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Ann Thorac Surg 1995;60:89
© 1995 The Society of Thoracic Surgeons

Discussion

	Introduction

Top Introduction

 
See also page 84.

DR CHARLES B. HUDDLESTON (St. Louis, MO): I thank The Society for the opportunity to discuss the paper and compliment Dr Turley and his colleagues on their excellent series presented here.

I think that most would agree now that a two-coronary type of reconstruction for this disease is the appropriate procedure, and most do it by coronary transfer rather than a tunnel technique. The uniqueness of this particular series is in the extensive use of pulmonary artery tissue to reconstruct by direct anastomosis the coronary artery that originates at a distance from the aorta. The experience with the arterial switch procedure has indicated that we can mobilize coronaries when they are at a distance, but, again, the concept of using the pulmonary artery tissue to construct tubes, as performed by Dr Turley and associates, is really the uniqueness of this series, and for that reason I think the focus should be on the 4 patients in whom that was performed.

I assume that the long-term patency of these coronaries would be good on the basis of using autologous tissue, but there is a very long suture line in the lumen of this newly constructed coronary artery. Echocardiography gives some indication of patency but by no means is the gold standard, and I think it may be a little bit presumptuous to say that there is 100% patency on the basis of the echocardiogram alone. I urge that a follow-up cardiac catheterization be performed not only to assess the patency but to see if there are any stenotic areas that have developed in these long tubes to get a better idea of their long-term results.

A technical modification that we have used in this operation is do a transverse aortotomy to locate precisely the place for implantation of the coronary. That allows for the direct visualization of the aortic valve leaflets and avoids potential injury to those when a button of aorta is excised for the anastomosis, particularly in very small children.

One difference in our series from Dr Turley and associates, is that 70% of our patients are less than 1 year of age at presentation and many of those, if not most, are in extremis, requiring inotropes and mechanical ventilation after presentation. Their series is somewhat different in that the majority were more than 1 year of age. Doctor Turley, would you comment about that?

I congratulate Dr Turley and his associates on their excellent results and appreciate the opportunity to review the manuscript beforehand.

DR CONSTANTINE E. ANAGNOSTOPOULOS (New York, NY): I enjoyed the presentation. The existence of another autologous tissue with a potential of growth should be noted, namely the rectus sheath, in addition to the pulmonary artery; it has been used in 7 patients with long-term follow-up showing potential for growth and absence of thromboembolism.

The questions that I have are, first, what was the form of myocardial protection, particularly for your very advanced patients, and second, have you had any patients who were turned down and recommended for transplantation, and what was the indication for that?

DR TURLEY: I thank the discussants for their questions. In answer to Dr Huddleston, in the 11 patients, 4 angiograms have been performed postoperatively, including in 2 of the 4 patients with tubular reconstruction. Both demonstrated patency without anastomotic stenosis. With the advent of extensive use of echocardiography, follow-up angiograms rarely are used unless there are questions of an anatomic problem. We agree, however, clearly it would be beneficial to follow up such patients with this more precise method of anatomic delineation.

The age of the patients represented the distribution during this time frame. In our earlier experience we have noted, as did you, infants often with a recent infarction. Their absence in the current study is noted in the manuscript, and they clearly represent a difficult group. However, 6 of our 11 patients did present in the first year including the 1 with prior ligation and the most recent, treated at 13 months.

In answer to Dr Anagnostopoulos, no patients during this period were refused operative intervention and none were recommended for transplantation. As to the question of myocardial protection, we used cold asanguineous cardioplegic solution in the first 4 patients and cold blood cardioplegic solution in the subsequent 7, with cold retrograde cardioplegia in the last 3. At the initiation of bypass in the first 4, occlusion of the coronary artery was performed at the time of injection into the aortic root. In subsequent patients, we have injected both the aorta and pulmonary artery with cardioplegic solution with cross-clamp of both vessels, ensuring delivery of the cardioplegia and preventing run-off through the pulmonary system.

I thank the discussants for their kind remarks.

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