Ann Thorac Surg 2003;75:1769-1773
© 2003 The Society of Thoracic Surgeons
Original article: cardiovascular
"Bay window" technique for the arterial switch operation of the transposition of the great arteries with complex coronary arteries
Masaaki Yamagishi, MD*a,
Keisuke Shuntoh, MDa,
Katsuji Fujiwara, MDa,
Takeshi Shinkawa, MDa,
Takako Miyazaki, MDa,
Nobuo Kitamura, MDa
a Department of Pediatric Cardiovascular Surgery, Children’s Research Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
Accepted for publication December 31, 2002.
* Address reprint requests to Dr Yamagishi, Department of Pediatric Cardiovascular Surgery, Children’s Research Hospital, Kyoto Prefectural University of Medicine, Kawaramachi, Hirokoji, Kamikyo-ku, Kyoto, 602-8566 Japan
e-mail: myama{at}koto.kpu-m.ac.jp
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Abstract
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BACKGROUND: The success of arterial switch operations for transposition of the great arteries largely depends on faultless coronary translocation and subsequent sufficient myocardial perfusion. However, in patients with complex coronary artery anatomy, coronary translocation is often difficult to perform by conventional surgical techniques alone. Therefore we developed the "bay window" technique as a useful adjunct in patients with complex coronary arteries undergoing concomitant coronary translocation and arterial switch operation. Early and midterm results of this technique are described.
METHODS: Between September 2001 and February 2002, 4 patients with transposition of the great arteries with complex coronary arteries underwent arterial switch operation. The ages of the patients at the time of operation ranged from 8 to 52 days. Great arterial relationships were anteroposterior in 2 patients, right-oblique in 1, and side-by-side in 1. One patient also had ventricular septal defect. Coronary arterial patterns were as follows: absent left main trunk in 1 patient, short left main trunk in 1, and short right main trunk in 1. Both coronary arterial orifices were resected as a tall U-shaped cuff. The inferior half of the coronary cuff was sewn into a J-shaped incision on the pulmonary stump. The superior half of the coronary cuff was folded down inside to form a bay window channel.
RESULTS: No coronary events occurred (ie, inclusive of coronary stenosis, myocardial infarction, and coronary death). Postoperative echocardiogram demonstrated normal ventricular wall motions in all 4 patients.
CONCLUSIONS: The bay window technique is an innovative and simple surgical adjunct for translocating complex coronary arteries.
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Introduction
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Currently the arterial switch operation (ASO) for transposition of the great arteries (TGA) is the standard definitive procedure which has low morbidity and mortality [1,2]. The most serious problem associated with ASO is inadequate myocardial perfusion through the reimplanted coronary arteries [3]. Patients with complex coronary anatomy in particular are susceptible to having coronary ischemia after reimplantation of the arteries develop. The coronary artery anatomy is an important predictor of surgical outcome [4–6]. Among the various types of the coronary anatomy requiring TGA [7, 8], single and intramural coronary arteries are the most difficult to translocate [9]. In addition, an absent or short main coronary trunk and a double orifice originating from the same sinus Valsalva also increase the risk of inadequate myocardial perfusion after the translocation.
Aubert and colleagues’ [10] procedure and Takeuchi and Katogi’s [11] technique, in which an intrapulmonary coronary tunnel is created instead of coronary translocation, are excellent alternative techniques for patients with a complex coronary anatomy. However, the intrapulmonary coronary tunnel may cause an obstructive lesion of the neopulmonary artery. Murthy and Cherian’s [12] modification without coronary translocation also involves the risk of pulmonary artery obstruction. Hence the ASO concomitant with coronary translocation is a common surgical option even in patients with complex coronary anatomy.
Various technical modifications concerning translocation of the complex coronary arteries have been introduced [2, 5, 8, 13–18]. However none of these modified techniques are widely applicable because each has its own drawbacks. We introduced an effective modification of the "trap-door" technique [13] to allow safer transfer in complex arterial configurations. Early and midterm results are described.
