Ann Thorac Surg 2009;87:1967-1968. doi:10.1016/j.athoracsur.2008.09.044
© 2009 The Society of Thoracic Surgeons
How To Do It
Arterial Switch Operation With a Single Coronary Artery: The Autograft Concept
Loïc Macé, MD, PhDa,*,
Fabrice Vanhuyse, MDa,
Jean-Marc Jellimann, MDa,
Dany Youssef, MDb,
Anne Moulin-Zinsch, MDb,
Jean-Paul Lethor, MDb,
François Marçon, MDb
a Department of Cardiovascular and Pediatric Cardiac Surgery, Nancy Hospital, Henri Poincaré University, Nancy, France
b Department of Pediatric Cardiology, Nancy Hospital, Henri Poincaré University, Nancy, France
Accepted for publication September 11, 2008.
* Address correspondence to Dr Macé, Département de Chirurgie Cardiovasculaire et Cardiaque Pédiatrique, CHU de Nancy, Hôpitaux de Brabois, Rue du morvan, 54511 Vandoeuvre Cedex, France (Email: l.mace{at}chu-nancy.fr).
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Abstract
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A single coronary artery, especially if associated with anterior looping, remains a risk factor when performing an arterial switch operation for transposition of the great arteries. In such a situation, to avoid the risk of overstretching, we used a modification of the aortic autograft concept to transfer the single coronary artery, resulting in a tension-free relocation.
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Introduction
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Single coronary anatomy presents technical challenges to the surgeon undertaking the arterial switch operation for transposition of the great arteries [1]. However, in the current era, it should be possible to minimize coronary artery pattern-related risks [1, 2]. Nevertheless, an anterior looping [3] or a commissural malalignment [4], both increasing the distance between the initial coronary artery location and its relocation in the neoaortic root, remain additional risk factors that may lead to an overstretching of the single coronary artery. In such situations, alternative procedures have been described to decrease the likelihood of postoperative myocardial ischemia: (1) large mobilization and reimplantation of the coronary button into a previously anastomosed neoaorta [2, 3], (2) use of the trap-door technique associated with pericardial or pulmonary artery hoods [5], (3) in situ coronary artery relocation [6], and (4) tube reconstruction of the coronary artery using the largest button of the aortic sinus of Valsalva wall [4] or autologous pericardium [1]. However, the abnormal course of the single coronary artery with anterior looping, even after an effective transfer, may still be at risk of stretching or compression, particularly during high-output states [3].
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Technique
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A 3.1 kg male neonate was referred to our institution with an antenatal diagnosis of transposition of the great arteries with intact ventricular septum {S,D,L} [7]. A balloon atrial septostomy was performed soon after birth. Right single coronary artery, with anterior looping (ie, left main coronary artery anterior to the aorta) and commissural malalignment was suspected on preoperative echocardiography.
At operation, on the day 14 of life, the coronary artery pattern was confirmed (IIRLCx, with anterior left course; sinus II refers to the right nonfacing sinus). The aorta was anterior and leftward in relation to the pulmonary artery (Fig 1A). Standard cardiopulmonary bypass was established, and the temperature was lowered to 26°C. The patent ductus arteriosus was divided and the pulmonary arteries were widely mobilized. Myocardial protection was achieved using cold blood anterograde cardioplegia. The aorta was transected a few millimeters above the sinotubular junction. The pulmonary trunk was divided just proximal to its bifurcation, and the Lecompte maneuver was performed. There was a major commissural malalignment of the sinus-facing of the aortic valve [4]. An aortic autograft was harvested, as previously described by Metras and colleagues [8]. It was longitudinally opened and trimmed in its inner curvature. We fashioned a tube by wrapping the aorta over a Hegar dilator to obtain a cylindrical shape and to reduce its diameter to 5 mm (Fig 1B). The right single coronary artery stem was detached from the aortic root and it was slightly mobilized. We then anastomosed this aorta tube end-to-end to the right coronary ostium. We placed its inner curvature toward the base of the heart. A hole in the sinus facing of the neoaortic root was done, using a 4.5 mm aortic punch. The autograft was anastomosed in an end-to-side fashion to the neo-aortic root, resulting in tension-free coronary artery relocation (Fig 1B). All sutures were performed using 7-0 absorbable monofilaments. The neoaorta was sutured and cardioplegic injection into the neoaortic root demonstrated an adequate morphology of the coronary artery anatomy. The pulmonary trunk was repaired with a large U-shaped patch of autologous pericardium. The remainder of the operation was conducted in the usual manner.
