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Eur J Cardiothorac Surg 2002;21:111-113
© 2002 Elsevier Science NL

Case report

Coronary revascularization after arterial switch operation

Edvin Priftia,b*, Massimo Bonacchib, Stefano Vincenzo Luisia, Vittorio Vaninia

a G.Pasquinucci Hospital, CREAS-IFC-CNR, Via Aurelia Sud, Massa 54100, Italy
b I.R.C.C.S NEUROMED, Via Atinense N.18, 86077 (ISERNIA), Pozzilli, Italy

Received 25 May 2001; received in revised form 30 September 2001; accepted 31 October 2001.

* Corresponding author. Tel.: +39-0685-300-0548; fax: +39-0585-493-616
e-mail: edvinprifti{at}hotmail.com


   Abstract
Top
 Abstract
1. Introduction
 2. Discussion
 References
 
We report two cases presenting bilateral coronary artery obstruction after arterial switch operation. The first patient underwent bilateral internal thoracic artery grafting to the left and right coronary arteries. The other patient, presenting a single coronary ostium, underwent surgical coronary ostial angioplasty in concomitance to proximal arterioplasty of both coronary arteries employing a single ‘pantaloon’ shape autologous pericardial patch. Both patients survived and, at 1 year and 9 months after the coronary revascularization procedures, the coronary angiography demonstrated a good patency of the internal thoracic grafts and excellent ostial plasty results, respectively. A complete literature review of patients undergoing different coronary revascularization procedures after arterial switch operation is reported.

Key Words: Transposition of the great arteries • Arterial switch operation • Coronary revascularization


   1. Introduction
Top
 Abstract
 1. Introduction
2. Discussion
 References
 
Arterial switch operation (ASO) enables definitive repair with acceptable operative mortality for most of patients with transposition of the great arteries (TGA). In addition, operations which require manipulation and reimplantation of coronary arteries, such as during ASO, establish a patient base which is at risk for acute or chronic ischemic complications [1]. Coronary artery bypass grafting (CABG) [1–3] and proximal pericardial patch coronary arterioplasty [4,5] have been employed successfully in patients presenting coronary obstruction after ASO. We are reporting two cases with coronary artery obstruction after ASO undergoing successful coronary revascularization procedures of both vessels.

1.1. Case 1
A 3.1 kg male-baby, simple TGA (type A Yacoub's classification), underwent ASO with Le Compte modification (translocation of the coronary arteries to the neoaorta was uncomplicated) in the 3rd day of life. The patient was discharged 1 month later. After 3 months, the patient was referred in emergency presenting signs of an evolving myocardial infarction. The ECG demonstrated ST elevation in V2–V5 and enzymatic alterations were present. Transthoracic echocardiography showed distal hypokinesia of the ventricular septum and moderate mitral insufficiency. The baby underwent urgent coronary angiography which revealed a <75% obstruction of the left anterior descending artery (LAD) next to the origin of the first septal branch (Fig. 1A) and total proximal obstruction of the right coronary artery (RCA) (Fig. 1B). The baby underwent emergent CABG employing both skeletonized internal thoracic arteries (ITA), which were found to have a good calibre. Under deep hypothermia, the LITA and RITA were anatomosed in the mid-segments of LAD and RC, respectively. The postoperative course was uneventful. One year later, the coronary angiography revealed good ITAs’ patency (Fig. 1C).



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  		Fig. 1. Patient 1: (A) stenotic lesion (>75%) of the proximal left anterior descending artery. (B) Ostial occlusion of the right coronary artery. (C) Patent left internal thoracic artery anastomosed to the left anterior descending artery at 1 year after revascularization. Patient 2: (D) the coronary ostial plasty in concomitance to coronary arterioplasty employing a ‘pantaloon’ autologous pericardial patch. (E) Angiographic examination demonstrating a good postoperative outcome after the surgical ostial angioplasty and arterioplasty at 9 months after operation.

 
1.2. Case 2
A 4 kg male-baby, simple TGA (single coronary ostium, type B, Yacoub's classification), underwent successful ASO with Le Compte modification, prior Rashkind procedure, in the 6th day of life. He was discharged in the 10th postoperative day. Two weeks later the baby was admitted due to tachypnea with chest retraction following common cold-like symptoms with fever for several days. The ECG revealed an antero-lateral myocardial infarction. The baby underwent urgent coronary angiography which revealed a severe stenosis of the single coronary ostium, obstruction of the left main coronary artery, moderate stenosis of the proximal RC and a small LITA calibre. The baby underwent surgery. The left main coronary trunk (LMCT) was identified. After clamping the aorta, an incision started on the anterior aspect of the aortic root was then performed, directed to the single coronary ostium and extended into the LMCT as a longitudinal atheretomy ending proximal to the LMCT bifurcation. After identifying the proximal RCA, a longitudinal atheretomy was performed extended towards the coronary ostium, joining the aortotomy. A ‘pantaloon’ shape autologous pericardial patch, with a similar angle degree as between the LMCT and RCA, was prepared. The patch's ‘legs’ were sutured, using a Prolene 8/0, to the proximal right and left coronary arteries walls. The common part of the patch was attached to the aortic wall, enlarging the coronary ostium, using a Prolene 6/0 (Fig. 1D). The postoperative course was uneventful. At 9 months, the coronary angiography showed a good patency of both coronary arteries (Fig. 1E).


   2. Discussion
Top
 Abstract
 1. Introduction
 2. Discussion
References
 
The coronary obstruction after ASO is one of the most risky complications of such a procedure with an incidence that remains still significant. Bonhoeffer et al. [6], in a series of 165 children undergoing ASO, found almost 12 coronary occlusions, eight major coronary stenoses, and ten other minor stenoses or stretchings.