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Patients and methods
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Between September 2001 and February 2002, 4 pediatric patients with complete TGA with complex coronary anatomy underwent ASO at our institution. These 4 patients had unusual patterns of coronary arteries with morphologic features associated with a considerably higher risk of coronary insufficiency after the translocation. The age of the patients at the time of ASO was 8, 9, 13, and 52 days. Body weights ranged from 3.0 to 3.8 kg (mean, 3.4 kg). All patients underwent preoperative echocardiography and angiocardiography. All 4 patients had a patent foramen ovale. One patient had a perimembranous ventricular septal defect. Coronary anatomy was examined by laid back aortography.
Relationships of the great arteries and coronary artery anatomy
In patient 1 (Fig 1
[1],) the aorta was located right and anterior to the pulmonary trunk. The right coronary artery originated from the right-facing sinus Valsalva (sinus 2 [19]). The left anterior descending artery, the left circumflex artery, the high lateral branch, and the conus branch originated from the left-facing sinus (sinus 1) with four separate orifices. There was no left main trunk.
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Fig 1. Coronary patterns. (1) Patient 1. (2) Patient 2. (3) Patient 3. (4) Patient 4. (A = anterior; CB = conus branch; HL = high lateral branch; L = left; LAD = left anterior descending artery; LCX = left circumflex artery; P = posterior; R = right; RCA = right coronary artery; RV = right ventricular branch; SN = sinus nodal artery.)
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In patient 2 (Fig 1[2]) there was a side-by-side relationship of the great arteries. Both the left and right coronary arteries originated from the posterior sinus (sinus 2) with a single orifice and a very short main stem. A large right ventricular branch artery originated from the anterior sinus (sinus 1).
In patient 3 (Fig 1[3]) the aorta was located anterior to the pulmonary trunk. The aortic and pulmonary commissures were out of alignment. The left main trunk originated from the left-facing sinus (sinus 1). The right coronary artery originated from the right-facing sinus (sinus 2) with a single orifice. The right coronary artery was immediately trichotomized into the main trunk, the sinus nodal artery, and the conus branch. The main stem of the right coronary artery was fairly short. The sinus nodal artery and the conus branch ran in opposite directions.
In patient 4 (Fig 1[4],) the aorta was located anterior to the pulmonary trunk. The aortic and pulmonary commissures were out of alignment. The left circumflex artery and the right coronary artery originated from the right-facing sinus (sinus 2) with two separate orifices. The orifice of the left circumflex artery was stenotic due to a membranous diaphragm. The left main trunk originated from the left-facing sinus (sinus 1). A large right ventricular branch artery also originated from sinus 1 with a separate orifice.
Operative procedure
All patients underwent the operation through a median sternotomy.
A rectangular pericardium was harvested. The aortic arch, neck arteries, and pulmonary artery were fully mobilized. The marking sutures were placed on the main pulmonary artery. After establishing cardiopulmonary bypass in the usual manner, the ductus arteriosus was ligated and divided. An aortic cross clamp was placed and the cardioplegic solution was infused. The ascending aorta was transected at a fairly high level of more than 10 mm above the origin of the coronary artery. The pulmonary artery was also transected just before the bifurcation. After careful confirmation of the coronary ostial configuration and angioplany of the coronary stem, both coronary cuffs were excised in a U-shape. Multiple orifices at the same sinus were excised all together with the same U-shaped cuff. Because the ascending aorta was transected a few millimeters more cranial than usual, the coronary cuff above the coronary orifice was left somewhat long. Using the marking suture on the proximal stump of the pulmonary artery as a reference, the anterior pulmonary wall was incised as a medially hinged J-shape (Fig 2). The incision was not extended into the sinus Valsalva beyond the sinotubular junction in order to preserve the sinus configuration. The coronary cuff was sewn with a running 7-0 polydioxanon suture (PDS II; Ethicon, Somerville, NJ), starting at the bottom of the J-shaped incision and the inferior end of the cuff. When the anastomosis reached the transverse section of the pulmonary trunk, the superior excess cuff was folded down inside. The outer edge of the folded-down cuff was anastomosed along the superior edge of the J-shaped pulmonary flap to form a bay window bulged coronary channel.
