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Ann Thorac Surg 2006;81:742-744
© 2006 The Society of Thoracic Surgeons

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Case report

Relief of Compromised Translocated Right Coronary Artery Blood Flow by Clockwise Rotation of the Heart in a Jatene Procedure

^a Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan, Republic of China
^b Division of Cardiovascular Surgery, Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan, Republic of China
^c Institute of Clinical Medicine, Medical College, National Cheng Kung University, Tainan, Taiwan, Republic of China

Accepted for publication November 18, 2004.

^_* Address correspondence to Dr Yang, Department of Surgery, National Cheng Kung University Hospital, 138 Sheng-Li Rd, Tainan, 704 Taiwan, Republic of China (Email: kcd56{at}mail.ncku.edu.tw).

	Abstract

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A 1.9-kg premature boy with transposition of the great arteries, ventricular septal defect, and patent ductus arteriosus received a Jatene procedure at 16 days of age. His coronary artery pattern was type A. His arteries were harvested and translocated to appropriate holes in the sinus portion of his neoaorta. Partial obstruction due to torsion of the translocated right coronary artery was suspected, because the right ventricle turned pink in color to blue and bradycardia developed when cardiopulmonary bypass support was weaned. This was relieved by clockwise rotation of the heart, and the patient recovered well. Follow-up echocardiography 6 months later revealed good biventricular function.

	Introduction

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Even though the arterial switch operation had been the standard procedure for patients with transposition of the great arteries, and excellent results have been achieved by using it in some institutions, an inappropriately translocated coronary artery with the compromised blood flow is still the most fatal patient outcome. Revision of the coronary artery anastomosis and some meticulous techniques have been proposed for its correction [1–4]. We report herein a case of transposition of the great arteries undergoing arterial switch operation, resulting in a compromised right coronary artery blood flow that was relieved by the clockwise rotation of the heart.

A 1.9-kg baby was born prematurely at the gestational age of 37 weeks. He was immediately referred to our hospital because of cyanosis. Physical examination of the neonate demonstrated central cyanosis, but no evidence of respiratory distress. Cardiovascular examination revealed a grade II/VI systolic ejection murmur at the left sternal border. Chest roentgenogram showed levocardia and mild cardiomegaly. Echocardiographic studies revealed situs solitus, dextro-transposition of the great arteries, a small ventricular septal defect, a patent foramen ovale, and a large patent ductus arteriosus. Cardiac catheterization confirmed the diagnosis, and coronary angiography showed a type A coronary artery pattern according to Yacoub's classification [5].

At 16 days of age the patient underwent surgery. The great arteries were dissected out and mobilized as usual; cardiopulmonary bypass was instituted using single arterial and single atrial cannulation. Immediately after initiating cardiopulmonary bypass, the ductus arteriosus was divided and further mobilization of both pulmonary arteries was performed. When the rectal temperature decreased below 20°C, the aorta was cross clamped and the heart was arrested with cold blood cardioplegic solution. The ascending aorta and main pulmonary artery were transected. The coronary orifices were excised as buttons with 2-mm to 4-mm margins. A 2.8-mm aortic punch was used twice to create two separate holes in the sinus portion of the neoaorta, and the lower margin of the holes was approximately at the level of the top of the neoaortic valve commissures. Next, the coronary arteries were translocated to their designated sites without rotation. After the Lecompte maneuver, the proximal neoaorta was anastomosed to the distal aorta. As a result of severe discrepancies in caliber between the proximal neoaorta and the distal aorta (2:1), the neoaorta required plication; we plicated the right lateral third of the neoaorta with interrupted sutures, ending it medially at a point that lay medial to the right coronary artery anastomosis site sagittally. A brief period of circulatory arrest was used for repair of the patent foramen ovale; the small ventricular septal defect was untouched. Cardiopulmonary bypass was resumed and rewarming started. Immediately after release of the aortic cross-clamp, the right ventricle (RV) became pinkish in color and cardiac activity gradually returned spontaneously. During rewarming, the new proximal pulmonary artery was reconstructed with a single pericardial patch (Equine pericardial patch, Edwards Lifesciences, Santa Ana, CA). After a meticulous hemostatic procedure, we tried to wean the patient from cardiopulmonary bypass. Unfortunately, when volume increased, the RV became distended and blue in color and bradycardia developed. Cardiopulmonary bypass was resumed, and RV color returned to pinkish. No problem was found in the perfusion of the translocated coronary arteries. However, the same events occurred during the second attempt to wean the patient from cardiopulmonary bypass. Then we rotated the operative table toward the left side of the patient about 30 degrees for a better view of the right coronary artery tract. Unexpectedly, the RV instantly turned pink and bradycardia disappeared. The right coronary artery was smoothly oriented. When the table was returned to neutral position, RV color became blue and bradycardia recurred. The right coronary artery looked mildly flaccid, but without kinking. Again, the operative table was rotated to the left, the patient's condition improved, and the right coronary artery seemed to straighten. We opened the left pleural cavity widely, lifted the right pericardium with two stay sutures located 0.5 cm below the pericardial edge, and tightened it to the overhung ribs equivalent to clockwise rotation of the heart about 30 degrees. Afterward, weaning from cardiopulmonary bypass was uncomplicated with table in the neutral position, and only a moderate amount of inotropic agent was used. The sternum was left open because of cardiac swelling. We tried to close the sternum 72 hours later, but failed. The sternal closure was delayed until postoperative day 9 when the patient's body weight returned to his preoperative weight. Follow-up echocardiography 6 months postoperatively showed good biventricular function.

