A 26-day-old neonate with a body weight of 3.7 kg was admitted to our hospital with diagnoses of d-transposition of the great arteries, restrictive patent foramen ovale, intact interventricular septum, patent ductus arteriosus with the use of prostaglandin E1, and pulmonary bicuspid valve. The infant’s arterial oxygen saturation was 70 %, which elevated to 90 % after balloon atrial septostomy. Coronary angiography revealed a Yacoub type A coronary pattern. At 28 days of age, the patient underwent ASO under conventional cardiopulmonary bypass with moderate hypothermia. The location of the aorta was right anterior oblique to the pulmonary artery. The coronary pattern was Yacoub type A, but a dominant conus branch diverged from the proximal LCA (Fig. 1a). An aortic cross clamp was placed, and the cold crystalloid cardioplegia was infused. After the transection of the aorta, cardiac protection was to infuse directly into the coronary ostia by a 4-Fr tube every 20 min. The left coronary ostium was seen near the remote commissure in sinus 1 (Fig. 1b). Both coronary arteries were mobilized with surrounding cuffs. The pulmonary trunk was transected just below the bifurcation. The LCA including conus branches was dissected free as much as possible, but the distance to the neoaorta remained too great. To bridge this distance, a coronary elongation technique was adopted. An inverted U-shaped flap was made from the wall of the neoaorta; the LCA cuff was anastomosed to this flap with 7-0 Prolene (Fig. 1c, d). By this technique, we elongated the LCA about 2–3 mm. The right coronary artery was transferred to the punched-out hole in the neoaorta, according to our usual technique. The pulmonary artery was reconstructed with the Lecompte maneuver. To avoid LCA compression by the neopulmonary artery, the anastomosis of the pulmonary trunk was shifted to the right. The orifice of the distal pulmonary artery was extended to the right, and most of the original orifice was over-sewn. A fresh autologous pericardial patch was used to cover the coronary cuff defects. The cardiopulmonary bypass time was 306 min, and the aorta cross-clamp time was 207 min.
The patient’s postoperative course was uneventful. Postoperative echocardiography showed good left ventricular wall motion without dyskinesis. Computed tomography clearly revealed both coronary arteries including conus branches, with no compression of the LCA by the pulmonary artery (Fig. 2).
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 [2] and was later used in ASO [3, 4]. Compared to the usual trapdoor technique [5], 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.