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Fig 2. Schematic representation of the operative procedure. (1) Anterior pulmonary wall was incised as a medially hinged J-shape. (2) The coronary cuff was sewn, starting at the bottom of the J-shaped incision and the inferior end of the cuff. (3) The superior excess cuff was folded down inside. (4) The outer edge of the folded-down cuff was anastomosed along the superior edge of the J-shaped pulmonary flap to form a bay window-like bulged channel and represent a unilateral bay window channel. (5) In case of bilateral bay window channels, the superior ends of the bilateral cuff were directly anastomosed together.
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After bringing the pulmonary bifurcation anterior to the ascending aorta, the proximal pulmonary stump bearing the bay window-like coronary channel was anastomosed to the ascending aorta with a running 6-0 polydioxanon suture (PDS II; Ethicon). The anterior wall of the transverse section of the ascending aorta was anastomosed to the inner edge of the folded-down cuff. The defects of the aortic sinuses were filled with a pantaloon-shaped autologous pericardium with running 7-0 polydioxanon sutures (PDS II; Ethicon). Last, according to Lecompte and colleagues’ [20] maneuver, the neopulmonary proximal stump was anastomosed with the anterior translocated pulmonary bifurcation in 3 patients (patient 1, 2, and 4). In patient 3, who had side-by-side great arteries, the neopulmonary artery was reconstructed posterior to the neo-aorta according to the original method by Jatene and colleagues’ [21].
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Results
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The follow-up period ranged from 10 to 15 months (mean, 12.5 months). The progress of all patients has been well with good weight gain. No coronary events (including coronary stenosis, myocardial infarction, and coronary death) occurred in any of the patients. No ischemic changes were seen on postoperative electrocardiography. Postoperative echocardiograms demonstrated normal ventricular wall motions in all patients. Postoperative aortograms demonstrated the bulged bay window channel and well-developed coronary arteries (Fig 3A, 3C).
The bay window channels were not compressed by the anterior pulmonary artery. Pulmonary arteriograms demonstrated that there were no deformities and stenotic lesions of the pulmonary artery caused by bay window compression (Fig 3B, 3D).
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Fig 3. Postoperative angiograms (upper: patient 1; lower: patient 4). Aortogram (A, C) demonstrated the bulged bay window channels and well-developed coronary arteries. White arrows indicate the bay window channel. Pulmonary arteriogram (B, D) demonstrated that there were no stenotic lesions at the pulmonary artery caused by the bay window compression.
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Comment
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Coronary translocation and consequent adequate coronary blood flow greatly affect the early mortality and late morbidity of the ASO. Kinking or overstretching of the translocated coronary artery, or both, can lead to insufficient coronary blood flow followed by lethal myocardial ischemia. Furthermore, trivial kinking or overstretching, or both, may cause a growth disorder of the coronary artery later in life. In addition to the course of the coronary artery, figuration of the origin of the coronary artery such as intramural origin of the coronary artery is also an important factor for ASO. In addition to a growth disorder of the coronary cuff itself, a thin coronary artery secondary to unsuitable translocation may cause late coronary obstruction [22, 23]. An impeccable coronary translocation procedure is essential to achieve good early and late results after ASO. As well as the technical problems, early results are also greatly influenced by the coronary arterial anatomy. Among the various coronary anatomies seen in TGA, coronary patterns that are technically difficult to translocate include intramural coronary arteries, a coronary artery with short main stem, multiple coronary orifices in the same sinus, and a coronary artery running between both great arteries (Yacoub and Randley-Smith’s [8] type B and C, Shaher and Puddu’s [7] type 5A and 5C). The spatial relation between the coronary cuff and the stem of the coronary artery are changed after the translocation. There is a divergence angle of about 90 degrees between the original position of the coronary cuff at the aortic wall and the assumed implanted site on the opposite pulmonary wall. The spatial difference before and after the translocation causes bending or kinking at the stem of the coronary artery, which, in turn, can cause the proximal coronary branches to become overstretched. To avoid bending or kinking of the coronary arteries, it is important to maintain the spatial geometry of the translocated coronary arteries. However, conventional surgical measures do not always preserve the original geometry of the coronary cuff and the stem of the coronary arteries. Minor technical modification of Yacoub and Randley-Smith’s [8] type D coronary artery, in which the circumflex artery that originated from the right posterior sinus ran behind the pulmonary trunk and consisted of a cranial shift of the translocated site, was developed to avoid kinking of the stem of the circumflex artery [24]. Although this technique is certainly useful, the risk of overstretching has yet to be satisfactorily addressed.