	Comment

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Transposition of the great arteries is one of the most common cyanotic congenital heart conditions. In 1975, Jatene and colleagues [6] introduced the arterial switch procedure for babies with transposition of the great arteries. Initial surgical results were rather poor; however, after a learning period, the Jatene procedure has recently yielded very excellent results [7], and it is now accepted as the procedure of choice. The Jatene surgery was a complicated procedure during which coronary artery translocation was the most important step for a successful outcome [1].

Compromised coronary artery blood flow by any overstretching or kinking of the coronary artery could be fatal. There were many techniques such as trap-door augmentation, pericardial hood augmentation, or coronary reallocation without transfer, which had been proposed to improve surgical results [2–4].

Major obstruction to the coronary artery flow could be readily identified as soon as the aortic clamp was released, because RV color did not turn pinkish, and only rarely did spontaneous heartbeat return [1]. Revision of the transferred coronary artery is necessary in this situation. Our patient had return of a spontaneous heartbeat and pinkish RV color after aortic cross-clamping was released; however, the right coronary artery blood flow was slightly compromised when the patient was weaned from cardiopulmonary bypass. The only atypical feature came from the RV distension when any degree of volume was infused. How could such a subtle change cause a fatal outcome? We speculated on pathogenesis in a manner shown in Figure 1. In Figure 1A, the right coronary artery was oriented smoothly when the patient was on cardiopulmonary bypass. In Figure 1B, during weaning from bypass, the RV was distended and upward movement of the RV rotated the distal axis of the right coronary artery counterclockwise, which resulted in compromised right coronary artery blood flow. In Figure 1C, clockwise rotation of the heart relieved the compromised blood flow by restoring the distal axis of the right coronary artery.

View larger version (20K): [in this window] [in a new window]   Fig 1. (A) Translocated right coronary artery was aligned smoothly when the patient was on cardiopulmonary bypass; the dotted line indicates axis direction. (B) During weaning from cardiopulmonary bypass, the distended right ventricle distorted the distal axis line in a counterclockwise direction. (C) Clockwise rotation of the heart restored the distal axis of the translocated right coronary artery.

	References

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1. Goor DA, Shem-Tov A, Neufeld HN. Impeded coronary flow in anatomic correction of transposition of the great arteriesprevention, detection, and management. J Thorac Cardiovasc Surg 1982;83:747-754.[Abstract]
2. Brawn WJ, Mee RB. Early results for anatomic correction of transposition of the great arteries and for double-outlet right ventricle with subpulmonary ventricular septal defect J Thorac Cardiovasc Surg 1988;95:230-238.[Abstract]
3. Parry AJ, Thurm M, Hanley FL. The use of ‘pericardial hoods' for maintaining exact coronary artery geometry in the arterial switch operation with complex coronary anatomy Eur J Cardiothorac Surg 1999;15:159-165.[Abstract/Free Full Text]
4. Murthy KS, Coelho R, Kulkarni S, Ninan B, Cherian KM. Arterial switch operation without coronary translocationmid-term results. Asian Cardiovasc Thorac Ann 2004;12:38-40.[Abstract/Free Full Text]
5. Yacoub MH, Radley-Smith R. Anatomy of the coronary arteries in transposition of the great arteries and methods for their transfer in anatomical correction Thorax 1978;33:418-424.[Abstract/Free Full Text]
6. Jatene AD, Fontes VF, Paulista PP, Souza LC, Neger F, Galantier M, Sousa JE. Anatomic correction of transposition of the great vessels J Thorac Cardiovasc Surg 1976;72:364-370.[Abstract]
7. Pretre R, Tamisier D, Bonhoeffer P, et al. Results of the arterial switch operation in neonates with transposed great arteries Lancet 2001;357:1826-1830.[Medline]

This article has been cited by other articles:

				M. Ugurlucan, B. Surmen, O. A. Sayin, E. Nargileci, and E. Tireli Coronary Reimplantation During Jatene Procedure Ann. Thorac. Surg., January 1, 2007; 83(1): 356 - 357. [Full Text] [PDF]

				C.-D. Kan and Y.-J. Yang Reply. Ann. Thorac. Surg., January 1, 2007; 83(1): 357 - 358. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yu-Jen Yang Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kan, C.-D. Articles by Yang, Y.-J. Search for Related Content PubMed PubMed Citation Articles by Kan, C.-D. Articles by Yang, Y.-J. Related Collections Congenital - cyanotic