|Year : 2004 | Volume
| Issue : 4 | Page : 76-78
Coronary reimplantation prior to main pulmonary arterial transection in arterial switch operations
Basaran Murat, Kafali Eylul, Ugurlucan Murat
Istanbul University, Istanbul Medical Faculty, Department of Cardiovascular Surgery, Turkey
|Date of Web Publication||22-Jun-2010|
Bozkurt Caddesi, No: 110-112, Benli Apt., Daire: 6, 80250 Kurtulus / Istanbul
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Arterial switch operation is the current procedure of choice in the surgical repair of transposition of the great arteries. Patients with complex coronary arterial anatomy in particular are more susceptible to having myocardial ischemia after this operation. The technical modification described in this article proposes a new idea of re-implantation to reduce the risk of incorrect positioning of the coronary buttons.
The technique has not been applied on humans. The technical modification was performed only on extracted sheep hearts.
|How to cite this article:|
Murat B, Eylul K, Murat U. Coronary reimplantation prior to main pulmonary arterial transection in arterial switch operations. Heart Views 2004;5:76-8
|How to cite this URL:|
Murat B, Eylul K, Murat U. Coronary reimplantation prior to main pulmonary arterial transection in arterial switch operations. Heart Views [serial online] 2004 [cited 2020 Jul 13];5:76-8. Available from: http://www.heartviews.org/text.asp?2004/5/4/76/64542
| Introduction|| |
Arterial switch operation (ASO) is the current procedure of choice in the surgical repair of the transposition of great arteries (D-TGA). Since the first successful operation made by Jatene in 1975  , a great number of series have been reported and ASO may be performed today with acceptable morbidity and mortality rates. With increasing experience and knowledge, all authors now agree that the leading cause of postoperative morbidity and mortality in ASO is myocardial ischemia. Therefore, the most critical step of the operation is the successful translocation of the coronary arteries without producing kinking or tension. The technical modification described in this article proposes a new idea of re-implantation to reduce the risk of incorrect positioning of the coronary buttons.
| Surgical Technique|| |
The technique that we describe has not been applied on humans. The technical modification was performed only on extracted sheep hearts. The technique was carried out in 15 extracted sheep hearts. Of these, the new technique was applied in eight sheep hearts and seven were used as control to compare the results.
The operation was performed through a median sternotomy. Following pericardiotomy, the patent ductus arteriosus was dissected out and the branches of the right and left pulmonary arteries mobilized well out to the hilum of the lung bilaterally and controlled. Cardiopulmonary bypass (CPB) was instituted using high aortic and bicaval cannulations. Moderate hypothermia was used during CPB. After the establishment of cardiac arrest, anterior great vessel was transected approximately 1cm above the aortic valve. The coronary ostia were then examined carefully and excised from the anterior great vessel with a button of surrounding aortic wall extending down to the base of the sinuses of Valsalva. The courses of the coronary arteries were mobilized and freed from the epicardium adequately to permit translocation of the coronary arteries to the posterior great vessel. Both branches of pulmonary artery were snared to prevent runoff and this vessel was then distended with cold saline solution to determine the exact coronary implantation points [Figure 1]. The left coronary artery was then anastomosed to the medially based flap incision made to the predetermined point on the posterior great vessel. After the completion of first coronary anastomosis, if needed, cold crystalloid cardioplegia might be given through the previously placed needle [Figure 2]. The right coronary anastomosis was then performed by using the same re-implantation technique. Following the completion of both coronary anastomosis, the posterior great vessel was transected close to its bifurcation.
Then, the LeCompte maneuver was performed and neoaorta was reconstructed. After the removal of cross-clamp, neopulmonary artery was constructed by using single pantaloon patch technique.
| Discussion|| |
Successful transfer of the coronary artery is the cornerstone of the arterial switch operations and greatly affects the early morbidity and mortality of ASO  . Abnormal coronary anatomy can still complicate the task of coronary transfer and is considered a major determinant of post-operative morbidity and mortality  . Although many modifications including direct re-implantation, trap door and hood augmentation techniques , were proposed, it is not always simple to determine the exact coronary implantation points especially in cases with abnormal coronary arterial pattern and size discrepancy between great vessels.
The identification of the correct implantation points on the neoaorta completely depends on the surgeon's experience. However, especially in cases with size mismatch, the spatial relationship between the coronary buttons and neoaorta may change after the completion of all anastomoses. The distention of the posterior great vessel allows more accurate determination of ideal coronary implantation points.
The possible disadvantage of closed re-implantation technique is the possibility of iatrogenic injury of neoaortic valve leaflets and commissures.
Whereas generally the sinuses of the aortic and pulmonary valves face each other, the incidence of commissural malalignment is reported to be 46%  . Fortunately, in the current sugical era, the anatomic positions of facing sinuses can be determined preoperatively by echocardiographic evaluation which becomes increasingly more important in defining the morphology of the coronary arteries and the alignment of the commissures in semilunar valves. The detection of unusual great arterial positions should alert the surgeon to potentially complicated arrangements of the origin of the coronary arteries and commissural alignment.
The achievement of correct angulation is not the single advantage of this modification. Although it is possible to mark the translocation sites in the neoaorta prior to the institution of CPB, this technique offers also other advantages including the infusion of cardioplegic solution during anastomosis and the ability to control the suture lines for bleeding before the reconstruction of the great vessels. The delivery of cardioplegia directly through coronary ostia with appropriate sized cannules may be considered by some authors, but the possible risk of intimal injury or ostial stenosis is a subject of considerable debate.
In conclusion, the prevention of coronary kink and myocardial ischemia is the most important step for the success of ASO. This simple modification described above can help the surgeon in the determination of exact coronary implantation points in complicated cases and give surgeons the opportunity of giving cardioplegic solution before the reconstruction of neoaorta.
| References|| |
|1.||Jatene AD, Fontes VF, Paulista PP, Souza LCB, Neger F, Glantier M, Souza JEMR. Anatomic correction of transposition of the great vessels. J Thorac Cardivasc Surg 1976; 72:364-369. |
|2.||Wernovsky G, Mayer JE, Jonas RA, Hanley FL, Blackstone EH, Kirklin JW, Castaneda AR. Factors influencing early and late outcome of the arterial switch operation for transposition of the great arteries. J Thorac Cardivasc Surg 1995; 109:289-301. |
|3.||Yacoub MH, Radley SR. Anatomy of the coronary arteries in transposition of the great arteries and methods for their transfer in anatomical correction. Thorax 1978; 33:418-424. |
|4.||Parry AJ, Thurm M, Hanley FL. The use of the pericardial hoods for maintaining exact coronary artery geometry in the arterial switch operation with complex coronary anatomy. Eur J Cardiothorac Surg 1999; 69(6):159-164. |
|5.||Kim SJ, Kim WH, Lim C, Oh SS, Kim YM. Commissural malalignment of aortic-pulmonary sinus in complete transposition of great arteries. Ann Thorac Surg. 2003;76 (6):1906-1910 . |
[Figure 1], [Figure 2]