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Outcomes of the arterial switch operation in patients with inverted coronary artery anatomy

  • Tyson A. Fricke
    Affiliations
    Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia

    University of Melbourne, Melbourne, Victoria, Australia

    Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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  • Edward Buratto
    Affiliations
    Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia

    University of Melbourne, Melbourne, Victoria, Australia

    Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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  • Kaushik Thungathurthi
    Affiliations
    Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia
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  • Antonia Schulz
    Affiliations
    Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia

    University of Melbourne, Melbourne, Victoria, Australia

    Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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  • Robert G. Weintraub
    Affiliations
    Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia

    University of Melbourne, Melbourne, Victoria, Australia

    Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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  • Christian P. Brizard
    Affiliations
    Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia

    University of Melbourne, Melbourne, Victoria, Australia

    Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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  • Igor E. Konstantinov
    Correspondence
    Address for reprints: Igor E Konstantinov, MD, PhD, FRACS, Royal Children's Hospital, Flemington Rd, Parkville, VIC 3052, Australia.
    Affiliations
    Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia

    University of Melbourne, Melbourne, Victoria, Australia

    Murdoch Children's Research Institute, Melbourne, Victoria, Australia

    Melbourne Children's Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Victoria, Australia
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      Abstract

      Objective

      Patients undergoing the arterial switch operation (ASO) with inverted coronary anatomy represent a technical challenge. We sought to determine the long-term outcomes of patients with inverted coronary anatomy who underwent an ASO.

      Methods

      A retrospective analysis of patients who underwent an ASO with inverted coronary anatomy at a single institution was performed and comparison was made between patients with inverted and normal coronary anatomy.

      Results

      There were 43 (5.1% [43 out of 844]) patients with inverted coronary anatomy. Twenty patients (46.5% [20 out of 43]) had a right coronary artery that arises from sinus 1 and the left anterior descending and circumflex coronaries arise from sinus 2 anatomy and 23 (53.5% [23 out of 43]) patients with right coronary artery that arises from sinus 1 and gives rise to the left anterior descending with the circumflex coronaries arising from sinus 2. Median follow-up was 17 years (interquartile range, 12-21 years). Overall early mortality was 7.0% (3 out of 43) compared with 3.1% (17 out of 556) in patients with normal coronary anatomy undergoing operation over the same time period (P = .17). There were 2 (10% [2 out of 20]) early deaths in the right coronary artery that arises from sinus 1 and gives rise to the left anterior descending with the circumflex coronaries arising from sinus 2 group and 1 (4.3% [1 out of 23]) early death in the right coronary artery that arises from sinus 1 and the left anterior descending and circumflex coronaries arise from sinus 2 group. There was 1 late death occurring at 40 days after ASO. Nine (23% [9 out of 39]) patients had 15 reinterventions occurring at median 3.6 years (interquartile range, 1.1-8.2 years). The most common cause of reintervention was main or branch pulmonary artery stenosis (15% [6 out of 39]). Freedom from reintervention was 78% (95% CI, 68%-93%) and 75% (95% CI, 56%-86%) at 10 and 15 years, respectively. At final follow-up, all surviving local patients except 1 was in New York Heart Association functional class I.

