Ann Thorac Surg 2009;88:e44. doi:10.1016/j.athoracsur.2009.07.065
© 2009 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Unusual "Single Coronary" Anatomy in Transposition of the Great Arteries
Giovanni Battista Luciani, MDa,*,
Gianluigi Franchi, MDb,
Giuseppe Faggian, MDa,b,
Alessandro Mazzucco, MDa,b
a Division of Cardiac Surgery, University of Verona, Verona, Italy
b Division of Anesthesiology, University of Verona, Verona, Italy
* Address correspondence to Dr Luciani, Division of Cardiac Surgery, University of Verona, OCM Piazzale Stefani 1, Verona, 37126, Italy (Email: giovanni.luciani{at}univr.it).
A 7-day-old full-term neonate with prenatal diagnosis of {S, D, D} transposition with intact ventricular septum underwent balloon atrial septostomy at birth. Suspicion of single coronary ostium from the right hand sinus (two RLCx [two right-left anterior descending-circumflex arteries]) emerged as seen on a transthoracic two-dimensional echocardiogram and was confirmed during an intraoperative transesophageal echocardiography. Unexpectedly, a previously unreported, far more complex, coronary anatomy was found during the operation (two Cx [circumflex]; aorta LR [left anterior descending-right coronaries]). In detail (Fig 1A), the aorta (Ao) was anterior and to the right of the pulmonary artery (pulmonary artery band, [asterisk]; ductus arteriosus [DA]). An extremely high origin of a main stem coronary artery from the distal ascending aorta was identified, well above the bifurcation of the main pulmonary artery and at the level of the ductus arteriosus, which coursed parallel to the ascending aorta toward the aortic root. The main stem branched into the right coronary artery (RCA) and the left anterior descending coronary artery (LAD), in front, yet outside of the left hand sinus. The RCA further divided into two large conal branches, whereas the LAD followed a usual course (anterior interventricular groove). The circumflex (Cx) coronary artery was identified as stemming separately from the right hand sinus (Fig 1B) and then taking a retropulmonary course to reach the left atrioventricular groove. Whereas high take-off of coronary arteries, at or slightly above the sinotubular junction, has been described in at least 5% of patients with transposition, this has invariably been associated with intramural coronaries [1]. Unique to the present anatomic variant are the exaggerated high origin and the totally extramural course of the coronary arterial trunk. Arterial switch repair was deemed at high risk of coronary trunk kinking or compression, or both, by the left pulmonary artery branch after the Lecompte maneuver [1, 2]. Therefore, the neonate underwent atrial septectomy and pulmonary artery banding as a staged approach to repair (Nikaidoh or main stem fenestration onto pulmonary root) in later infancy [3]. Preoperative echocardiographic identification of a single coronary ostium does not rule out rare anatomic patterns not amenable to uneventful arterial switch repair [1, 2, 4]. Advanced cardiovascular imaging (angiography, magnetic resonance imaging or multi-slice computed tomographic scan) should be considered in case of single coronary anatomy.
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References
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- Pasquali SK, Hasselblad V, Li JS, Kong DF, Sanders SP. Coronary artery pattern and outcome of arterial switch operation for transposition of the great arteries: a meta-analysis Circulation 2002;106:2575-2580.[Abstract/Free Full Text]
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- Pasquini L, Sanders SP, Parness IA, et al. Coronary echocardiography in 406 patients with d-loop transposition of the great arteries J Am Coll Cardiol 1994;24:763-768.[Abstract]
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