Rare coronary artery variants are associated with increased mortality and reinterventions following the arterial
Stephanie N Nguyen1, Alice V Vinogradsky1, Alice M Tao1
1Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY.
Insights
Rare coronary artery variants, especially intramural ones, increase mortality and reinterventions after arterial switch operation (ASO). Early unroofing of intramural coronary arteries may improve outcomes, but long-term fate requires further study.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Congenital Heart Disease
Background:
- The arterial switch operation (ASO) is a standard surgical procedure for treating transposition of the great arteries and Taussig-Bing anomaly.
- Coronary artery anatomy can vary significantly in patients undergoing ASO, potentially impacting surgical outcomes.
Purpose of the Study:
- To investigate the long-term impact of different coronary artery anatomies on patient outcomes following the arterial switch operation.
- To identify specific coronary variants that pose increased risks for mortality and reintervention.
Main Methods:
- Retrospective review of 632 patients who underwent ASO between 1992 and 2022.
- Categorization of coronary anatomy into usual, circumflex from sinus 2, inverted, single sinus, and intramural types.
- Analysis of long-term outcomes, including death, transplantation, and coronary reintervention, using Cox modeling.
Main Results:
- Overall operative mortality was 3%, with the highest rates observed in patients with intramural coronary anatomy (10%).
- Twenty-year freedom from adverse events was significantly lower for intramural coronary arteries (80%) compared to usual anatomy (95%).
- Intramural coronary arteries and intraoperative coronary revision were identified as significant risk factors for adverse composite endpoints.
Conclusions:
- Rare coronary artery variants, particularly intramural types, are associated with increased mortality and coronary reinterventions after ASO.
- A proactive approach, such as unroofing intramural coronary arteries, may lead to improved outcomes.
- Further research is necessary to fully understand the long-term implications of coronary artery anatomy after ASO.
Objective:
To determine the influence of coronary anatomy on long-term outcomes of the arterial switch operation (ASO).
Methods:
We retrospectively reviewed patients with transposition of the great arteries or Taussig-Bing anomaly who underwent ASO at our institution between 1992 and 2022. The primary endpoint was freedom from a composite of death, transplantation, and coronary reintervention.
Results:
A total of 632 patients (median age, 5.0 days; interquartile range [IQR], 4.0-7.0 days) underwent ASO. Coronary anatomy included the following categories: usual (n = 411; 65%), circumflex (Cx) from sinus 2 (n = 89; 14%), inverted (n = 55; 9%), single sinus (n = 46; 7%), and intramural (n = 31; 5%). Overall operative mortality was 3% (n = 16) and highest in patients with intramural cardiac anatomy (n = 3; 10%), although it dropped to 0% in this group in the most recent decade. The median duration of follow-up was 14.5 years (IQR, 6.0-20.3 years). Twenty-year freedom from the primary endpoint was 95 ± 1% for usual anatomy, 99 ± 1% for Cx from sinus 2, 90 ± 4% for inverted, 91 ± 4% for single sinus, and 80 ± 9% for intramural (P < .001). Intramurals had the highest 20-year incidence of coronary reintervention (11 ± 8%). Cox modeling identified intraoperative coronary revision (hazard ratio [HR], 20.1; 95% confidence interval [CI], 9.4-53.9; P < .001), Taussig-Bing anomaly (HR, 4.9; 95% CI, 2.2-10.9; P < .001), and an intramural coronary artery (HR, 2.9; 95% CI, 1.0-8.2; P = .04) to be risk factors for the composite endpoint.
Conclusions:
Rare coronary artery variants-particularly intramural-are associated with increased mortality and coronary reinterventions after ASO. A low threshold for unroofing intramurals is likely associated with declining mortality and improved outcomes. Additional investigations are needed to determine the long-term fate of the coronary arteries after ASO.