      Conclusions

      Patients with inverted coronary anatomy who underwent an ASO had a higher mortality but this was not statistically significant. However, there were no coronary reinterventions in survivors.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      ASO (arterial switch operation), Cx (circumflex coronaries), ECMO (extracorporeal membrane oxygenation), IVS (intact ventricular septum), LAD (left anterior descending), LVAD (left ventricular assist device), MCS (mechanical circulatory support), NYHA (New York Heart Association), RCA (right coronary artery), TGA (transposition of great arteries), VSD (ventricular septal defect)
      Figure thumbnail fx2
      Anatomical patterns of inverted coronary arteries.
      Patients with inverted coronary anatomy undergoing the arterial switch operation had a higher early mortality, but this was not statistically significant.
      Patients with inverted coronary anatomy undergoing the arterial switch operation had a higher mortality but this was not statistically significant. These patients also had a high risk of postoperative mechanical support. However, most survivors have normal left ventricular function with no coronary reintervention in the long-term.
      See Commentary on page 2001.
      The arterial switch operation (ASO) is performed with excellent outcomes in the modern era. In general, low rates of late mortality and morbidity have been reported in adolescents and young adult survivors.
      • Fricke T.A.
      • d'Udekem Y.
      • Richardson M.
      • Thuys C.
      • Dronavalli M.
      • Ramsay J.M.
      • et al.
      Outcomes of the arterial switch operation for transposition of the great arteries: 25 years of experience.
      • Tobler D.
      • Williams W.G.
      • Jegatheeswaran A.
      • Van Arsdell G.S.
      • McCrindle B.W.
      • Greutmann M.
      • et al.
      Cardiac outcomes in young adult survivors of the arterial switch operation for transposition of the great arteries.
      • Khairy P.
      • Clair M.
      • Fernandes S.M.
      • Blume E.D.
      • Powell A.J.
      • Newburger J.W.
      • et al.
      Cardiovascular outcomes after the arterial switch operation for d-transposition of the great arteries.
      • Lo Rito M.
      • Fittipaldi M.
      • Haththotuwa R.
      • Jones T.J.
      • Khan N.
      • Clift P.
      • et al.
      Long-term fate of the aortic valve after an arterial switch operation.
      Patients with inverted coronary arteries are rare. In these patients, either the right coronary artery (RCA) arises from sinus 1 and the left anterior descending (LAD) and circumflex coronaries (Cx) arise from sinus 2 (1RCA;2LAD,Cx) or the RCA arises from sinus 1 and gives rise to the LAD with the Cx arising from sinus 2 (1RCA,LAD;2Cx). To the best of our knowledge, no study has been published examining the long-term outcomes in these rare patients. Thus, we sought to determine the long-term outcomes of patients with inverted coronary artery anatomy undergoing the ASO.

      Materials and Methods

      Patients

      This study was approved by The Royal Children's Hospital Human Research Ethics Committee (No. 29123D) on July 20, 2015. All data of all children who underwent ASO for patients operated at the Royal Children's Hospital between 1983 and 2015 were collected retrospectively from hospital records. Of 844 patients who underwent an ASO, 15 patients, who underwent conversion of atrial switch to arterial switch were excluded, leaving 829 patients enrolled in subsequent analysis (Figure 1). The follow-up after hospital discharge was available for 36 of the 39 survivors (92%) and was obtained from cardiologists and general practitioners. Coronary anatomy was recorded using the Leiden classification.
      Figure thumbnail gr1
      Figure 1Flow diagram showing patient distribution and mortality. There were 844 patients who underwent arterial switch operation (ASO). Fifteen who underwent prior ASO with later conversion to ASO were excluded. There were 501 patients with transposition of the great arteries with intact ventricular septum (TGA-IVS), 271 patients with TGA with ventricular septal defect (TGA-VSD) and 57 patients with Taussig-Bing anomaly (TBA).

      Definitions

      Inverted coronary anatomy was defined as the RCA arising from sinus 1 with the LAD and Cx arteries arising from sinus 2 (1RCA;2LAD,Cx) or the RCA and LAD arising from sinus 1 with the Cx from sinus 2 (1RCA,LAD;2Cx) (Figure 2). Taussig-Bing anomaly was determined in accordance to the Van Praagh
      • Van Praagh R.
      What is the Taussig-Bing malformation?.
      definition. Early mortality was defined as mortality within 30 days of ASO repair or before hospital discharge and all other deaths were classified as late mortalities.
      Figure thumbnail gr2
      Figure 2Patterns of inverted coronary artery anatomy. A, Children with transposition of great arteries with intact ventricular septum (TGA-IVS) have similar size of aortic and pulmonary root. B, Children with transposition of great arteries with ventricular septal defect (TGA-VSA) have significantly large pulmonary artery. C, Children with Taussig-Bing anomaly (TBA) have very large pulmonary artery with side-by-side arrangement of great arteries. TGA, Transposition of the great arteries; LAD, left anterior descending coronary artery; LCx, left circumflex coronary artery; RCA, right coronary artery,

      Statistical Analysis

      Data were imported into Stata version 12 (Stata Corp). Continuous variables were reported as a median with an accompanying interquartile range (IQR). Categorical variables were presented as frequencies and percentages. Kaplan-Meier survival was used to display freedom from reintervention. Fisher exact test was used to detect significant differences in early mortality between groups. Time dependent end points were assessed using the Kaplan-Meier method. Additionally, reintervention was assessed using a competing risk analysis framework, with death as the competing outcome, using nonparametric cause-specific estimates of the cumulative incidence function.

