The Arterial Switch Procedure: Closed Coronary Artery Transfer

Abstract

The arterial switch operation has been the accepted procedure for the repair of transposition of the great arteries (TGA) with or without associated defects for over 2 decades. Many of the technical intricacies have been developed and modified over these years such that this procedure is now associated with very low risk even in the neonate with complex forms of TGA. 1,2 From the earliest experience, the surgical techniques involved for the transfer of the coronary arterieshavereceivedthemostscrutiny.Inthemostcommon coronary artery pattern, the right coronary artery arises from the right aortic sinus of Valsalva and the left main coronary artery from the left aortic sinus (Fig 1). This pattern, in addition to the most common variant in which the circumflex coronary artery arises from the right coronary and passes posterior to the pulmonary artery root, is seen in approximatelytwo-thirdsofallpatientswithd-TGA.Withincreasing operative experience, a variety of coronary artery patterns were encountered by the surgeon, some rarely, and the techniques were altered to deal with these anomalies. Both early and late follow-up reports emphasized the importance of proper coronary artery alignment, the avoidance of tension on the anastomoses, and the need to develop a reliable, reproducible technique to deal with even subtle coronary artery anatomic variations. At the University of Michigan CS Mott Children’s Hospital, the technique of transferring the coronary artery buttons after reconstruction of the neo-aorta has been utilized since the beginning of our experience in the mid 1980s. 3 This approach was used in an effort to minimize