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Arterial switch operation with a single coronary artery
Albertus M Scheule1, David Zurakowski, Elizabeth D Blume
1Department of Cardiac Surgery, Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
Insights
The arterial switch operation is safe for patients with a single coronary artery, regardless of anatomy. However, specific coronary patterns increase the risk of reintervention after this procedure.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Congenital Heart Disease
Background:
- The arterial switch operation (ASO) is a standard treatment for transposition of the great arteries.
- Patients with a single coronary artery present unique challenges during ASO.
- Understanding the impact of coronary patterns is crucial for optimizing ASO outcomes.
Purpose of the Study:
- To evaluate how coronary artery patterns influence survival and reintervention rates in patients undergoing ASO with a single coronary artery.
Main Methods:
- Retrospective analysis of 53 patients with single coronary arteries who underwent ASO (1983-2000).
- Follow-up data collected for 40 long-term survivors (mean 7.3 years).
- Analysis of survival and reintervention based on specific coronary artery anatomy.
Main Results:
- Overall survival was 87% at 1, 5, and 10 years post-ASO.
- Patients with a single right coronary artery had higher mortality, particularly before 1992.
- Higher reintervention rates were observed in patients with a single left ostium and right coronary artery anterior to the aorta.
Conclusions:
- ASO can be performed safely in patients with single coronary arteries, irrespective of anatomy in the current era.
- Specific coronary patterns, such as single left ostium with RCA anterior to aorta, are associated with increased reintervention risk.
- Long-term outcomes are favorable, but careful consideration of coronary anatomy is important for risk stratification.
Objective:
Our purpose was to evaluate the impact of coronary pattern on survival and reintervention in patients who underwent the arterial switch operation with a single coronary artery.
Methods:
We conducted a retrospective analysis of 53 patients with a single coronary artery who underwent the arterial switch operation between 1983 and 2000 at Children's Hospital Boston. Recent follow-up information was obtained for 40 of the 46 long-term survivors (mean follow-up 7.3 +/- 4.5 years).
Results:
Thirty-five patients had a single right coronary artery, with the left coronary artery posterior to the pulmonary artery in 27. Eighteen patients had a single left coronary artery (16 with the right coronary artery anterior to the aorta). Six of 7 total patients who died had a single right coronary artery; all died before 1992. There were 5 early deaths, all with a single right coronary artery, with 4 deaths due to coronary malperfusion. Survivals for all patients were 91% at 6 months and 87% at 1, 5, and 10 years after the arterial switch operation. Survival figures were lower for patients having a single right ostium with the left main coronary artery posterior to the pulmonary artery compared with all other subtypes (P =.02, log-rank test). Seven patients had reintervention, 4 because of right ventricular outflow tract obstruction, 1 for heart transplantation, 1 for mitral valve repair and 1 for pacemaker implantation. Freedom from reintervention for all patients was 96% at 6 months, 92% at 1 year, 86% at 5 years, and 82% at 10 years after the arterial switch operation, with lower rates for patients having a single left ostium with the right coronary artery anterior to the aorta (P =.0003, log-rank test).
Conclusions:
In the current era, the arterial switch operation with a single coronary artery can be performed safely irrespective of the coronary anatomy. Risk of reintervention is higher in patients having a single left ostium with the right coronary artery anterior to the aorta.