Oblique coronary transfer technique in arterial switch operation for transposition of the great arteries
Yusuke Yamamoto1, Koji Nomura2, Takahiro Tomoyasu2
1Department of Pediatric Cardiovascular Surgery, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.
Insights
This study introduces an oblique coronary transfer technique for arterial switch operation (ASO) in transposition of the great arteries (TGA). This modification significantly improves coronary artery patency and reduces postoperative mortality, enhancing patient outcomes.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Congenital Heart Disease
Background:
- Arterial switch operation (ASO) for transposition of the great arteries (TGA) has suboptimal mortality rates.
- Postoperative myocardial ischemia is a primary cause of mortality after ASO for TGA.
Purpose of the Study:
- To evaluate the clinical impact of a modified coronary transfer technique in ASO for TGA.
- The modification involves transferring coronary cuffs obliquely to the pulmonary trunk to prevent coronary artery torsion.
Main Methods:
- Retrospective review of 37 consecutive patients undergoing ASO with the oblique coronary transfer technique (September 2010 - August 2020).
- Assessment of cardiac dimensions and coronary artery patency via cineangiography.
- Hemodynamic parameters evaluated using cardiac catheterization and transthoracic echocardiography.
Main Results:
- Median follow-up of 5.3 years showed zero deaths and no need for mechanical circulatory support.
- 98.2% of transplanted coronary arteries remained patent; two circumflex arteries occluded late with preserved ventricular function.
- Five patients required re-intervention for peripheral pulmonary stenosis, but none for coronary insufficiency.
Conclusions:
- The oblique coronary transfer technique effectively avoids coronary artery torsion.
- This technique leads to excellent coronary artery patency and improved postoperative mortality rates in ASO for TGA.
Background:
Mortality rates after the arterial switch operation (ASO) for transposition of the great arteries (TGA) are still suboptimal mainly due to postoperative myocardial ischemia. The present study aimed to investigate the clinical impact of our modification of coronary transfer technique, wherein the coronary cuffs are transferred oblique to the pulmonary trunk to avoid torsion of the coronary arteries.
Methods:
From September 2010 to August 2020, all 37 consecutive patients who underwent ASO for TGA with our modification, that is, the oblique coronary transfer technique, were retrospectively reviewed. Cardiac dimensions and patency of the coronary arteries were examined by cineangiography, and hemodynamic parameters were measured by cardiac catheterization and transthoracic echocardiography.
Results:
During a median 5.3 years of postoperative follow-up, there were no deaths and no patient required mechanical circulatory support. Median left ventricular ejection fraction was 68.8% (interquartile range 66.8-71.0, minimum 54.6). All patients maintained normal sinus rhythm without arrhythmia, except in the early postoperative period. Five patients underwent unplanned re-intervention for peripheral pulmonary stenosis, but none for coronary insufficiency. The 8-year freedom from re-intervention rate was 85.6%. Among a total of 110 transplanted coronary arteries, 108 (98.2%) remained patent, and two circumflex arteries were occluded much later after surgery, although with preserved ventricular function due to compensatory growth of other coronary branches.
Conclusion:
The oblique coronary transfer technique, which aims to avoid torsion of the coronary arteries, provides good patency of the coronary arteries and subsequent improvement of postoperative mortality rates following ASO.
