Coronary artery problems late after arterial switch operation for transposition of the great arteries
Takeshi Tsuda1, Abdul M Bhat, Bradley W Robinson
1Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children.
Insights
Late coronary artery abnormalities after arterial switch operation (ASO) are common and often asymptomatic. Routine coronary imaging is recommended for all patients post-ASO before sports participation.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease Surgery
- Cardiovascular Imaging
Background:
- Late coronary artery abnormalities following arterial switch operation (ASO) for d-loop transposition of the great arteries may be underdiagnosed.
- ASO is a critical surgical procedure for complex congenital heart defects.
Purpose of the Study:
- To evaluate the incidence and presentation of late coronary artery abnormalities after ASO.
- To determine the effectiveness of non-invasive screening in detecting these abnormalities.
Main Methods:
- Retrospective review of coronary artery morphology in 40 patients post-ASO.
- Analysis of clinical presentation, diagnostic tests (exercise stress test, myocardial perfusion imaging), and outcomes.
Main Results:
- 11.3% of patients developed significant late coronary artery stenosis or occlusion.
- Abnormalities were often asymptomatic and detected after negative non-invasive screening.
- Severe left coronary artery ostial stenosis was noted in fatal and collapsed patients.
Conclusions:
- Late coronary stenosis or occlusion is a significant concern after ASO.
- Routine coronary imaging is crucial for all post-ASO patients, especially before competitive sports.
- Non-invasive screening may not reliably detect these potentially serious abnormalities.
Background:
The incidence of late coronary artery abnormalities after arterial switch operation (ASO) for d-loop transposition of the great arteries may be underestimated.
Methods And Results:
We retrospectively reviewed coronary artery morphology in 40 of 97 patients who survived the first year after ASO. Seven asymptomatic patients developed significant late coronary artery abnormalities. One patient died suddenly at home with severe left coronary artery (LCA) ostial stenosis at age 3.8 years. The second patient collapsed during exercise at age 9.6 years due to ventricular fibrillation and severe LCA ostial stenosis despite prior negative exercise stress test (EST) and myocardial perfusion imaging (MPI). The third patient was found to have moderate ostial stenosis of the LCA with negative EST and MPI. The fourth patient with exercise-induced ST-T depression and myocardial perfusion defect was shown to have complete LCA occlusion with collateral vessel formation. Three other patients had complete proximal obliteration of either of the coronary arteries with collateral supply. An additional 4 asymptomatic patients had trivial-mild narrowing of the LCA on routine selective coronary angiogram.
Conclusions:
Incidence of late coronary stenosis or occlusion was not infrequent after ASO (11.3%) and presented usually without preceding symptoms and often after negative non-invasive screening. We advocate routine coronary imaging in all patients after ASO before they participate in competitive sports.
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