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

Abstract

Background-Prior studies of coronary pattern and outcome after arterial switch operation (ASO) for transposition of the great arteries (TGA) have been hindered by limited statistical power. This meta-analysis assesses the effect of coronary anatomy on post-ASO mortality, both overall and adjusted for time. Methods and Results-A literature search revealed 9 independent series that reported post-ASO mortality by coronary pattern in a total of 1942 patients. Odds ratios comparing all-cause mortality in patients with usual versus variant coronary patterns were calculated and combined by use of an empirical Bayesian model. Single coronary patterns, both of which loop around the great vessels, were associated with significant mortality (OR 2.9, 95% CI 1.3 to 6.8), whereas looping patterns that arose from 2 separate ostia were not (OR 1.2, 95% CI 0.8 to 1.9). This latter group includes patients with the most common variant, circumflex from right coronary artery. Patients with an intramural coronary artery had the greatest mortality (OR 6.5, 95% CI 2.9 to 14.2). Overall, patients with any variant coronary pattern had nearly twice the mortality seen in those with the usual pattern (OR 1.7, 95% CI 1.3 to 2.4). Single ostium patterns and intramural coronary arteries remained associated with significant added mortality after adjustment for time-trend effects. Conclusions-Over the past 2 decades, patients with common coronary variants have undergone ASO without added mortality compared with those with the usual coronary pattern. Those with intramural or single coronary arteries have significant added mortality that has persisted over time.

ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease

“…Patients with intramural or single coronary arteries have increased mortality compared with those with the typical coronary pattern. 570 Coronary ischemia is a recognized late complication after ASO, with concern about ischemia or infarction reported in up to 8% of patients after ASO. These complications are due to reimplantation of the coronary arteries during surgery.…”

ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease: Executive Summary

“…Patients with intramural or single coronary arteries have increased mortality compared with those with the typical coronary pattern. 167 Coronary ischemia is a recognized late complication after ASO, with concern about ischemia or infarction reported in up to 8% of patients after ASO. These complications are due to reimplantation of the coronary arteries during surgery.…”

Follow-up of our patients with transposition of the great arteries and arterial switch operation; comparison of simple and complex transposition cases

“…Yakın zamana kadar ASO yapılan hastalarda koroner anomali bulunmasının mortaliteyi önemli oranda arttırdığı düşünülürken (11,13), gelişen cerrahi teknikler ve deneyimdeki artış sonucu koroner anomaliler ASO için kontrendikasyon olmaktan çıkmıştır (6,7). Ancak intramüral seyirli koroner arterler, "inverted" koroner arter yapısı, sol anteriyor sinüsten çıkan tek koroner arter gibi anomaliler ASO sırasında bazı komplike teknik modifikasyonlara ihtiyaç gösterir.…”