ORIGINAL ARTICLE

Coronary Re-implantation after Completion of Neo-aortic
Reconstruction in Arterial Switch Operation: Accurate
Intraoperative Assessment for the Optimal Re-implantation Site
Takaaki Suzuki,1 Kentaro Hotoda,2 Mika Iwazaki,1 Ayumu Masuoka1 and Toshiyuki Katogi1
1

Department of Pediatric Cardiac Surgery, Saitama International Medical Center Saitama Medical University,
Saitama, Japan
2
Division of Cardiovascular Surgery, Tokyo Metropolitan Kiyose Children’s Hospital, Tokyo, Japan(Received for publication on May 13, 2009)(Revised for publication on June 6, 2009)(Accepted for publication on June 25, 2009)

Abstract
The arterial switch operation (ASO) has evolved into the treatment of the choice for mostforms of transposition of the great arteries (TGA). Despite advancement in the technical aspects of the procedure, certain anatomical variations of the coronary arteries are still considered as surgical risks. We have recently employed a novel technique for coronary artery reconstruction in ASO to achieve further improvement of coronary transfer in cases with complex
coronary anatomy. The technical key of the procedure is that reconstruction of the coronary
arteries is preceded by neo-aortic anastomosis. After neo-aortic reconstruction is accomplished, the neo-aorta is temporarily distended with removal of the cross-clamp. The distended
neo-aorta informs us its postsurgical geometry, which facilitates accurate assessment for the
optimal site of coronary button transfer. The technique was feasible in 13 of 15 children who
were consecutively treated by our group between 2003 and 2008. All patients recovered uneventfully and no coronary perfusion issue has occurred during the follow-up period. However,the complex anatomy of the coronary arteries in two children was not amenable to this technique. One with double loops (1RL; 2Cx) accompanied by side-by-side relationship of the greatarteries underwent the open trapdoor technique, while the other with intramural coronary artery underwent the Imai method, that is one of procedure in which the coronary arteries areleft in situ . The coronary re-implantation after neo-aortic reconstruction is promising to minimize postsurgical coronary ischemia and suitable for most ASO cases. However, various modifications of coronary transfer are required in a few variations of the coronary anatomy and wehave to pursue further technical refinement of coronary artery transfer in ASO. (Keio J Med 58(4) : 227－233, December 2009)

Keywords: transposition of the great arteries, arterial switch operation, coronary re-implantation

Introduction
The arterial switch operation (ASO) is now the surgical treatment of choice for those patients with transposition of the great arteries (TGA). Although the technicalrefinement and evolving concept of ASO have reduced
the postoperative mortality, there is still room for the im-provement in this operative procedure. It is the most integral part of ASO to re-implant coronary buttons to theposterior neo-aorta without tension, torsion, or kinkingof the coronary arteries. Recently, a technical refinement
was discussed in the literature, in which coronary re-implantation after neo-aortic reconstruction yielded better
result.1, 2 This technique informs us the postsurgical neo-

Reprint requests to: Takaaki Suzuki, MD, Department of Pediatric Cardiac Surgery, Saitama International Medical Center, Saitama Medical University,
1397-1 Yamane, Hidaka-shi, Saitama 350-1298, Japan, Tel: +81-42-984-4584, Fax: +81-42-984-4584, E-mail: tksuzuki@saitama-med.ac.jp227Suzuki T, et al: Coronary Re-implantation in Arterial Switch Operation

228

aortic geometry, and facilitates accurate assessment forthe optimal site for coronary button transfer. Since weintroduced this technique in 2003 to achieve further improvement of coronary transfer in cases with complex
coronary anatomy, we have substantiated its technicalbenefit. Thus, we report here on our results of the technique, and review its feasibility and efficacy for various
anatomical variants of the coronary arteries.
Patients and Methods
Patients
Between November 2003 and June 2008, 15 patientswith dTGA underwent ASO in our group hospital. Ageand weight at the time of operation ranged from 2 to 18
days (median 10 days) and from 2490 to 3650 g (median
3086 g), respectively. The morphological feature of thecoronary arteries in those children included the normal
coronary arteries (1LCx; 2R) in 8, posterior looping circumflex artery (1L; 2RCx) in 2, and double loops (1RL;
2Cx) in 2. Two patients had single orifice coronary system with posterior looping left coronary artery (2RLCx).
Remaining one child showed an intramural course of theleft coronary artery that ran between the great arteries(2RLCx). Associated cardiac anomalies comprised ventricular septal defect in 5 children and coarctation of theaorta in one, which were repaired simultaneously.
Technique
Our standard technique is based upon the method reported by University of Michigan group which is detailed as follows (Fig. 1).3 After a standard median sternotomy, a large section of pericardium is harvested for
neo-pulmonary artery reconstruction. The coronary artery distribution and the relationship of great arteries areinspected carefully. All patients undergo bicaval and aortic cannulation and are perfused with moderate hypothermia. Cardiac arrest is achieved by the repeated infusionof the cold blood cardioplegic solution with topical cooling. Atrial and/or ventricular septal defects are repaired
first in the majority of patients. The aorta is transected
approximately 5 mm distal to the level of pulmonary artery bifurcation. The coronary ostia are inspected andcoronary buttons are excised. The entire wall of the sinus
of Valsalva is removed, which allows as large scallop as
possible, preventing coronary arteries from kinking,stretching, and torsion with bulging out after restoring
blood pressure. After the excision, slight mobilization is
performed to achieve a tension-free anastomosis. The
pulmonary artery is then transected just below its bifurcation. We transect the pulmonary artery to keep anteriorwall somewhat taller than posterior wall, keeping the suture line of the neo-aorta away from the re-implanted
coronary buttons. The point where the anterior commis-

