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%

-- posterior posterior 20%20%

-- anterioranterior 1%1%

-- double loopingdouble looping 14%14%

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

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%

-- 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

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

Division of the Great VesselsDivision of the Great Vessels

Shorten the NeoShorten the Neo--AortaAorta

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

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

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

�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

Arterial Switch with Abnormal Coronariesaz9194.vo.msecnd.net/pdfs/120401/11.07.pdf · Arterial...

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