Ann Thorac Surg 2007;83:357-358
© 2007 The Society of Thoracic Surgeons
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Chung-Dann Kan, MDa,
Yu-Jen Yang, MD, PhDb
a Department of Surgery, National Cheng Kung University Hospital, Institute of Clinical Medicine and Cardiovascular Research Center, Medical College, National Cheng Kung University, 138 Sheng-Li Road, Tainan, 704 Taiwan, Republic of China
b Department of Surgery, National Cheng Kung University Hospital, Cardiovascular Research Center, Medical College, National Cheng Kung University, 138 Sheng-Li Road, Tainan, 704 Taiwan, Republic of China
(Email: kcd56{at}mail.ncku.edu.tw; yangyj{at}mail.ncku.edu.tw).
To the Editor:
We appreciate the interest of Ugurlucan and colleagues [1] in our recent report [2]. Regarding their first question about the effect of clockwise rotation on the left coronary artery anatomy, we, frankly speaking, do not have a definitive answer, especially for an in-vivo condition. However, we would like to express our rationale for the approach we took with a simple geometric-mathematical method (Fig 1). Looking at the coronal section of the neoaorta with the two coronary artery implantations, consider the radius of the circle (representing the neoaorta) as "1," "X" as the fulcrum point, "A" as the position of the orifice of the right coronary artery (RCA), and "B" as the position of the orifice of the left coronary artery (LCA). When the circle is rotated clockwise at point "X" by approximately 30 degrees, the RCA orifice moves upward from "A" to "C," whereas the LCA orifice moves horizontally a shorter distance (0.517/0.897 = 57%) from "B" to "D." The change in the height of the position of the RCA orifice is nearly 5 times (0.634/0.134) that of the LCA orifice. So if the depicted figure realistically simulates the clinical situation, we can hypothesize that the effects of a clockwise rotation of the heart on the LCA anatomy results in a smaller horizontal displacement of the LCA orifice. Furthermore, the change in the height of the LCA orifice is even less (or changes none at all) when compared with that of the RCA orifice. This explains why the rotation effect on the LCA blood flow would be minimal, if any, as evidenced by there being no change in the segment elevations (ST) segment of the electrocardiographic monitor and good left ventricular contraction.
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Fig 1. Geometric-mathematical method demonstrating the rationale of using clockwise rotation of the heart.
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Regarding the second question of Dr Ugurlucan and colleagues [1] concerning whether the delayed sternal wound closure was related to LCA insufficiency, we note that this premature baby had severe capillary leakage after the prolonged bypass procedure. Fortunately he had a diuretic phase 48 hours after the operation. Although we attempted to close the sternal wound within 72 hours of the operation, heart swelling had not subsided sufficiently so as to do so. To know with certainty if the swelling was due to the secondary myocardial edema ischemia was difficult, but there were several indirect signs that led us to conclude that the heart swelling did not result from the myocardial ischemia. These indicators were that using a higher than normal central venous filling pressure to maintain adequate arterial pressure was unnecessary [3], that the inotropic agents tapered very simply and quickly, and that there were no abnormal findings in the electrocardiographic and echocardiographic studies.
We completely agree that accurate coronary reimplantation is the most important component of the arterial switch operation. Although we initially considered that the baby may benefit by a translocation of the coronary orifice to a higher location, we would have had to anastomose the coronary orifice to the sutured line of the neoaorta where we had done the plication, thereby jeopardizing it, as well as prolong the operation time even more. For these reasons, we chose the simpler method of using the pericardium to rotate the coronary artery. We also considered the findings of several authors who advocate positioning the coronary reimplantation after neoaortic reconstruction yields better results in a Jatene operation [4, 5]. This is the method we have used with several of our patients with encouraging results.
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References
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- Ugurlucan M, Surmen B, Sayin OA, et al. Coronary reimplantation during Jatene procedure (letter) Ann Thorac Surg 2007;83:356-357.[Free Full Text]
- Kan CD, Roan JN, Wu JM, Yang YJ. Relief of compromised translocated right coronary artery blood flow by clockwise rotation of the heart in a Jatene procedure Ann Thorac Surg 2006;81:742-744.[Abstract/Free Full Text]
- Jonas RA. Transposition of the great arteriesIn: Jonas RA, DiNardo J, Laussen PC, et al. editors. Comprehensive surgical management of congenital heart disease. London: Arnold; 2004. pp. 256-278.
- Brown JW, Park HJ, Turrentine MW. Arterial switch operation: factors impacting survival in the current era Ann Thorac Surg 2001;71:1978-1984.[Abstract/Free Full Text]
- Chang YH, Sung SC, Lee HD, Kim S, Woo JS, Lee YS. Coronary reimplantation after neoaortic reconstruction can yield better result in arterial switch operation: comparison with open trap door technique Ann Thorac Surg 2005;80:1634-1640.[Abstract/Free Full Text]
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Coronary Reimplantation During Jatene Procedure
- Murat Ugurlucan, Benguhan Surmen, Omer Ali Sayin, Erol Nargileci, and Emin Tireli
Ann. Thorac. Surg. 2007 83: 356-357.
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