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Intraoperative coronary artery pulse Doppler patterns in patients with complete transposition of the great arteries
Derek Wong1, Fraser Golding, Lembie Hess
1Hospital for Sick Children, Labatt Heart Centre, University of Toronto, Toronto, Ontario, Canada.
Insights
Transesophageal echocardiography during arterial switch operations can predict outcomes. Abnormal left main coronary artery flow patterns indicate a higher risk for surgical revision in patients with complete transposition of the great arteries (TGA).
Area of Science:
- Pediatric Cardiology
- Cardiac Surgery
- Echocardiography
Background:
- Arterial switch operation is the standard repair for complete transposition of the great arteries (TGA).
- Coronary artery abnormalities are a leading cause of morbidity and mortality post-operatively.
- Assessing intraoperative coronary artery flow may predict patient outcomes.
Purpose of the Study:
- To determine if transesophageal echocardiography (TEE) coronary artery pulse Doppler flow patterns correlate with acute postoperative outcomes in TGA patients undergoing arterial switch.
- To identify specific flow patterns indicative of adverse outcomes.
Main Methods:
- Retrospective review of 63 TGA patients who underwent arterial switch operation (2004-2006).
- Intraoperative TEE coronary artery pulse Doppler flow patterns analyzed by blinded investigators.
- Multivariable regression analysis used to associate flow patterns with clinical outcomes.
Main Results:
- Sixty-three patients analyzed; 3 required mechanical support (2 died), 19 had delayed sternal closure, 17 had arrhythmias, 9 had ST changes.
- The most common normal pattern was a late systolic peak with low diastolic flow.
- Left main coronary artery (LMCA) velocity time integral >0.14 and peak systolic velocity >0.6 cm/s were linked to surgical revision (P=.01 and P=.05, respectively).
Conclusions:
- Abnormalities in LMCA flow patterns are associated with the need for surgical revision in TGA patients after arterial switch.
- Normal coronary artery pulse Doppler flow post-arterial switch operation is characterized by a late systolic peak and low diastolic flow.
Background:
Arterial switch operation is standard repair for complete transposition of the great arteries (TGA). Coronary artery abnormalities are the most common cause of morbidity and mortality in the acute postoperative phase. This study was designed to determine whether coronary artery pulse Doppler flow patterns obtained by transesophageal echocardiography during the arterial switch operation are correlated with acute postoperative outcomes.
Methods:
A retrospective review of all patients with TGA undergoing the arterial switch operation between 2004 and 2006 was performed. Intraoperative coronary artery pulse Doppler flow patterns were analyzed by 2 blinded investigators. Associations of coronary artery pulse Doppler flow patterns with clinical outcomes were sought using multivariable linear and logistic regression analysis.
Results:
Sixty-three patients (48 male, gestational age 38 +/- 2 weeks, birth weight 3,514 +/- 613 g) were analyzed. Three patients needed mechanical support (2 died), 19 had delayed sternal closure, 17 had arrhythmias, and 9 had ST changes. The most common coronary artery pulse Doppler flow pattern consisted of a late systolic peak followed by low-velocity flow throughout diastole. A left main coronary artery (LMCA) velocity time integral >0.14 (P = .01) and an LMCA peak systolic velocity >0.6 cm/s (P = .05) were associated with need for surgical revision.
Conclusion:
Abnormalities in LMCA flow were associated with the need for surgical revision in patients with TGA undergoing the arterial switch operation. Normal coronary artery pulse Doppler flow patterns after the arterial switch operation consisted of a late systolic peak followed by low-velocity flow throughout diastole.
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