A case of arterial switch operation with coronary elongation technique
© Matsuba et al. 2016
Received: 21 November 2015
Accepted: 29 January 2016
Published: 3 February 2016
A 28-day-old infant with d-transposition of the great arteries underwent arterial switch operation. The coronary pattern was Yacoub type A, in which coronary transfer is usually thought to be easy. However, a dominant conus branch diverged from the proximal portion of the left coronary artery (LCA). Moreover, the LCA ostium itself was near the remote commissure in sinus 1, very far from the target re-implantation point. All of these conditions made LCA transfer very difficult. We used a coronary elongation technique to solve this problem. An inverted U-shaped flap was made in the wall of the neoaorta, and the LCA cuff was anastomosed to this flap (the inferior half from the neoaortic flap and the superior half from the LCA cuff). To prevent compression of the LCA, the neopulmonary trunk was shifted rightward. Postoperative echocardiography showed good left ventricular wall motion, and the LCA was easily visualized on chest computed tomography, with no compression from the neopulmonary artery.
Coronary artery transfer without kinking or overstretching is the key to a successful arterial switch operation (ASO). Anatomical variation of the coronary arteries, such as a single coronary orifice as in a Yacoub type B coronary pattern, with or without the intramural coronary artery, is considered a surgical risk [1–5]. However, even with a normal coronary artery pattern, coronary transfer can be difficult in some cases. We present herein such a case, in which the gap between the left coronary artery (LCA) orifice and the neoaorta could not be bridged with usual mobilization of the LCA because of other anatomical characteristics. ASO was successfully performed with a coronary elongation technique for the LCA.
We were able to fill the gap between the LCA ostium and the neoaorta with the use of a coronary elongation technique. This maneuver was first performed in coronary transfer in Bland-White-Garland syndrome  and was later used in ASO [3, 4]. Compared to the usual trapdoor technique , this technique maximizes elongation, because vascular tissues extend from both sides of the anastomosis: the inferior half from the neoaortic flap and the superior half from the LCA cuff. Although lengthening of the LCA was achieved with this method, the course of the left main trunk was rather straight and ran near the neopulmonary trunk. Thus, the reconstructed LCA segment seemed vulnerable to compression by the pulmonary trunk. Therefore, we shifted the neopulmonary trunk to the right. Careful follow-up is needed to assess the status of the reconstructed coronary artery.
Difficulty with coronary transfer in ASO may be encountered even in patients with a normal coronary artery pattern because of the positional relationship between the coronary ostium and the neoaorta. Coronary elongation techniques can be useful in such cases.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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