Coronary Artery Pattern and Outcome of Arterial Switch Operation for Transposition of the Great Arteries

Mayer, John E. Jr. MD
Sanders, Stephen P. MD
Jonas, Richard A. MD
Castanieda, Aldo R. MD, PhD
Wernovsky, Gil MD

Departments of Cardiac Surgery and Cardiology, Children's Hospital, and the Departments of Surgery and Pediatrics, Harvard Medical School, Boston, Mass.

Address for correspondence: John E. Mayer Jr., MD, Department of Cardiovascular Surgery, Children's Hospital, 300 Long- wood Avenue, Boston, MA 02115.

Supported in part by grant HL-41876 from the National Heart, Lung, and Blood Institute, National Institutes of Health, Be-thesda, Md.

Circulation 82(5):p IV-145, November 1990.

A successful outcome of an arterial switch operation (ASO) for dextro-transposition of the great arteries (D-TGA) depends in large part on the transfer of the coronary arteries to the neoaorta without distortion or narrowing. However, the origins and distribution of the coronary arteries are quite variable in D-TGA; therefore, the entire experience with ASO at the Children's Hospital in Boston was reviewed. From 1983 through November 1989, 314 patients underwent surgery for D-TGA with the intent to perform an ASO. An ASO was actually performed in 290 patients, and 20 patients died, with 12 deaths (4.2%) clearly related to problems with the coronary arteries (CA deaths). The ASO was aborted to a Senning operation in 24 patients (7.6%), primarily due to coronary anatomy. Eight coronary patterns were identified and related to the outcome of the ASO. In 182 patients with the “usual” coronary pattern for D-TGA (i.e., anterior descending and circumflex arteries from the left sinus and right coronary artery from the right sinus), five CA deaths occurred, and two patients had Senning operations. Sixty-seven patients had right coronary and circumflex arteries from the right sinus and anterior descending arteries from the left sinus. Three CA deaths occurred, and one patient had a Senning operation. Single right coronary artery was found in 14; 12 had ASOs with three CA deaths (25%); and two had Senning operations. One late death was due to diffuse narrowing of the single right coronary artery. Single left coronary artery occurred in 11 patients, and seven had ASO with no early but one late “sudden” death, whereas four had Senning operations. “Inverted” coronary pattern (i.e., right coronary artery from left sinus and left coronary artery from right sinus) was found in 10 patients, and eight had ASO without operative mortality. Two deaths (25%) occurred within 3 months of discharge from diffuse narrowing of the proximal CAs. In 15 patients, the right coronary artery and anterior descending artery arose from the left sinus, and the circumflex artery arose from the right sinus. Ten had ASO without mortality, and five had Senning procedures. In 14 patients, both right coronary artery and left coronary artery arose from the right sinus, and the left coronary artery pursued an intramural course between the aorta and pulmonary artery. Seven had ASO with one death, and seven had Senning operations. One patient had an intramural anterior descending artery arising from the right sinus and had a Senning operation. Early and late CA deaths were reduced from 11 of 144 patients (7.2%) in the first half of the experience to five of 146 patients (3.4%) in the second half. Therefore, all CA patterns appear to be “switchable,” but single right coronary artery and “inverted” CA patterns carried increased risk. Increasing experience will likely lead to improved results with less common coronary patterns.