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Rare Coronary Artery Variants Are Associated With Increased Mortality And Reinterventions Following The Arterial Switch Operation
Stephanie N. Nguyen, MD, Alice V. Vinogradsky, BA, Alice M. Tao, BS, David M. Kalfa, MD, PhD, Emile A. Bacha, MD, Andrew B. Goldstone, MD, PhD.
Columbia University Irving Medical Center, New York City, NY, USA.

Objective: To determine the influence of coronary anatomy on long-term outcomes of the arterial switch operation (ASO).
Methods: We retrospectively reviewed patients with transposition of the great arteries or Taussig-Bing anomaly who underwent ASO at our institution from 1995-2022. The primary endpoint was freedom from the composite of death, transplant, or coronary reintervention. Subanalysis was performed to determine the influence of intramural coronary arteries.
Results: A total of 637 patients (median age: 5 days [IQR, 4-7]) underwent ASO. Coronary anatomy included: usual (n=416, 65.3%), common variants (n=98, 15.4%), inverted (n=54, 8.5%), single (n=38, 6.0%), and intramural (n=31, 4.9%). Early mortality was 2.5% (n=16) and highest in the intramural group (n=3, 9.7%). Median follow-up was 13.4 years [range, 4.8-20.0]. Twenty-year freedom from the primary endpoint was 95.1%1.3% for usual anatomy, 98.0%1.4% for common variants, 90.1%4.2% for inverted, 91.9%4.5% for single, and 79.6%8.9% for intramural (p<0.01). Intramurals had the highest 20-year incidence of coronary reintervention (10.6%7.9%). Multivariable Cox modeling identified intraoperative coronary revision (HR 9.88, 95% CI: 3.58-27.3, p<0.001) as a risk factor for the composite endpoint. Patients with two intramural coronary arteries had the lowest freedom from death, transplant, or coronary reintervention at 5 years (50%25.0%).
Conclusions: Rare coronary artery variants-particularly intramural involving either the left main or left main and right coronary-are associated with increased mortality and coronary reinterventions after ASO. Routine angiography is warranted.



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