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Complex coronary arterial anatomy in transposition of the great arteries. Arterial switch procedure without coronary
1Wessex Cardiothoracic Centre, Southampton General Hospital, Shirley, United Kingdom.
Insights
This study presents a novel surgical technique for complex transposition of the great arteries, avoiding coronary artery relocation to prevent myocardial ischemia in neonates. The method ensures adequate coronary perfusion, leading to successful outcomes.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Congenital Heart Disease
Background:
- Anatomic correction of transposition of the great arteries (TGA) poses challenges, particularly regarding coronary artery translocation.
- Myocardial ischemia due to coronary relocation difficulties is a major cause of morbidity and mortality in TGA repair, especially with complex coronary anatomy.
Observation:
- Two neonates with TGA and intact ventricular septum presented with complex coronary anatomy, featuring multiple ostia originating from sinus 1, one severely eccentric.
- A modified anatomic switch procedure was performed, omitting direct coronary artery relocation.
Findings:
- The technique utilized an aortopulmonary fenestration with a bovine pericardial tunnel to ensure coronary artery perfusion from the neoaorta.
- An additional pericardial patch was applied to the neopulmonary artery.
- Both infants experienced uneventful recoveries without myocardial ischemia, though a mild pulmonary artery gradient was noted.
Implications:
- This surgical approach may be a viable alternative for TGA patients with complex coronary anatomy where translocation is technically challenging.
- It offers a strategy to mitigate perioperative risks associated with coronary artery manipulation in complex TGA cases.
Abstract:
Translocation of the coronary arteries remains a technical problem in anatomic correction of transposition of the great arteries. Myocardial ischemia related to difficulties with coronary relocation is a significant factor in perioperative morbidity and mortality, particularly in those patients with complex coronary anatomy. Two neonates with transposition of the great arteries and intact ventricular septum are described in whom the coronary arteries arose from multiple ostia, all lying within sinus 1, with one of the ostia in each instance being severely eccentric. An anatomic switch of the great vessels was done without coronary relocation. This was achieved by means of an aortopulmonary fenestration with a bovine pericardial tunnel to allow coronary artery perfusion with blood from the neoaorta. An additional pericardial patch was placed to the contralateral wall of the proximal neopulmonary artery. Both infants had an uneventful postoperative recovery with no evidence of myocardial ischemia, although both have a mild gradient across the proximal pulmonary artery. This operative technique may be appropriate in those patients in whom there is concern over the feasibility of translocating the coronary arteries without producing myocardial ischemia.