      Results

      An ASO was performed in 844 children between 1983 and 2015 at The Royal Children's Hospital. Anomalous coronary anatomy occurred in 290 (34% [290 out of 844]) patients. There were 43 (5.1% [43 out of 844]) patients with inverted coronary anatomy. Twenty patients (46.5% [20 out of 43]) with 1RCA;2LAD,Cx anatomy and 23 (53.5% [23 out of 43]) patients with 1RCA,LAD;2Cx. Table 1 summarizes the perioperative and operative data of the patients. Sixteen patients (37.2% [16 out of 43]) had transposition of the great arteries (TGA) with an intact ventricular septum (TGA-IVS), 16 patients (37.2% [16 out of 43]) had TGA with a ventricular septal defect (TGA-VSD), and 11 patients (25.6% [11 out of 43]) had Taussig-Bing anomaly. Median age was 10 days (IQR, 7-27 days) and median weight at operation was 3.6 kg (IQR, 3.2-4.0 kg) for patients with inverted coronary anatomy. Follow-up after hospital discharge was available for 36 of the 39 survivors (92%). Median follow-up was 17 years (IQR, 12-21 years).
      Table 1Preoperative and operative data
      Data pointOverall (N = 829)Patients with normal coronary anatomy (n = 540)Patients with anomalous coronary anatomy (n = 289)Patients with inverted coronary anatomy (n = 43)
      TGA-IVS60 (501)63 (342)55 (159)37 (16)
      TGA-VSD33 (271)31 (169)35 (102)37 (16)
      TBA7 (57)5 (29)10 (28)26 (11)
      AAO10.3 (85)9.4 (51)11.8 (34)16.3 (7)
      Previous cardiac surgery7.1 (59)8.9 (48)3.8 (11)4.7 (2)
      Median age at ASO (d)10 (7-23)10 (7-22)10 (7-24)10 (7-27)
      Median weight at ASO (kg)3.5 (3.2-4.0)3.5 (3.2-4.0)3.5 (3.2-3.9)3.6 (3.2-4.0)
      Weight <2.5 kg4.2 (35)4.3 (23)4.2 (12)4.7 (2)
      Median duration of CPB (min)170 (130-204)169 (129-201)173 (132-210)175 (135-264)
      Median duration of aortic crossclamp (min)92 (70.5-116)91 (67.5-114)96.5 (74.8-122)94 (77.5-129)
      Mechanical circulatory support5.5 (46)4.4 (24)7.6 (22)9.3 (4)
      Values are presented as % (n) or median (interquartile range). TGA, Transposition of the great arteries; IVS, intact ventricular septum; VSD, ventricular septal defect; TBA, Taussing-Bing anomaly; AAO, aortic arch obstruction; ASO, arterial switch operation; CPB, cardiopulmonary bypass.