There are many potential causes of early coronary artery obstruction following ASO such as kinking, thrombus formation secondary to intramural or intimal injury and extrensic compression. During the past decade, authors have reported successful coronary revascularization according to different techniques (Table 1). We found in the literature almost 23 patients undergoing coronary revascularization after ASO. What was unusual in our cases, was the presence of stenotic lesions in both coronary arteries, necessitating revascularization of left and right coronary arteries. It is very important to well select the type of revascularization procedure which should be performed in each case. In almost 16 patients, the authors preferred to undergo CABG using one of the ITAs. Such a procedure seems to have excellent outcome regarding the early and long-term outcome. In all reported cases, a good patency of the ITAs graft was demonstrated at 8–30 months postoperatively. Such grafts are live conduits with growth and adaptation's potential. All the ITAs grafts in the presented reports became longer as the body surface area increased, and the anastomotic junction did grow. Recently Nair et al. [7] reported a patient which underwent bilateral ITAs grafting during ASO, for avoiding a difficult coronary transfer. According to our knowledge, our first patient is the unique reported case undergoing successful bilateral ITAs grafting, due to post ASO coronary obstruction.


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  		Table 1. Literature reports of pediatric patients undergoing coronary revascularization according to different surgical techniques after the arterial switch operationa

 
Other surgical strategies for coronary revascularization in this pool of patients have been employed. Han et al. [8] reported a case undergoing successful left subclavian artery grafting to the left coronary artery. Albert et al. [9] reported another patient undergoing CABG using polytetrafluorethylene graft to the RCA, with a very good postoperative patency. Pericardial patch coronary arterioplasty alone [4,5] or in concomitance to ITAs grafting [1] have been employed with excellent short and mid-term outcome for coronary perfusion restoration in patients post-ASO. Recently, Bonnet et al. [5] reported a series of ten patients undergoing successful surgical angioplasty employing pericardial, saphenous vein or polytetrafluoroethylene patch. In our second case, due to the small LITA's diameter, demonstrated by angiography, we decided to perform a pericardial patch arterioplasty associated with a surgical coronary ostial angioplasty. Due to the presence of a single coronary ostium, we modified the coronary ostial angioplasty previously described [10] performed in adults with coronary artery disease, by employing a single ‘pantaloon’ shape autologous pericardial patch.

From our limited experience and literature reports, we may conclude that if the post ASO coronary obstruction is diagnosed and treated in time, excellent results could be obtained even in cases with obstruction of both coronary arteries. The best surgical alternatives in such cases are all the arterial coronary revascularization procedures such as ITAs grafting and surgical coronary ostial angioplasty.


   References
Top
 Abstract
 1. Introduction
 2. Discussion
 References
 

  1. Mavroudis C., Backer C.L., Duffy C.E., Pahl E., Wax D.F. Pediatric coronary artery bypass for Kawasaki, congenital, post arterial switch, and iatrogenic lesions. Ann Thorac Surg 1999;68:506-512.[Abstract/Free Full Text]
  2. Bonnet D., Bonhoeffer P., Aggoun Y., Accar P., Sidi D., Vouhe P., Kachaner J. Aortocoronary bypass in children. Apropos of six cases. Arch Mal Coeur Vaiss 1998;91(5):581-585.[Medline]
  3. Brackenbury E., Gardiner H., Chan K., Hickey M. Internal mammary artery to coronary artery bypass in paediatric cardiac surgery. Eur J Cardiothorac Surg 1998;14(6):639-642.[Abstract/Free Full Text]
  4. Serraf A., Roux D., Lacour-Gayet F., Touchot A., Bruniaux M., Sousa-Uva M., Planche C. Reoperation after the arterial switch operation for transposition of the great arteries. J Thorac Cardiovasc Surg 1995;110:892-899.[Abstract/Free Full Text]
  5. Bonnet D., Bonhoeffer P., Sidi D., Kachaner J., Acar P., Villain E., Vouhe P.R. Surgical angioplasty of the main coronaries in children. J Thorac Cardiovasc Surg 1999;117(2):352-357.[Abstract/Free Full Text]
  6. Bonhoeffer P., Bonnet D., Piechaud J.E., Sumper O., Aggoun Y., Villain E., Kachaner J., Sidi D. Coronary artery obstruction after the arterial switch operation for transposition of the great arteries in newborns. J Am Coll Cardiol 1997;29(1):202-206.[Abstract]
  7. Nair K.K., Chan K.C., Hickey M.S. Arterial switch operation: successful bilateral internal thoracic artery grafting. Ann Thorac Surg 2000;69(3):949-951.[Abstract/Free Full Text]
  8. Han J.J., Lee Y.T., Park Y.K., Hong S.N., Kim S.H. Left subclavian artery bypass graft in complicated arterial switch operation. Ann Thorac Surg 1996;61(5):1523-1525.[Abstract/Free Full Text]
  9. Albert D., Castilla J., Amengual E., Casaldiga J., Concalves A., Miro L., Murtra M., Girona J. Arterial switch: aortocornary bypass with interposition of polytetrafluorethylene (Gore-tex) vascular graft. Rev Esp Cardiol 1998;51(12):1009-1010.[Medline]
  10. Bonacchi M., Prifti E., Giunti G., Leacche M., Ballo E., Furci B., Salica A., Miraldi F., Mazzesi G., Toscano M. Mid-term outcome of surgical coronary ostial plasty: our experience. J Card Surg 1999;14(4):294-300.[Medline]



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This Article
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Massimo Bonacchi
Vittorio Vanini
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