Original article
Congenital heart surgery
Excellent Long-Term Outcomes of the Arterial Switch Operation in Patients With Intramural Coronary Arteries

Presented at the Ninety-fifth Annual Meeting of the American Association for Thoracic Surgery, Seattle, WA, April 24–29, 2015.
https://doi.org/10.1016/j.athoracsur.2015.08.090Get rights and content

Background

Intramural coronary arteries may complicate coronary artery transfer during the arterial switch operation. We sought to determine the long-term outcomes of 28 patients with intramural coronary arteries who underwent an arterial switch operation at a single institution.

Methods

All patients who had intramural coronary arteries and underwent an arterial switch operation were identified from the hospital database and retrospectively reviewed.

Results

From 1983 to 2009, 720 patients underwent an arterial switch operation at our institution. Twenty-eight (3.9%, 28 of 720) had intramural coronary arteries. Patients with intramural coronary arteries had transposition of the great arteries (96%, n = 27) or Taussig-Bing anomaly (4%, n = 1). There were no deaths. Follow-up was 100% complete. Mean follow-up was 16.3 years (median, 15.5 years; range, 5.6 to 26.9 years). No patient required reoperation or catheter reintervention on the coronary arteries. Freedom from reoperation was 93% at 10 years. No patient had more than mild aortic regurgitation at last follow-up. Nine (32%, 9 of 28) patients had coronary angiograms at median 16 months (range, 14 months to 17 years) after arterial switch operation. All patients were asymptomatic at the time of angiogram. One patient had mild stenosis of the circumflex coronary artery demonstrated on a routine coronary angiogram 14 months postoperatively. All 28 patients were asymptomatic and in New York Heart Association functional class I at last follow-up.

Conclusions

Patients with intramural coronary arteries are not at increased risk of death or coronary reinterventions and have excellent late outcomes after the arterial switch operation.

Section snippets

Patients

The study was approved by the Royal Children’s Hospital Human Research Ethics Committee. Between May 1983 and January 2009, a total of 720 patients underwent an ASO at the Royal Children’s Hospital. An ASO was performed for TGA (n = 618), Taussig-Bing anomaly (TBA; n = 57), congenitally corrected TGA (n = 21), for atrial to ASO conversion (n = 15) and TGA with univentricular physiology (n = 9). All operation reports were reviewed and all patients with IMCA were identified. There were 28 (3.9%,

Early Outcomes

The intramural course involved the left main coronary artery in 24 (86%, 24 of 28) patients, the left anterior descending artery in 2 (7%, 2 of 28) patients, the right coronary artery in 1 (3.5%, 1 of 28) patient, and both left and right coronary arteries in 1 (3.5%, 1 of 28) patient (Fig 1). Our approach to the IMCA (Fig 2A) was detachment of the posterior commissure of the aortic (neopulmonary) valve in 25 (89%, 25 of 28; Fig 2B) patients and unroofing of the IMCA (Fig 2C) in 16 (57%, 16 of

Comment

Coronary transfer during the ASO in patients with IMCAs presents a surgical challenge. Few studies in the literature have looked specifically at the outcomes of this subgroup. A meta-analysis of 1,942 patients by Pasquali and colleagues [7] demonstrated that an IMCA had a 6.5-fold increased risk of mortality as compared to normal coronary anatomy. Metton and associates [6] reviewed 46 patients with IMCAs out of a cohort of 919 patients who underwent ASO between 1987 and 2008. They reported a

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