Modification of the arterial switch operation for transposition of the great arteries with complex coronary artery patterns

Abstract

The arterial switch operation has evolved into the treatment of choice for most forms of transposition of the great arteries (TGA). Recently reported operative mortality of the procedure has fallen to the range of 1.1%-6.0%, even for complex forms of TGA. Despite advancement in the technical aspects of the procedure, certain anatomical variations of the coronary arteries, such as a single coronary orifice and/or intramural coronary artery, are still considered surgical risks in many centers. Optimizing the surgical technique for relocating these challenging variations of the coronary anatomy is key to improving the surgical outcomes for the procedure. In this review, the surgical modifications of the arterial switch operation for TGA associated with complex patterns of the coronary arteries are examined.

Impact of Coronary Artery Anatomy in Arterial Switch Procedure on Early Mortality and Morbidity

“…19 A unique procedure for the ASO was first reported by Aubert et al 20 A modified Aubert technique was described by Takeuchi and Katogi, 21 then Imai method was demonstrated as an alternative modification of the Aubert technique by Mee. 17,22 Brawn and Mee described the trapdoor technique in case of a looping course coronary artery anatomy. 23 Murthy reported an alternative arterial switch technique with in situ coronary reallocation by creating flaps in the proximal aorta and pulmonary artery.…”

The half-turned truncal switch operation adds a new spin for patients with complex coronary anatomy and transposition of the great arteries

“…For example, an intramural coronary artery has been associated with a 5-fold increased risk of death versus normal coronary anatomy. 4,5 Likewise, a coronary artery that arises from a single ostium and travels in a looping pattern has been associated with a 3-fold increased risk of death. 4 Although numerous reimplantation techniques have been described for a variety of defects, strong evidence-based repair strategies remain limited for complex anomalies.…”

“…As such, unfavorable coronary artery anatomy remains a contraindication for switch operations at some institutions. 5 Aberrant coronary arteries with a looping pattern have proved particularly difficult to reimplant during a switch operation. 4,5 A coronary artery is considered to loop posteriorly if one or more major branches travels posteriorly around the pulmonary trunk, as was observed in the current case.…”

“…5 Aberrant coronary arteries with a looping pattern have proved particularly difficult to reimplant during a switch operation. 4,5 A coronary artery is considered to loop posteriorly if one or more major branches travels posteriorly around the pulmonary trunk, as was observed in the current case. A looping artery arising from single ostium may be at increased risk of kinking and distortion after reimplantation because of a shorter distance and acute turn between the neocoronary orifice and the coronary artery.…”

“…A looping artery arising from single ostium may be at increased risk of kinking and distortion after reimplantation because of a shorter distance and acute turn between the neocoronary orifice and the coronary artery. 5 Perhaps the most important determinate of a successful outcome after a switch operation is a tension-and torsion-free reimplantation of the coronary arteries. 6 Therefore, it is not surprising to suggest that the favorable outcome of the current case was due to decreased distortion of the implanted coronary artery associated with HTTSO.…”