Late complication of intramural coronary transfer during the arterial switch operation

Area of Science:

• Cardiovascular Surgery
• Pediatric Cardiology
• Congenital Heart Disease

Background:

• Intramural coronary arteries are a known complication of the arterial switch operation (ASO) for transposition of the great arteries (TGA).
• These intramural coronary arteries pose a significant technical challenge and risk factor for acute coronary syndrome (ACS) late after ASO.
• Complex coronary patterns, such as intramural origins from the non-coronary sinus, can exacerbate these challenges.

Observation:

• A 27-year-old woman presented with acute coronary syndrome (ACS) years after undergoing arterial switch operation for TGA.
• Computed tomography revealed a complex coronary pattern with both left and right coronary arteries arising intramurally from the second sinus.
• The pericardial graft used for coronary reconstruction was noted to be compressed between the neoaortic root and neopulmonary trunk.

Findings:

• The compression of the pericardial graft likely led to the compromised flow in the intramural coronary arteries, precipitating ACS.
• Surgical intervention involved opening the coronary system directly into the neoaorta.
• Patch enlargement of the coronary ostia was performed to ensure adequate blood flow.

Implications:

• This case highlights a rare but serious late complication of the arterial switch operation.
• Successful surgical management involving direct coronary ostial reconstruction can restore coronary blood flow and improve outcomes in patients with complex intramural coronary arteries.
• The findings underscore the importance of vigilant long-term follow-up for patients with TGA repaired by ASO, particularly those with complex coronary anatomy.