      Mortality and Functional Status at Last Follow-up

      There were 3 (7.0% [3 out of 43]) early deaths in patients with inverted coronary anatomy compared with 3.8% (11 out of 290) (P = .41) and 3.1% (17 out of 544) (P = .18) in patients with abnormal and normal coronary anatomy, respectively (Table 2). Causes of early death in 2 patients with inverted coronary anatomy were myocardial infarction and cerebral air embolism. The cause of death was unknown for 1 patient.
      Table 2Mortality and mechanical circulatory support
      VariableOverallPatients with normal coronary anatomyPatients with anomalous coronary anatomyPatients with inverted coronary anatomy
      Early mortality3.4 (28/829)3.1 (17/540)3.8 (11/289)7 (3/43)
      Late mortality1.2 (10/801)1.1 (6/523)1.4 (4/278)2.5 (1/40)
      Mechanical circulatory support5.5 (46/829)4.4 (24/540)7.6 (22/289)9.3 (4/43)
      Values are presented as % (n/N).
      Patient 1 (1RCA;2LAD,Cx) with TGA-VSD underwent the ASO in 1985 at age 10 months. The ASO was complicated by a laceration to the LAD, which resulted in myocardial infarction. The patient died on the second postoperative day.
      Patient 2 (1LAD,RCA;2Cx) with TGA-VSD underwent the ASO in 1993 at age 11 days. The patient died on postoperative day 15 at home due to presumed arrhythmia.
      Patient 3 (1LAD,RCA;2Cx) with TGA-IVS underwent the ASO in 2003 at age 5 days. This patient required revision of the coronary at the time of ASO, postoperative mechanical circulatory support (MCS), second coronary revision on postoperative day 8, and eventually coronary artery bypass grafting on postoperative day 13 and died due to cerebral embolism, while on MCS.
      There was 1 late death. This patient with TGA-IVS (1RCA;2LAD,Cx) underwent the ASO in 2014 and died 40 days after ASO from accidental sleep strangulation at home. All deaths occurred within 2 months of surgery (Figure 3, A). There were no deaths in patients with TBA (Figure 3, B). Although not statistically significant, the early mortality improved in the most recent decade (1983-1993: 11.1% [2 out of 18]; 1994-2003: 9.1% [1 out of 11]; 2003-2015: 0% [0 out of 14]). It should be mentioned that there was 1 late death of noncardiac cause in the last decade as mentioned above. At last follow-up, all patients (n = 37) except 1 were in New York Heart Association (NYHA) functional class I and the remaining patient was in NYHA functional class II.
      Figure thumbnail gr3
      Figure 3Survival after the arterial switch operation (ASO). Survival for the entire cohort (A) and by the anatomic subgroup (B). Overall survival at 5 and 20 years was 91% (95% CI, 77%-96%). No Taussig-Bing anomaly (TBA) patients died. Survival for transposition of great arteries with ventricular septal defect (TGA-VSD) at 5 and 15 years was 88% (95% CI, 59%-97%). Survival for TGA with intact ventricular septum (TGA-VSD) at 5 years was 87% (95% CI, 56%-96%).

      Postoperative MCS

      Postoperative MCS was required in 4 (9.3% [4 out of 43]) patients (Table 2). One (25% [1 out of 4]) of these patients died. Three patients required extracorporeal membrane oxygenation (ECMO) and 1 patient required a left ventricular assist device (LVAD).
      Patient 1 (1LAD,RCA;2CX) with TGA-IVS underwent the ASO in 2000 at age 20 days and required LVAD due to ventricular dysfunction. The patient came off MCS on postoperative day 3 with normalized biventricular function.
      Patient 2 (1LAD,RCA;2Cx) with TGA-IVS underwent ASO in 2003 at age 5 days, required postoperative ECMO support and died. This patient was discussed above in mortality section.
      Patient 3 (1RCA;2LAD,Cx) had TGA-IVS and underwent ASO in 2012 at age 26 days due to delayed diagnosis. The left coronary anastomosis was revised by placing a pericardial patch in a trapdoor fashion in the origin of the left coronary artery that divided into Cx and LAD. The patient was kept on ECMO and was successfully decannulated 6 days later.
      Patient 4 (1LAD,RCA;2Cx) with TGA-VSD and AAO underwent ASO in 2014 at day 24 of life due to delayed diagnosis. On arrival to ICU the patient had cardiac arrest and was placed on ECMO. The patient was uneventfully decannulated on postoperative day 2.
      There was no need for mechanical support in patients with Taussig-Bing anomaly.