Fig. 1 The left coronary artery is implanted after an oblique
incision is made in the left anterior sinus of Valsalva of the
neo-aorta. The cross-clamp is removed during the incision toclose the neo-aortic valve and protect it from injury. The sameprocedure is repeated for the right coronary artery.
(Reprinted from Bove EL. Current technique of the arterial
switch procedure for transposition of the great arteries. Journalof Cardiac Surgery, Volume 4, Page 197, (1989) with permission
from Blackwell Publishing.)

sure attached to the vessel wall is marked with a suture
exteriorly. LeCompte maneuver is then performed andthe distal aorta is anastomosed to the proximal pulmonary artery with a single running suture. Following completion of the neo-aortic anastomosis, the cross-clamp is
temporarily removed so as to distend the sinus of Valsalva of the neo-aorta. Removal of the aortic cross-clamp
facilitates identifying the optimal location of each coronary anastomosis, since it allows the neo-aorta to distend
and tell us its postoperative composition. An oblique incision is made in the left anterior facing sinus of the neoaortic root to accommodate the left coronary button. The
aortic cross-clamp is left off until the incision is begun,closing the valve and protecting it from injury, and thenre-applied to avoid further bleeding. The previously
placed marking sutures also serve as a guide to locationof the valve commissures. The left coronary button isheld next to the openings in the neo-aorta in tension-free
position to be certain that no twist occurs during theanastomosis. The button is anastomosed with a running
suture. In a similar fashion, the right coronary button is
re-implanted (Fig. 2). Both anastomosis were made intoa trap door type of configuration by extending the superior margin of the opening medially. Finally, reconstruction of the neo-pulmonary artery is begun by repairing
the defects left after coronary artery excision. For thisrepair, a large quadrangular-shaped patch of the autologous pericardium is now preferably utilized, because itKeio J Med 2009; 58 (4): 227－233

229

Fig. 2 The schema of coronary transfer after neo-aortic reconstruction in normal coronary artery (1LCx; 2R).
LAD: Left anterior descending artery, RCA: Right coronary artery.

provides an adequate tissue for the sinuses of Valsalva
and enables to augment the entire anastomotic circumference. The aortic cross-clamp is generally removed
during this portion of the operation and systemic rewarming is begun, allowing careful inspection of bothcoronary suture lines. A left atrial monitoring catheter isinserted and bypass is discontinued in the usual fashion.
Results
There was no hospital death or late death in children
who underwent our standard technique, and nobody
showed coronary perfusion deficiency during the followup period (mean 41 months, 9 ~ 64 months). Re-operation for branch pulmonary artery stenosis was required
in one child. Neo-aortic insufficiency of the trace to mild
severity was found in 4 children on postoperative echocardiography.
Our standard technique with or without modifications
was feasible in 13 of 15 children. In 11 children, the procedure was completed only with minor individual arrangement of adding rotation and/or height control of thecoronary buttons. Among those 11 children, one child
had major commissural malalignment between the aortic
and pulmonary valves. The coronary artery showed thenormal anatomy (1LCx; 2R), however, the aorta wasslightly deviated leftward, and the pulmonary valve
showed a counterclockwise rotation with 15~25 degrees.
In order to prevent arterial kinking, we have to move theright coronary button more distally than usual together
with a modest counterclockwise rotation. We were able
to readily intend the modification with our maneuver(Fig. 3).
Major technical arrangements were required in twochildren. Those two children had single coronary ostium
at sinus 2 and posterior looping left coronary arteries,

and we completed most of the neo-aortic anastomosis,
leaving 5mm region for attaching the coronary button.
We had concern that the left anterior descending artery(LAD)/ the circumflex coronary artery (Cx) combination
would kink, unless coronary button was transferredabove the neo-aortic anastomosis. During the neo-aortic
root was filled and dilated, the open area was occluded
with forceps to determine the exact place either at or
above the neo-aortic suture line. In both cases, coronary
buttons were required to be implanted at the level of suture line before finishing neo-aortic anastomosis. Yet, wewere able to readily decide optimal site and the open
area was used for attaching the coronary button.
Our standard technique was not applicable to two children. One was an 11-days-old boy weighing 3098g. The
coronary arteries showed double loops (1RL; 2Cx) withside-by-side great vessels relationship and commissuralmalalignment, in which the coronary button of the common trunk of the right coronary artery/LAD had to be
moved far toward the left, and extreme stretching of theright coronary artery might have ensued. We therefore
chose the open trapdoor technique to make a generous
trapdoor incision safely in the facing sinus as large as
possible, so that the trapdoor was sufficiently expanded
toward the right to reduce the transfer distance. Then, a
direct anastomosis was done with a running suture. Cx
was subsequently implanted into the adjacent facing sinus after neo-aortic reconstruction (Fig. 4). On the other
hand, our standard technique was readily accomplishedin the other case with double loops (1RL; 2Cx) accompanied by anterior-posterior relationship of the great arteries without commissural malalignment. A child with
Yacoub type C intramural coronary artery underwent themodified Imai method.4 This method is one of procedurein which the coronary arteries are left in situ. The procedure is applied to children whose coronary orifices areSuzuki T, et al: Coronary Re-implantation in Arterial Switch Operation

