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• W2782121585 abstract "Central MessageTransfer of the IMCA in the ASO can be challenging. However, excellent results can be achieved with reproducible techniques of coronary translocation.See Article page e127. Transfer of the IMCA in the ASO can be challenging. However, excellent results can be achieved with reproducible techniques of coronary translocation. See Article page e127. Today, the operative mortality of the arterial switch operation (ASO) is expected to be less than 2% for children born with transposition of the great arteries and an intact interventricular septum.1Fricke T.A. d'Udekem Y. Richardson M. Thuys C. Dronavalli M. Ramsay J.M. et al.Outcomes of the arterial switch operation for transposition of the great arteries: 25 years of experience.Ann Thorac Surg. 2012; 94: 139-145Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar A single coronary artery is no longer a risk factor for death in most large-volume institutions.1Fricke T.A. d'Udekem Y. Richardson M. Thuys C. Dronavalli M. Ramsay J.M. et al.Outcomes of the arterial switch operation for transposition of the great arteries: 25 years of experience.Ann Thorac Surg. 2012; 94: 139-145Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar, 2Gerelli S. Pontailler M. Rochas B. Angeli E. Van Steenberghe M. Bonnet D. et al.Single coronary artery and neonatal arterial switch operation: early and long-term outcomes.Eur J Cardiothorac Surg. 2017; 52: 90-95Crossref PubMed Scopus (14) Google Scholar In contrast, an intramural coronary artery (IMCA) has been reported to increase operative mortality to more than 20%.3Metton O. Calvaruso D. Gaudin R. Mussa S. Raisky O. Bonnet D. et al.Intramural coronary arteries and outcome of neonatal arterial switch operation.Eur J Cardiothorac Surg. 2010; 37: 1246-1253Crossref PubMed Scopus (69) Google Scholar In the current issue of the Journal, Ko and colleagues4Ko Y. Nomura K. Kinami H. Kawamura R. Aortic sinus pouch technique for transposition of the great arteries with intramural coronary artery.J Thorac Cardiovasc Surg. 2018; 155: e127-e129Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar describe a technique for coronary translocation in a patient with an IMCA undergoing the ASO. They have previously applied this aortic sinus pouch technique for a patient with a single coronary artery undergoing the ASO.5Ko Y. Nomura K. Nakao M. New coronary transfer technique for transposition of the great arteries with a single coronary artery.J Thorac Cardiovasc Surg. 2017; 153: 1150-1152Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Such implantation of a single coronary button is an interesting approach to deal with an IMCA. In fact, the initial approach to IMCA transfer used by Roger Mee in the 1980s at the Royal Children's Hospital in Melbourne was also a single button transfer of both coronary arteries.6Asou T. Karl T.R. Pawade A. Mee R.B.B. Arterial switch: translocation of the intramural coronary artery.Ann Thorac Surg. 1994; 57: 461-465Abstract Full Text PDF PubMed Scopus (91) Google Scholar Subsequently, a trapdoor technique for coronary translocation during the ASO, which was originally described by Brawn and Mee,7Brawn W.J. Mee R.B.B. Early results for anatomic correction of transposition of the great arteries and for double-outlet right ventricle with subpulmonary ventricular septal defect.J Thorac Cardiovasc Surg. 1988; 95: 230-238Abstract Full Text PDF PubMed Google Scholar has been modified for translocating IMCA by the Royal Children's Hospital team.6Asou T. Karl T.R. Pawade A. Mee R.B.B. Arterial switch: translocation of the intramural coronary artery.Ann Thorac Surg. 1994; 57: 461-465Abstract Full Text PDF PubMed Scopus (91) Google Scholar Our technique involves detaching the posterior commissure of the neopulmonary valve if the coronaries arise in close proximity and unroofing the IMCA if the ostium is stenotic. The excised coronary button is then transferred to a medially based trapdoor (Figure 1). We have previously reported outcomes on 28 patients with IMCA operated with this technique with no deaths.8Fricke T.A. Bulstra A.E. Naimo P.S. Bullock A. Robertson T. d’Udekem Y. et al.Excellent long-term outcomes of the arterial switch operation in patients with intramural coronary arteries.Ann Thorac Surg. 2016; 101: 725Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar The first 3 patients in our experience had coronary translocation as a single button facilitated by a pericardial hood. After a mean follow-up of 26.3 years (median, 26.6 years; range, 25.3-26.9 years), these 3 patients are alive and well. The subsequent 25 children with IMCA underwent ASO with individual translocation of both coronary arteries using the trapdoor technique.8Fricke T.A. Bulstra A.E. Naimo P.S. Bullock A. Robertson T. d’Udekem Y. et al.Excellent long-term outcomes of the arterial switch operation in patients with intramural coronary arteries.Ann Thorac Surg. 2016; 101: 725Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar The latter 25 patients are all alive without the need for coronary reintervention after a mean 16.5 years (median, 17.7 years; range, 5.5-25.3 years). Thus, IMCA has not been a risk factor for mortality at our institution.1Fricke T.A. d'Udekem Y. Richardson M. Thuys C. Dronavalli M. Ramsay J.M. et al.Outcomes of the arterial switch operation for transposition of the great arteries: 25 years of experience.Ann Thorac Surg. 2012; 94: 139-145Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar The patient described by Ko and colleagues4Ko Y. Nomura K. Kinami H. Kawamura R. Aortic sinus pouch technique for transposition of the great arteries with intramural coronary artery.J Thorac Cardiovasc Surg. 2018; 155: e127-e129Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar had Shaher 2a coronary anatomy, with the left anterior descending coming from sinus 1 and the circumflex coronary artery and the right coronary coming from sinus 2. Of the 28 patients with IMCAs described in our recent article, 2 patients had this specific anatomy.8Fricke T.A. Bulstra A.E. Naimo P.S. Bullock A. Robertson T. d’Udekem Y. et al.Excellent long-term outcomes of the arterial switch operation in patients with intramural coronary arteries.Ann Thorac Surg. 2016; 101: 725Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Both patients underwent unroofing of the IMCA, division into 2 buttons, and a standard coronary translocation using our trapdoor technique. These patients are alive and asymptomatic 22 and 23 years after ASO. It appears that the technique of Ko and colleagues4Ko Y. Nomura K. Kinami H. Kawamura R. Aortic sinus pouch technique for transposition of the great arteries with intramural coronary artery.J Thorac Cardiovasc Surg. 2018; 155: e127-e129Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar is an elegant approach and might become a useful addition to the armamentarium of the congenital cardiac surgeon, provided that this technique results in good long-term outcomes. Time will tell. Aortic sinus pouch technique for transposition of the great arteries with intramural coronary arteryThe Journal of Thoracic and Cardiovascular SurgeryVol. 155Issue 4PreviewThe arterial switch operation (ASO) for transposition of the great arteries (TGA) has been developed for many anatomic coronary artery variants, and numerous coronary transfer techniques have been reported. TGA with intramural coronary arteries, however, is still associated with increased risk. We achieved a good result by applying an aortic sinus pouch technique for dextro-TGA (d-TGA) with an intramural coronary artery. Full-Text PDF Open Archive" @default.
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• W2782121585 title "Translocation of intramural coronary artery in the arterial switch operation: Divide and conquer?" @default.
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