      Reintervention

      Nine (23% [9 out of 39]) survivors had 15 reinterventions occurring at median 3.6 years (IQR, 1.1-8.2 years) after surgery. Five (13% [5 out of 39]) patients required more than 1 reintervention. Seven (35% [7 out of 20]) patients with 1RCA;2LAD,Cx required reintervention compared with 2 (8.7% [2 out of 23]) patients in the 1RCA,LAD;2Cx group. The most common cause of reintervention was main or branch pulmonary artery stenosis (15% [6 out of 39]). Two (5.1% [2 out of 39]) patients required reoperation on the neoaortic valve (Table 3). Only 1 patient (1LAD,RCA;2Cx) with TGA-IVS, described as patient 3 in the Mortality section, required revision of the left coronary button and later required coronary bypass grafting.
      Table 3Reintervention types
      Reintervention typeNo. of reinterventions
      Right-sided reintervention
       MPA repair3
       Branch PA stenosis repair2
       MPA balloon angioplasty2
       Branch PA stent2
       Subvalvular pulmonary stenosis resection1
       Pulmonary valve repair1
       Pulmonary valve replacement1
      Left-sided reintervention
       Neoaortic root replacement2
       Neoaortic valve replacement2
       MV repair2
       Neoaortic valve repair1
       Subvalvular aortic stenosis resection1
      Other
       VSD closure1
       Revision of coronary anastomosis1
       Coronary artery bypass graft surgery1
      MPA, Main pulmonary artery; PA, pulmonary artery; MV, mitral valve; VSD, ventricular septal defect.
      Freedom from reintervention was 78% (95% CI, 68%-93%) and 75% (95% CI, 56%-86%) at 10 and 15 years, respectively (Figure 4). A competing risks analysis was used for death and reintervention (Figure 5). The cumulative incidence for reintervention at 10 years was 21% (95% CI, 9.6%-34%).
      Figure thumbnail gr4
      Figure 4Freedom from reintervention after the arterial switch operation (ASO). Overall freedom from reintervention was 84% (95% CI, 68%-93%) at 5 years and 78% (95% CI, 56%-86%) at 15 years.
      Figure thumbnail gr5
      Figure 5Competing risk for reintervention and death. Competing risks analysis was used for death and reintervention. The cumulative incidence for reintervention at 10 years was 21% (95% CI, 9.6%-34%). Shaded area represents 95% CI.

      Valvular and Left Ventricular Function at Last Follow-up

      Table 4 summarizes valvular function at last follow-up. Thirty-six (92% [36 out of 39]) patients had a transthoracic echocardiogram assessing valvular function at last follow-up. Qualitative assessment of left ventricular function was available in 33 (84.6% [33 out of 39]) survivors with follow-up and was normal in 31 patients, mildly reduced in 1 patient, and severely reduced in 1 patient.
      Table 4Valvular function at final follow-up (n = 36)
      Valvular lesionResult
      Moderate tricuspid regurgitation or greater2.8 (1)
      Moderate tricuspid stenosis or greater0 (0)
      Moderate neopulmonary valve regurgitation or greater2.8 (1)
      Moderate pulmonary stenosis or greater2.8 (1)
      Moderate mitral regurgitation or greater8.3 (3)
      Moderate mitral stenosis or greater0 (0)
      Moderate neoaortic regurgitation or greater2.8 (1)
      Moderate neoaortic stenosis or greater0 (0)
      Values are presented as % (n).
      The patient with severe left ventricular dysfunction underwent ASO at age 26 days with inverted coronary anatomy (1RCA;2LAD,CX). Seven years postoperatively, she had progressive development of severe neoaortic valve regurgitation that required neoaortic valve repair. Despite an initial good result, the patient again developed severe aortic regurgitation and mild–moderate mitral regurgitation with severe left ventricle systolic dysfunction. The patient subsequently underwent the Ross procedure and mitral valve repair at age 8 years. At last follow up, she remained stable on medical therapy in NYHA functional class II.

