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PubMed1983

Anatomic problems associated with arterial switch procedures for double outlet right ventricle with subpulmonary ventricular septal defect.

Two cases of double outlet right ventricle with subpulmonary ventricular septal defect treated by arterial switch operations are reported. The anatomical problems of coronary artery transfer, occult outflow tract obstruction and position of the pulmonary bifurcation are discussed. Cases of double outlet right ventricle and subpulmonary ventricular septal defect with anterior-to-posterior relation of the great arteries are suited to the repair techniques pioneered by Jatene for complete transposition and ventricular septal defect. Cases in which the great arteries are side-by-side pose more difficult problems, partly because of the more complex and varied anatomy of the coronary arteries, and because of the spatial relation of the roots of the great arteries. Although it may be possible to overcome these technical problems, we have reservations about the reproducibility of such a procedure. We believe, however, that cases of this type are best treated without recourse to "inflow" correction. The options are either the arterial switch procedure or a modified Rastelli operation.

Child, Preschool↗
PubMed2004

Arterial switch operation with in situ coronary reallocation for transposition of great arteries with single coronary artery.

OBJECTIVES: Transposition of great arteries (TGA) with single coronary artery pattern is one of the high-risk groups for arterial switch operation (ASO). Any traction or kinking during coronary transfer can lead to a fatal outcome. With increase in experience, surgical results improved, but it did not completely eliminate the risks of coronary translocation. Many techniques have been described for transfer of single coronary and each one has its own merits and problems. We here in describe a new technique of in situ coronary reallocation during ASO for TGA with single coronary and also report the early and mid-term results with this new technique. METHODS: From September 1988 to June 2002, five consecutive cases of TGA with single coronary artery were operated employing this new technique. Their age ranged from 16 days to 9 months. ASO was done by transecting the great arteries just above the commissures. For coronary reallocation, hockey stick-shaped incisions were made in the facing sinuses of the proximal aorta and the pulmonary artery. These flaps were sutured in such a way that the coronary ostium was committed to the neo-aorta with the rest of surgical procedure done in the usual manner. RESULTS: All five patients had ASO. Additionally, four patients had closure of an associated ventricular septal defect and one patient had repair of the coarctation of the aorta. There was no in hospital mortality. All patients had follow-up echocardiograms at regular intervals, which showed no significant right or left ventricular outflow obstruction, no regional wall motion abnormalities and no neo-aortic or neo-pulmonary regurgitation. Three of five patients had cardiac catheterization and angiocardiography, which showed normal coronary arteries with no obstructive lesions and no neo-aortic regurgitation. Their follow up ranged from 5 to 50 months and there was no late mortality. CONCLUSIONS: This new coronary reallocation technique avoids problems related to coronary translocation such as traction and kinking. It spares the need for dissection of proximal coronary artery and its branches, and thereby eliminates the risk of development of fibrosis and stenosis. The same technique can be used regardless of the sinus of origin of the coronary artery. It is a reliable and a reproducible technique. The early and mid-term results appear excellent in this series.

Aortography↗
PubMed1994

Coronary artery anatomy in complete transposition of the great arteries.

Knowledge of the variations in coronary artery pattern is important in the arterial switch operation for complete transposition of the great arteries (TGA). As autopsy specimens provide the most definitive means of identifying the coronary anatomy, 255 hearts with complete TGA were reviewed by a single pathologist. The age of the patients ranged from 1 day to 34 years (mean, 2.9 years). The origin of the coronary arteries was defined as seen by an observer looking from the pulmonary artery toward the aorta. The usual pattern with the right coronary artery originating from the right hand sinus and the left coronary artery from the left hand sinus (184 cases) and the circumflex coronary artery arising from the right coronary artery (46 cases) accounted for 90% of the cases. Eleven other patterns were identified. The usual coronary artery pattern was more prevalent in TGA with the aorta in a right anterior or anterior position (74.8%) than in TGA with a side-by-side relationship of the great arteries (38.9%). In only 2 cases (0.8%) was an aortic intramural course of the left coronary artery identified. The latter 2 cases confirm our belief that an aortic intramural course of the left coronary artery or the left anterior descending coronary artery must be assumed when the vessel has an aberrant origin from the right sinus or when it is in intimate relationship with the commissure between the right and left sinuses and courses between the great arteries. In the vast majority of specimens a favorable coronary artery pattern with regard to feasibility of the arterial switch operation was encountered.

