How I Teach It - Coronary Revision Following Arterial Switch Operation
Alan O'Donnell, James Tweddell.
Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
Patient is a 9-day old 3.56kg male with an antenatal diagnosis of simple Transposition with intact ventricular septum. Patient was managed with a PGE-1 infusion and 2L NC. Patient underwent balloon atrial septostomy on DOL2 due to worsening saturations despite escalating respiratory support. On DOL9 patient was taken to the operating room for an Arterial Switch Operation. Pre-operative transesophageal echocardiogram (TEE) demonstrated good biventricular function. The operation was undertaken by the Congenital ACGME Fellow at the time under the supervision of the attending surgeon. Coronary artery anatomy was typical for simple Transposition (Sinus 1 - LMCA bifurcating into Cx and LAD; Sinus 2 - RCA). The operation was relatively uneventful. Post-operative TEE demonstrated a dilated left ventricle with severe dysfunction despite inotropes. Ischemic changes were seen on ECG. Cardiopulmonary bypass (CPB) was reinitiated and the attending surgeon took down the neo-pulmonic and neo-aortic roots. Upon inspection, there was no obvious defect appreciated with both coronary easily accepting dilators. The left coronary artery button was taken down. The button was found to have adequate sinus around the ostia. The proximal course of the coronary artery was thought to be stretched. The reimplantation site was extended inferiorly by 2mm. The medial border of the site was patched with homograft. The final result was a more inferolateral position of the coronary artery button. Additionally, the neopulmonary root suture line appeared to catch adjacent adventitia that was divided. Following TEE demonstrated normal biventricular function. Patient convalesced well and was discharged on POD7.
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