arterial switch with abnormal coronariesaz9194.vo.msecnd.net/pdfs/120401/11.07.pdf · arterial...

Arterial SwitchArterial Switch

with Abnormal Coronarieswith Abnormal Coronaries

ASO, Cx. Coronaries AATS, SF 2012

with Abnormal Coronarieswith Abnormal Coronaries

Francois LacourFrancois Lacour--Gayet, MDGayet, MDProfessor and Chief Professor and Chief Pediatric Cardiac SurgeryPediatric Cardiac Surgery

Montefiore Children’s Hospital, Montefiore Children’s Hospital,

Einstein College of Medicine, Einstein College of Medicine,

New York CityNew York City

DisclosureDisclosure

• None


Yacoub Classification

ASO, Cx. Coronaries AATS, SF 2012Yacoub MH, RadleyYacoub MH, Radley--Smith R.M. Smith R.M. Thorax. 1978;33:418. Thorax. 1978;33:418.

C C PlanchePlanche, F , F LacourLacour--GayetGayet et al et al Pediatric Cardiology 1998; 19: 297Pediatric Cardiology 1998; 19: 297--307307

Marie Lannelongue Classification

Based on the Course of the Coronaries

��Normal course:Normal course: 60%60%

��Looping courses: Looping courses: 35%35%


��Looping courses: Looping courses: 35%35%

-- posterior posterior 20%20%

-- anterioranterior 1%1%

-- double loopingdouble looping 14%14%

��IntraIntra--mural course:mural course: 5%5%

Right SinusRight Sinus Left SinusLeft Sinus

Normal Course: 60%


Not applicable to situs inversusNot applicable to situs inversus

Posterior Looping Course: 20%


19%19% 1%1%

Anterior Looping Course: 1%


Double Looping Course: 14%

Taussig Bing


Kinking of

Posterior Vessel

Risks Depending on CourseRisks Depending on Course


Stretching of

Anterior Vessel

Single OstiumSingle Ostium


Anterior

Looping

Posterior

Looping

Double

Looping

Nearly ALL CASESNearly ALL CASES


Intramural Course: 5%

Most Complex Form

Single ostium


Yacoub type C Yacoub type B

ASO TechniquesASO TechniquesClosed aortaClosed aorta

��Opened aorta: Opened aorta:

-- TrapTrap--doordoor

�� No trapNo trap--doordoor


�� CustodiolCustodiol cardioplegiacardioplegia

�� No circulatory arrestNo circulatory arrest

��LecompteLecompte ManeuverManeuver

��PA reconstruction: PA reconstruction:

PantaloonPantaloon autologous pericardiumautologous pericardium

Aorta

High

Division of the Great VesselsDivision of the Great Vessels

Shorten the NeoShorten the Neo--AortaAorta


PA

Low

LargeLarge coronary buttonscoronary buttons


The more complex, the more dissection The more complex, the more dissection

LeftLeft buttonbutton


No trap-door

RightRight buttonbutton


Right button in high positionRight button in high position


IntraIntra--mural coursemural course


Yacoub Type C

Yacoub Type BYacoub Type B


IntraIntra--mural coronarymural coronaryYacoub type B


C Planche C, F Lacour-Gayet et al. JTCVS 1988; 96: 354-63

Yacoub Type BRotation 180Rotation 180ºº

Yacoub type B,

No coronary relocation


P Aubert et al, British Heart Journal 1978; 40: 204-10

Yacoub type B,

No coronary relocation


N Moat et al JTCVS 1992, 103, 872-6

S Takeuchi, 1990; 50: 1000-2

Infundibular coronary branchInfundibular coronary branch


VERY FREQUENTVERY FREQUENT

Excentric OstiumExcentric Ostium


Malaligned CommissuresMalaligned Commissures


Important

AortoAorto--Pulmonary Diameter MismatchPulmonary Diameter Mismatch


Side by side vesselsSide by side vessels


ExampleExample


TGA-IVS

Double looping + Intra Mural + Side by Side

Harvesting common buttonHarvesting common button


Incising the stenosed left ostiumIncising the stenosed left ostium


Creating two buttonsCreating two buttons


Results Results


Results Results

Denver Children’s, 2002-2010

101 consecutive Arterial Switch, 49% cx ASO

Hospital Mortality : 0%

ATS, June 2012ATS, June 2012


Hospital Mortality : 0%

• Coronary Failure: 2 patients

•1 transplantation, single ostium

•1 late death, DORV, Malaligned commissure

• 3 angioplasty

• No late reoperation

Survival Curve, 101 ASO

90%

95%

100%

99%


50%

55%

60%

65%

70%

75%

80%

85%

90%

1 2 3 4 5 6 7 8 9 100 6M 1Y 2Y 3Y 4Y 5Y 6Y 7Y 8Y

ATS, June 2012ATS, June 2012

Mean LOS:13D

Complications: 25%

Most frequent in complex forms

No AV block

Failure to rescue: none

101 Arterial Switch101 Arterial Switch


Failure to rescue: none

Risk Factor for Morbidity:

Malaligned commissures

Aortic arch repair

Coronary anatomy no more a risk factor

1198 ASO, 1198 ASO,

Mean follow up 59MMean follow up 59M

324 coronary angiograms324 coronary angiograms

2% coronary reoperation2% coronary reoperation

Intra mural coronary p=0.002Intra mural coronary p=0.002

Late Coronary Complications after ASOLate Coronary Complications after ASO

Coronary events after arterial switch operation for TGA. Legendre A, Losay J, Serraf A et al. Coronary events after arterial switch operation for TGA. Legendre A, Losay J, Serraf A et al.

Circulation 2003, Suppl 1:II 186Circulation 2003, Suppl 1:II 186--9090


Intra mural coronary p=0.002Intra mural coronary p=0.002

��Late Coronary Control in complex coronaryLate Coronary Control in complex coronary(CT Scan, MRI, coronarography)(CT Scan, MRI, coronarography)

Late dilation of the neoLate dilation of the neo--aortaaorta

A Baruteau, V Lambert, Marie Lannelongue, Paris

2026 ASO2026 ASO, 1982-2012

118 Adult > 18Y with complex ASOMean Follow up 21.2 Y

�60% dilatation of the neo-aortic root

�8% reoperation for aortic regurgitation


�8% reoperation for aortic regurgitation

�1,5% coronary reoperation

ASO: They do wellASO: They do well


WilliamWilliam, 20Y, French Junior Formula 1 Champion., 20Y, French Junior Formula 1 Champion.

Arterial Switch, Oct. 1991

William, 20YWilliam, 20Y

Arterial Switch, 1991


William

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