. The reason for such high incidences of the SSCA and intramural left coronary artery is not clear. We tried to look for evidence of ethnic difference in the literature but few data are available.
Many techniques have been described for reimplantation of the SSCA to the neoaortic root. For the SSCA with single coronary ostium, the trap-door technique has been used by many surgeons with variable results. Parry and colleagues [5] used a pericardial hood for maintaining coronary artery geometry and emphasized natural geometry of the transferred coronary artery for a good long-term result. They successfully used this method in 4 of 5 patients who required revision of inadequately transferred coronary arteries. However, the fate of the pericardial patch, the possibility of thrombosis in the pericardial hood, and the possible compression of the pericardial hood by the neopulmonary artery are some of the concerns regarding this technique. A short autologous pericardial tube was advocated by some surgeons for difficult cases of SSCA arising from the left aortic sinus [12]. In our limited experience, all SSCA with single ostium in our series could be transferred without any problem.
Transferring the SSCA with separate ostia may be more complicated. Basically two methods have been developed. One method maintains the geometry of the coronary artery and renders coronary blood flow through a paraaortic channel roofed by a patch material or autologous tissue. The other method proceeds in the usual manner after making separate buttons by dividing the single coronary disc between the two coronary arteries. Each technique has its own theoretical advantages and disadvantages.
The main advantage of the technique using aortocoronary flap is to reduce the possibility of kinking, torsion, or overstretching of the coronary arteries by maintaining the geometry of the coronary arteries in situ. However, this technique could cause potential myocardial ischemia due to compression between the great arteries as the children grow up. Sudden death is known to happen among young adults with an abnormal course of their coronary arteries usually found between great arteries [15]. Moreover, problems caused by foreign patch materials used in this technique should be of concern even though some techniques use autologous tissues [6, 7]. In addition, the possibility of further narrowing of the small neopulmonary valve opening by the paraaortic channel should not be neglected.
The double-button technique is more technically demanding because of an insufficient cuff for the coronary artery button, and it frequently leads to more angled rotation of one of the coronary arteries. However, in contrast to the technique using the aortocoronary flap, there is no potential nidus of a coronary artery problem caused by their abnormal location, no need for patch material, and no space occupying problem of the neopulmonary valve. Asou and colleagues [8] reported excellent results with this technique in the cases with the intramural coronary arteries, but we have had a different experience. We attempted this procedure in 3 patients and we met substantial technical problems in 2 patients. Fortunately, we overcame the dangerous situations with free grafting to the left coronary artery using the left subclavian artery. We have, therefore, become somewhat reluctant to use the double-button technique. We are now exclusively using the aortocoronary flap technique for SSCA with separate coronary ostia unless each ostium of coronary arteries could be separated with enough cuff tissue.
We have also learned that the technique of left subclavian artery free grafting could be an excellent rescue procedure for failed coronary reimplantation even though there were some reports using the internal mammary artery [16–18].
Our experience of aortocoronary flap technique remains excellent. Six of 7 survivors who underwent this technique had excellent ventricular function up to 63 months of follow-up. A patient with arch anomaly, who required intraoperative revision of the aortocoronary flap due to bleeding, presented depressed ventricular function even though he had patent left coronary artery at coronary arteriography. We suspect that the patient’s depressed cardiac function was caused by inadequate myocardial protection during the long ischemic time. So far, there is no patient with sudden death or newly developed myocardial ischemia although long-term follow-up is mandatory.
In conclusion, all SSCA with single ostium can be transferred with the trap-door technique with excellent results. For those with separate ostia, with or without intramural left coronary artery, the aortocoronary flap technique can be a good option although close follow-up is required.
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References
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Abstract
Introduction