A trap-door technique [13] was previously devised to maintain the spatial geometry and divergence angle of the coronary artery. The trap-door technique minimizes the consequences of changes in the spatial geometry of the coronary cuff and divergence angle. The trap-door also provides sufficient protection at the lower end of the anastomosis between the open door-like pulmonary wall and the coronary cuff. However, the processing of the upper end of the trap-door procedure reduces its beneficial effect. Because the upper part of the flap-like pulmonary wall door and the coronary cuff is sewn to match the inside wall, the upper part of the coronary blood flow pathway is consequently narrowed down. In addition, the ideal geometry of the translocated coronary cuff will be wrapped by the anastomosis between the distal stump of the ascending aorta and the superior end of the trap-door.
Another surgical option is magnification of the translocated coronary arterial channel using a supplement patch to provide enough room at the channel [19]. However, the possibility of thrombosis, lack of growth, and degeneration can occur at coronary channels augmented with a prosthesis [25]. Therefore, augmentation of the coronary channel using a prosthesis is not satisfactory as a generalized technique.
In our technique, the superior part of the coronary channel is covered with a folded- down coronary cuff and a new coronary channel is consequently formed like a bay window. A wide coronary pathway, larger than that created by the trap-door method, can be provided. Furthermore, the divergence angle and the spatial relation between the coronary arterial stem and the aortic wall are maintained before transplant equally by the trap-door and the bay window techniques. The spatial relation and geometry of the translocated coronary cuff do not change after reconstruction of the aorta with end-to-end anastomosis between the distal stump of the aorta and the proximal stump of the neo-aorta. The basic concept of our surgical technique is similar to that of the pericardial hood technique by Parry and colleauges [18]. However, our modification is clearly distinguished from the conventional hood techniques using a supplement by the absence of any prosthetic material [15, 16, 18]. Moreover, our technique differs radically from Vouhe and colleagues’ [17] modification, in which the coronary cuffs were to pull the midportion by force and reimplant the same opening of the neo-aorta.
During the coronary translocation, the coronary cuff should be implanted above the sinotubular junction of the pulmonary proximal stump to avoid deformity of the sinus Valsalva and subsequent neo-aortic regurgitation. However, when the main pulmonary trunk is short, an incision into the sinus Valsalva is necessary in the trap-door technique to ensure that the height of the coronary channel is adequate. In contrast, using the bay window technique, the coronary cuff is neatly implanted without an incision into the sinus. In spite of its low profile, the bay window-like channel by the folded coronary cuff ensures that the pathway is sufficient for adequate coronary flow. Moreover, in patients with associated misalignment of the commissures between the aortic and pulmonary valves, as in patients 3 and 4, the bay window technique provides a clear advantage over the trap-door technique, because no incision into the sinus Valsalva is required.
In the conventional techniques, identification of the best implanted position on the neo-aorta completely depends on the surgeon’s subjective experience. A minor modification is necessary according to individual differences. These factors complicate coronary translocation of the ASO. The bay window technique does not require special coordination and can become a standardized universal procedure for the transfer of complex coronary arteries in the ASO. This technique can be also applied to patients not just with complex coronary arteries but also with general coronary arteries. The specific coronary arrangements for which this technique is recommended are complex coronary arterial patterns such as intramural coronary artery, short main trunk, or Shaher and Puddu’s [7] classification types 3, 5, and 7. However, this modification may be exceptionally difficult to perform on Yacoub and Randley-Smith’s [8] B type and some C type coronary arteries. Postoperative aortogram demonstrated that the bay window channels did not overbulge. However, possibility of aneurismal change of the bay window channel cannot be completely denied. Further observation about aneurismal change of the bay window channel in the late phase should be needed.
In conclusion, the bay window technique, which does not require specialized technical skill, provides a wide and smooth coronary pathway and achieves excellent midterm results of the ASO for the transposition of the great arteries with complex coronary arteries.
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References
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Abstract
Introduction
