Can we predict potentially dangerous coronary patterns in patients with transposition of the great arteries after an arterial switch operation?

Abstract

Introduction:Coronary artery complications are the main reason for early mortality after an arterial switch operation. Late complications are relatively rare, and there is no consensus regarding the need or indications for routine follow-up coronary artery evaluations or the best first-line assessment modality. The aim of this study was to present the long-term post-operative frequency of coronary abnormalities in asymptomatic patients with transposition of the great arteries discovered by coronary CT angiography and potential “red flags” revealed by other examinations.Patients and methods:A group of 50 consecutive asymptomatic patients who underwent routine long-term coronary artery evaluation after an arterial switch operation according to our institutional protocol were qualified for this study. This routine in-hospital visit included a detailed medical interview, electrocardiography, echocardiography, Holter electrocardiography examinations, and laboratory and cardiopulmonary exercise tests. Patients who showed significant abnormalities were qualified for perfusion scintigraphy.Results:Unfavourable coronary abnormalities were detected in 30 patients (60%) and included ostial stenosis, muscular bridge, coronary fistula, interarterial course, proximal kinking, high ellipticity index, proximal acute angulation (<30 degree) of the left coronary artery, and proximal acute angulation of the right coronary artery. These features could not be predicted based on the medical interviews, surgical reports, or non-invasive screening test results.Conclusion:Complex coronary configurations with potentially dangerous coronary features are common in patients with transposition after an arterial switch operation. Such high-risk patients cannot be identified indirectly, and coronary CT angiography provides accurate information that is useful for post-operative management.

The Coronary Arteries in Adults after the Arterial Switch Operation: A Systematic Review

“…All coronary complications are summarized in Table 2 . Seventeen out of 192 (8.9%) patients [ 19 , 27 , 42 ] were suspected to have myocardial ischemia based on symptoms or exercise testing; after additional examinations, 3 out of 17 patients underwent coronary intervention (PCI or CABG).…”

“…Two studies [ 9 , 42 ] examined coronary anatomy in adults using routine cCT. The combined results of both studies demonstrated that 4 out of 80 (5%) patients were suspected of coronary stenosis.…”

Long-term outcome after the arterial switch operation: 43 years of experience

“…Given the small number of coronary reoperations, it is unclear whether TBA patients are at increased risk or whether this is related to the prevalent non-usual coronary artery pattern in TBA. Although abnormal coronary artery patterns have been reported as risk factor for early coronary artery obstruction [ 8 , 9 , 26 ], it is suggested that the acquired coronary anatomy after ASO may be more important as a risk factor for late coronary artery obstruction [ 27 ]. Correspondingly, half of the patients necessitating coronary reoperation from this study had a usual coronary artery pattern without problems during coronary artery transfer.…”

“…Correspondingly, half of the patients necessitating coronary reoperation from this study had a usual coronary artery pattern without problems during coronary artery transfer. Acquired abnormal coronary anatomy may result from the surgically created pattern after reimplantation and changes by growth, arterial distortion or root dilatation [ 25 , 27 ].…”

Commentary: The arterial switch operation: Is it still all about the coronaries?

“…In a recent study of 50 asymptomatic patients who underwent computed tomography angiography 14 to 25 years after ASO, 30 (60%) patients had coronary abnormalities such as ostial stenosis, acute branching of a vessel, muscular bridge, kinking, etc. 9 In another study of 40 patients, mostly asymptomatic, 11% had late coronary artery stenosis. 10 The effect that an abnormal coronary pattern has on the long-term occurrence of these abnormalities is unknown.…”