Abnormalities, Multiple↗
PubMed1981

Coronary arterial pattern in superoinferior ventricular heart. Implications on significance of morphogenesis of this anomaly.

The coronary arterial pattern was studied in two patients with superoinferior ventricular heart and haemodynamically complete transposition. In one of them the aorta was dextro-positioned and in the other laevo-positioned. In both the right coronary artery arose from the posterior aortic sinus and the left coronary artery from the left aortic sinus. This pattern is similar to the common coronary arterial pattern in complete transposition of the great arteries. The similarity supports the theory that in the superoinferior ventricular heart the connections between the ventricles and the great arteries (concordant or discordant) area those of the basic condition--complete transposition or corrected transposition. The angiocardiographic findings indicate that relations are not always as expected for a given connection.

Child, Preschool↗
PubMed1977

Anatomic correction of transposition of the great arteries.

Complete anatomic correction of transposition of the great arteries (TGA) and ventricular septal defect (VSD) was performed on 2 infants with high pulmonary arterial resistance. Both patients were operated upon under deep surface-induced hypothermia and limited cardiopulmonary bypass. Direct repair of the anomaly was accomplished by switching the aorta and the pulmonary artery with reattachment of the coronary arteries. The clinical result in the first patient was satisfactory. The postoperative cardiac catheterization and angiogram demonstrated no gradient across either outflow tracts and normal arrangement of the great vessels. The second patient died in the operating room, probably owing to compression or kinking of the left coronary artery.

Angiocardiography↗
PubMed2003

Implantation of the coronary arteries after reconstruction of the neoaorta by using pericardial or pulmonary hood techniques. A significant impact on the outcome of arterial switch operations.

AIM: Coronary artery anomaly and techniques used for their transfer are the major risk factors for the arterial switch operation. Although various methods have been described, torsion and stretching of the coronary arteries continue to trouble surgeons. Especially, in cases in which there is a size mismatch between the aorta and the pulmonary artery, the true coronary implantation points can change. METHODS: We studied the incidence of myocardial ischemia in 40 patients who underwent a Jatene procedure from January 1997 to August 2000 at Istanbul Medical Faculty of Istanbul University. In all cases; firstly, the neo-aortic anastomosis was performed. After filling the neo-aorta by removing the aortic cross-clamp, we aimed to identify the exact coronary implantation points. In 26 cases, direct re-implantation or trap-door techniques were the method of choice used for the implantation. In 14 cases, we used pericardial or pulmonary hood augmentation techniques. In 12 of these 14 cases, we used directly pericardial or pulmonary hood for the maintenance of the exact coronary geometry because of the unfavorable anatomy. In the remaining 2 patients, because of the determination of ischemic changes on the electrocardiogram during the rewarming phase, we should revise the coronary anastomosis by a pericardial hood. RESULTS: One patient with intramural course of the coronary arteries died from of myocardial ischemia. In the remaining 39 patients, we did not see postoperative morbidity and mortality because of the myocardial ischemia. CONCLUSION: The use of pericardial or pulmonary hood augmentation techniques is very helpful for the maintenance of the exact coronary geometry. Reconstruction of the neoaorta prior to coronary anastomosis allows a more accurate determination of the true coronary implantation points; especially, if there is an abnormal relationship and size mismatch between the great vessels. By this innovative technique, the more accurate geometry and angulation of the coronary arteries can be achieved.

Anastomosis, Surgical↗
PubMed1988

The conus with no great artery.

In three patients with complex cyanotic congenital heart disease, the conus was found to have no arterial outlet. The semilunar valves were at similar, caudad levels, and there was malposition of the great arteries. The aorta was related to the body--not the outflow portion--of the right ventricle in two patients with transposition and to the body of the left ventricle in one child with single ventricle. These cases confirm the independent embryological segregation of the conus and the truncus. Failure to recognize this condition can lead to erroneous relationship diagnoses and may adversely influence surgical decisions.

Arteries↗