Preoperative Coronary Anatomy Assessment with Echocardiography and Morbidity After Arterial Switch Operation of Transposition of the Great Arteries

Abstract

In transposition of the great arteries (TGA), certain coronary patterns have been associated with major adverse events early after the arterial switch operation (ASO). We sought to determine the impact of preoperative echocardiographic (ECHO) diagnosis on the intra­ and postoperative morbidity. All patients with TGA born between June 2001 and June 2017 and who underwent ASO were reviewed. Data on presumed coronary anatomy (CA) preoperatively were obtained from the preoperative ECHO report. Intraoperative CA was categorized according to Yacoub classification. Major postoperative morbidity included at least one of the following: delayed sternal closure (DSC), prolonged (> 72 h) mechanical ventilation, reintubation, peritoneal dialysis (PD), ECMO, reoperation, and readmission within 30 days after surgery. 240 patients with median age of 5 days (range 1–614) and mean weight at surgery was 3.6 kg (1.8–8.4) were included. Preoperative ECHO assessment of CA was available in 228 patients. Intraoperatively, 181 patients (75%) were found to have type A, 25 patients had type B or C or intramural (B–C–IM; 10%), and 34 patients had type D or E (D–E; 14%). Patients with types B, C, and intramural coronary (B–C–IM) had increased risk for delayed sternum closure (9/25 vs. 20/181 in type A and 8/34 in type D–E; p = 0.04), peritoneal dialysis (4/25 vs. 8/181 and 1/34; p = 0.04), and ECMO (2/25 vs. 1/131 and 1/34; p = 0.02). Within the B–C–IM group, preoperative ECHO raised suspicion of type A in 13 patients (i.e., incorrect diagnosis, ID; 52%), whereas non-A CA was suspected in 12 patients (i.e., correct diagnosis, CD; 48%). With the exception of reoperation, which was seen only in the ID subgroup (4/12 vs. 0/10 in the CD subgroup; p = 0.04), the intraoperative (cardiopulmonary bypass time and cross-clamp time) and postoperative morbidity indices were comparable in both ID and CD subgroups (p > 0.1). Although there is a significant risk for early postoperative morbidity in TGA patients with single, interarterial, and intramural CA, there seems to be relatively limited influence of preoperative ECHO assessment of coronary anatomy on this morbidity burden.

Results of Arterial Switch Operations we performed in our clinic in 2 years

“…In our cases, we closed these defects in some patients with their own pericardium fixed with glutaraldehyde and in others with a bovine pericardial patch. Hence, after the proximal neo-pulmonary artery anastomosis was anastomosed to the patch by continuous suture method, the commissure tissue between the defects was sutured to the inner wall of the neopulmonary artery (10). We support the idea that long-term pulmonary artery stenosis can be prevented using this method.…”

Anomalous connection of the circumflex coronary artery to the pulmonary trunk in a patient with Taussig–Bing anomaly: a case report

“…Furthermore, echocardiography can accurately diagnose coronary anatomy in the majority of cases, including the more common cases of ACAPT involving the left or right coronary artery. 17 Thus, echocardiography remains the gold standard imaging modality for coronary assessment prior to the arterial switch operation, while CTA is reserved for selected TGA cases prior to the arterial switch operation (i.e. those with suspected complex coronary anatomy such as interarterial and intramural coronary arteries, those with large coronary fistulae, and those with unclear coronary anatomy due to poor acoustic windows) and for screening for coronary complications after the arterial switch operation.…”

Lessons learned from ECMO support in pediatric patients with D-transposition of the great arteries: preoperative, intraoperative and postoperative

“…Coronary problems, such as kinking, stretching, or thrombosis, will have a profound effect in these patients, and even sudden cardiac death may occur after ECMO weaning. 18 For such cases, there is a great challenge for the surgeon, and it is necessary to fully evaluate the satisfaction of the coronary artery transfer operation when considering the ECMO indications. It has been reported that patients who require postoperative ECMO and undergo cardiac catheterization or CTA for diagnosing residual lesions or other unrecognized pathologies have better outcomes.…”