      Discussion

      The anomalous coronary anatomy may complicate coronary translocation during the ASO. Such atypical coronary patterns occur in approximately 1 in 3 patients.
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      The impact of coronary artery anatomy on mortality after the arterial switch operation.
      Good results can be achieved in patients with complex coronary artery anatomy.
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      • Radford D.J.
      Translocation of a single coronary artery from the nonfacing sinus in the arterial switch operation: long-term patency of the interposition graft.
      Although patients with single and intramural coronary arteries undergoing the ASO have been the focus of previous publications,
      • Fricke T.A.
      • Bulstra A.E.
      • Naimo P.S.
      • Bullock A.
      • Robertson T.
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      outcomes of patients with inverted coronary anatomy remained unknown. This could be explained by the rarity of inverted coronary anatomy, where such patients make up 6% to 11% of all patients.
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      It is only in patients with Taussig-Bing anomaly that inverted coronary anatomy appears common. Inverted coronary anatomy made up more than half the patients in the largest published Taussig-Bing anomaly cohort, whereas 25% of our patients had inverted coronary anatomy.
      There are a few studies attempted to shed light onto the outcomes of the patients with inverted coronary artery. Bonhoeffer and colleagues
      • Bonhoeffer P.
      • Bonnet D.
      • Piéchaud J.-F.
      • Stümper O.
      • Aggoun Y.
      • Villain E.
      • et al.
      Coronary artery obstruction after the arterial switch operation for transposition of the great arteries in newborns.
      performed angiography in 165 children after ASO. Of the 165, 11 (6.7%) had inverted coronary anatomy. Notably, 5 (45%) of the 11 children had coronary obstruction on angiography. Wernovsky and colleagues
      • Wernovsky G.
      • Mayer J.J.E.
      • Jonas R.A.
      • Hanley F.L.
      • Blackstone E.H.
      • Kirklin J.W.
      • et al.
      Factors influencing early and late outcome of the arterial switch operation for transposition of the great arteries.
      reported outcomes of 470 children who underwent the ASO. Thirty-two (6.8% [32 out of 470]) patients had inverted coronary anatomy. There were 7 (22% [7 out of 32]) deaths in these patients and both 1RCA;LAD,Cx and 1LAD,RCA;2Cx were risk factors for mortality on multivariate analysis in overall cohort of 470 patients.
      Although not statistically significant due to small numbers, the results of our study demonstrated higher mortality for patients undergoing the ASO with inverted coronary anatomy (Figure 6). While limited by numbers, we also found a high rate of postoperative MCS. Despite this, no survivors required coronary reintervention. Likewise, left ventricle function in survivors was normal in almost all patients in the long-term. Whereas the inverted coronary anatomy increased mortality substantially in TGA-IVS and in TGA-VSD groups, the opposite occurred in Taussig-Bing anomaly groups. There was no death in patients with Taussig-Bing anomaly. This observation may be due to the fact that in typical anteroposterior position of TGA the coronary transfer could cause distortion of the coronary arteries (Figure 2), which could be further complicated by the relatively enlarged neoaortic root in those with TGA-VSD (Figure 2). At the first glance, it appeared somewhat paradoxical that children with Taussig-Bing anomaly with inverted coronary anatomy did not have mortality, whereas those with Taussig-Bing anomaly with usual coronary anatomy had high operative mortality. However, the side-by-side arrangement of great arteries in children with Taussig-Bing anomaly and inverted coronary anatomy makes the coronary transfer safer and easier despite very large neo-aortic root (Figure 2). In fact, in children with Taussig-Bing anomaly the coronary transfer in those with inverted anatomy is easier compared with those with usual anatomy. Hence, operative mortality in children with Taussig-Bing anomaly and not inverted coronary anatomy was higher (Figure 1). The improvement of mortality in the most recent decade might be related to implementation of rapid MCS.
      Figure thumbnail gr6
      Figure 6Eight hundred forty-four patients underwent an arterial switch operation (ASO) at a single institution. Medical records were retrospectively reviewed. Forty-three patients had inverted coronary anatomy. Early mortality was 7.0% for the inverted coronary patients. There was 1 late death. Freedom from reintervention was 75% at 20 years and all patients were in New York Heart Association functional class I. Patients with inverted coronary anatomy have a higher mortality but long-term outcomes are excellent. RCA, Right coronary artery; LAD, left anterior descending coronary artery; Cx, circumflex coronary artery.

      Limitations

      A limitation of this study was its retrospective nature and the relatively small number of rare patients with this rare condition. The relatively small number of patients with inverted coronary anatomy limited the ability to detect a possible statistically significant difference in mortality between inverted coronary and normal coronary anatomy patients. This study covered a long period of time and changes in management may have influenced our outcomes.

      Conclusions

      Patients with inverted coronary anatomy who undergo the ASO had a higher mortality, but this was not statistically significant. However, coronary reintervention is rare and left ventricle function is normal in the majority of survivors.

      Conflict of Interest Statement

      Dr Brizard has a financial relationship with Admedus. All other authors reported no conflicts of interest.
      The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

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      Linked Article

      • Commentary: Inverted coronary arteries mostly seen in complex forms of transposition of the great arteries
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
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          In this issue of the Journal, Fricke and colleagues1 report on the “Outcomes of the Arterial Switch Operation (ASO) in Patients With Inverted Coronary Artery Anatomy.” The overall early mortality of ASO with inverted coronary mortality of 7% (3/43) was greater but not statistically different (P = .17) compared with ASO and normal coronary arteries. Late reintervention rate was 23% (9/39), principally caused by right ventricular outflow tract obstruction. There was no late coronary reintervention.
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