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Fig 1. Technique of operation. (A) Aspect of the single coronary artery and harvesting of the aortic autograft (dotted lines). (B) Reshaping of the autograft to the appropriate diameter using a 5-mm diameter Hegar dilator, and final aspect of the single coronary artery reimplantation.
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The postoperative course was uneventful, without any evidence of coronary artery distortion or myocardial ischemia. The patient was discharged from the hospital after 17 days. At 6 months post-procedure, he continues to do well, without medication, except daily aspirin. Color-coded Doppler echocardiography confirmed an excellent coronary artery patency without neoaortic valve regurgitation (Fig 2).
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Fig 2. Postoperative echocardiography demonstrating autograft implantation (arrows). (A) Two-dimensional aspect in long axis view. (B) Color-coded laminar flow within the graft.
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Comment
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The arterial switch operation is currently the procedure of choice for surgical correction of transposition of the great arteries. For most coronary patterns, direct reimplantation is the technique of choice [1, 2]. Nevertheless, the rarer coronary branching patterns, including single coronary artery with anterior looping [3], still represent a greater technical challenge. Moreover, our patient had the transposition of the great arteries {S,D,L} anatomy, which would have made for a stretch if direct reimplantation had been attempted. An approach that ensures exact persistence of coronary artery anatomy would be less likely to cause coronary insufficiency and may reduce the incidence of long-term coronary artery abnormalities [5], even if the abnormal anterior course of the coronary artery is not a correctable feature [3].
In such situations, the main advantages of the modified autograft concept are: (1) to eliminate the risk of overstretching while preserving the growth potential due to the use of autologous arterial tissue, and (2) to avoid an extensive dissection of the initial epicardial course of the coronary arteries, which could lead to scarring or fibrosis. However, long-term outcome of this procedure on the coronary artery patency remains to be assessed.
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References
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- Scheule AM, Jonas RA. Management of transposition of the great arteries with single coronary artery Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2001;4:34-57.[Medline]
- Qamar ZA, Goldberg CS, Devaney EJ, Bove EL, Ohye RG. Current risks factors and outcomes for the arterial switch operation Ann Thorac Surg 2007;84:871-879.[Abstract/Free Full Text]
- Shukla V, Freedom RM, Black, MD. Single coronary artery and complete transposition of the great arteries: A technical challenge resolved? Ann Thorac Surg 2000;69:568-571.[Abstract/Free Full Text]
- Kim SJ, Kim WH, Lim C, Oh SS, Kim YM. Commissural malalignment of aortic-pulmonary sinus in complete transposition of great arteries Ann Thorac Surg 2003;76:1906-1910.[Abstract/Free Full Text]
- 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]
- Murthy KS, Coelho R, Kulkarni S, Ninan B, Cherian KM. Arterial switch operation with in situ coronary reallocation for transposition of great arteries with single coronary artery Eur J Cardiothorac Surg 2004;25:246-249.[Abstract/Free Full Text]
- 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]
- Metras D, Kreitmann B, Riberi A, et al. Extending the concept of the autograft for complete repair of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction: A report of ten cases of a modified procedure J Thorac Cardiovasc Surg 1997;114:746-754.[Abstract/Free Full Text]
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Abstract
Introduction
