The arterial switch operation is without doubt the first choice in dealing with transposition of the great arteries. Around 60% of patients present with an A or normal Leyden coronary pattern, whereas the remaining 40% show other different patterns. The incidence of a single coronary ostium is 6%.Reference Jonas 1
Single-ostium patterns and intramural coronary arteries remain associated with significant added mortality after adjustment for time–trend effects.Reference Pasquali, Hasselblad and Li 2
We describe a case with a complex coronary pattern where we decided to perform a modification of an old-fashioned technique that may have a role in such situations.
Case report
A newborn with transposition of the great arteries was operated on his 5th day of life. We proceeded to aortic and bicaval cannulation. During the surgery, an antero-posterior aorta pulmonary disposition and a single posterior right coronary ostium – left-facing sinus – with an interarterial route were discovered. There was commissural alignment. The aorta was cross-clamped, and cold crystalloid antegrade cardioplegia was delivered.
We decided to perform the Aubert technique, creating an aortopulmonary window and a tunnel between the aorta and the coronary ostium with glutaraldehyde-treated native pericardial patch. The pulmonary artery was enlarged with a patch in its anterior portion. In this way, the need for translocating the single coronary ostium in a 180° turn, and therefore the consequent torsion risk was avoided. We introduced a modification, the Lecompte manoeuver, translocating the pulmonary arteries in front of the aorta (Fig 1). The chest was closed in the usual manner.
(1) Intraoperative photograph shows the anteriorized bifurcation of the pulmonary trunk (AP) (Lecompte maneuver) and the patch in its anterior portion (dashed circle) and the aorta (Ao). (2) Schematic drawing that explains the previous photo. (3) Schematic drawing of the lateral view of the preoperative relation of the aorta and pulmonary artery. (4) Schematic drawing of the lateral view after the correction with the Lecompte maneuver and the intraarterial tunnel (*).
The echocardiography (Fig 2) shows the aorta, the pulmonary artery, and the patch of the tunnel.
The echocardiography shows the aorta (Ao), the pulmonary artery (AP) and the patch of the tunnel (*).
The patient was extubated on the 4th day, and inotropic support was withdrawn on the 5th day. The electrocardiogram showed no significant changes. The patient stayed in the ICU for 9 days, and the patient was discharged on the 20th day. At the 6-month follow-up, the patient remained asymptomatic with good ventricular function (ejection fraction 60%) and without aortic or mitral insufficiency or pulmonary stenosis in echocardiogram checks.
Discussion
The arterial switch operation has become the preferred surgical procedure for correction of neonatal transposition of the great arteries, after its introduction by Jatene in 1975 and its modification by Lecompte in 1981.
Since then, mortality has been reduced significantly, thanks to improvement in diagnosis, surgical techniques, such as more extensive epicardial mobilisation of the proximal arteries and modifications of the implanted site, atrial balloon septostomy, and medical management. At present, most of the treated patients live to adulthood, with a 20-year survival of nearly 90%.Reference Pasquali, Hasselblad and Li 2
Nevertheless, the operative risk is higher in: single coronary ostium, intramural coronary arteries, the Taussig Bing anomaly, hipoplastic aortic, low birth weight and age presentation after four weeks.
Aubert described a technique for transposition of the great arteries in which an aortopulmonary window is created and a polyester patch is placed over the coronary ostia, so that the coronary arteries arise from the new aorta.Reference Aubert, Pannetier and Couvelly 3 Thus, direct surgery on the coronary arteries is avoided.
Takeuchi and KatogiReference Takeuchi and Katogi 4 suggested a modification for cases with either a single coronary or an intramural coronary artery. They created the internal tunnel with a flap of the anterior aortic wall and added the Lecompte manoeuver. With this modification, the surgeon must decide on the technique before transecting the aorta. We find it easier to create a custom patch with autologous pericardium once the aortopulmonary window is made to give enough space. We also incorporated the Lecompte manoeuver. Lecompte manoeuver is routinely performed in most of the switch operations except for transpositions of the great arteries side by side. When the Aubert technique was described (1978), the Lecompte manoeuver did not exist, as it was introduced in 1981. The advantage of the Lecompte manoeuver is the less distance between the neopulmonary root and the pulmonary bifurcation, avoiding the need to interject a conduit.
Yacoub and Radley-SmithReference Yacoub and Radley-Smith 5 reported another technique for transpositions of the great arteries type B and C in which after transecting the great arteries, the aortic wall is incised in a semi-circular manner 2 mm from the rim of the coronary ostium. The resulting disc is rotated 90°and anastomosed to the adjacent edge of the transected pulmonary artery and covered by a cuff of aortic tissue during the neo-aortic anastomosis. This rotation may cause kinking of the coronary arteries, which is avoided with the Aubert technique.
Imai introduced a modification of the Aubert technique. After creating the aortopulmonary window, the non-facing sinus was excised 1 mm above the aortic valve ring with the aortic wall just above the facing commissure as a hinged, pedicled flap. This flap was flipped on the bottom of the right-facing sinus, and was sutured along the base of the right-facing sinus to cover coronary orifices, creating a coronary pouch. The defect of the non-facing sinus was covered and enlarged with an autopericardial or bovine pericardial patch. Koshiyama et alReference Koshiyama, Nagashima and Matsumura 6 have recently reviewed their experience with the Imai technique. From 1985 to 2014, 14 patients with intramural coronaries were operated – five with the double-button method and 10 with the Imai technique. Actual survival and freedom from coronary complications at 15 years were 70 and 67%, respectively, with the Imai technique, and 40 and 20%, respectively, with the double-button method. From the Imai group, three patients (30%) underwent right ventricular outflow reconstruction for supravalvular pulmonary stenosis. We believe that the risk of suprapulmonary stenosis may be higher than with the Aubert technique, as more neopulmonary tissue is used for creating the pouch, increasing the need of a bigger patch to reconstruct the neopulmonary artery.
Adluri et alReference Adluri, Barron and Brawn 7 described a case of transposition of the great arteries with an aortopulmonary window. If the coronary arteries are close to the window and close together, then adequate mobilisation as two separate buttons may be difficult. They performed a modification of the Aubert technique, mobilising both coronary arteries in a single button, in continuity with the window, after taking down the aortic commissure, creating a pouch with a bovine pericardial patch. The difference was that the two arteries were separated; the posterior wall of the pulmonary artery was reconstructed with autologous pericardium, and the commissure was re-suspended. The Lecompte manoeuver was also performed.
Different strategies are important for the possible variations of anatomy in transposition of the great arteries. In complex coronary arteries as well as in aortopulmonary window association, a technique in which a tunnel or a pouch can be created avoiding the translocation of difficult coronary arteries might be of great value.
It is necessary to evaluate the results over a longer period of time.
Conclusion
The Aubert technique is a feasible option for complex coronary artery configurations that might be useful to have in the surgical armamentarium. As the interarterial coronary anatomy is a risk factor for future coronary events, even after a successful Aubert procedure, long-term follow-up is mandatory.
Acknowledgements
None.
Financial Support
This research received no specific grant from any funding agency or from commercial or not-for-profit sectors.
Conflicts of Interest
None.
Ethical Standards
The authors assert that all work reported complies with the ethical standards of the Helsinki convention, and consent for publication has been granted by the patient’s family.