230

Fig. 3 The schema of coronary transfer in patient with major commissural malalignment of the two arterial valve. Coronary arteries werenormal (1LCx; 2R), but the aorta was located left anterior to main pulmonary artery trunk. The pulmonary valve had counterclockwise
rotation with 15~25 degree. The right coronary button was required to be transferred more distally than usual and make a counterclockwise
twist to prevent kinking.

too close to separate them into two different coronary
buttons. In our case, we added a minor modification, i.e.,
the portion of intramural course was unroofed with taking down the commissure between the facing sinuses toavoid late obstruction.
Discussion
Anatomical variations of the coronary circulation inpatients with TGA are common and diverse. Somegroups reported no specific relation between the anatomical variations and mortality rates.1, 5 Yet, the recent literature has still implied that certain patterns of origin anddistribution of the coronary arteries increase surgicalrisks and some variations are more problematic than others from a technical viewpoint. Meta-analyses, including
the most recent, have revealed that patients with an intramural coronary artery have an approximately five-foldmortality risk as compared with those patients with theusual pattern. The presence of abnormal coronary looping with a single ostium is associated with a three-foldmortality risk.6 Scheule and colleagues reported that patients with a single right ostium (sinus 2) associated withthe posterior looping of left main coronary artery havelower survival than all other subtypes of a single coronary artery.7 Multivariate analyses showed that coronary
events were correlated with only the Yacoub type B (anabnormal course of one or more of the major coronary
arteries running between the great vessels with a single
coronary ostium) or type C (an abnormal course of one
or more of the major coronary arteries running between
the great vessels with separated coronary ostia).8
On the other hand, many different variations on how totransfer the complex coronary arteries have been suggested in order to achieve better result in ASO. Issues include the height of the implantation site, appropriate angle, and tilt of the coronary buttons. These factors areimportant to minimize tension, torsion, or kinking of thecoronary arteries. Particular attention to the relation between the great vessels and proximal segment of the coronary arteries must also be carefully considered. Fromtheir origin from the facing sinuses, the coronary arteries
can take a normal course, a looping course, or an intramural course. Posterior looping refers to one or more of
the three major arteries running posterior to the pulmonary trunk, while anterior looping refers to an abnormal
course anterior to the aorta. With posterior looping there
is a shorter distance and an acute turn between the neocoronary orifice and the coronary artery, resulting in arisk of kinking and/or distortion of the proximal segmentof the transferred coronary artery. Conversely, anterior
looping results in a greater distance between the neocoronary orifice and the distal coronary segment and thepotential for stretching of the transferred coronary arteryor bow stringing as it crosses the neo-pulmonary root. A
single coronary artery, in which all three main arteries
usually stem from a common arterial orifice in a solitarysinus, is invariably associated with the abnormal looping.
Brawn and Mee first reported the trapdoor technique in1988, which can minimize the rotation angle of a coronary button by transferring the coronary artery to medially hinged “trapdoor” in the neo-aorta.9 The trapdoor
technique was successfully applied to re-implantation oflooping coronary arteries, and enabled to avoid arterial
kinking or stretching of the transferred coronary arteries.

Keio J Med 2009; 58 (4): 227－233

231

Fig. 4 The schema of coronary transfer in patient with double loops (1RL; 2Cx). Right coronary artery/left anterior descending artery
combination must move toward far left due to side by side great vessels relationship and commissural malalignment of the two arterial
valves. A generous trapdoor incision in the facing sinus was required before neo-aortic reconstruction in order not to insult neo-aortic
valve. A direct anastomosis with a running suture was then done. The circumflex artery was then implanted into the adjacent facing
sinus after reconstruction of neo-aorta.

Following the successful large series reported by de Leval10 and Planché11 in mid 1990’s, the trapdoor technique
has gained in popularity. However, even when we utilize
the trapdoor technique, it is crucial for surgical successto decide the optimal location for coronary button re-implantation. The critical decision can be facilitated by the
neo-aortic distension maneuver technique we describedso far. After the neo-aortic anastomosis is completed, theaortic cross-clamp is removed to fill the sinuses of Valsalva of the neo-aorta with blood. This neo-aortic distension maneuver informs us the postoperative geometry of
the neo-aorta. Thus, we are able to predict the optimal
location for coronary button anastomosis. The technique
was first described by Jatene,1 2 and later advocated by
Pacifico13 and Bove3 during 1980’s. Since then, a number of series with excellent results have been reported
utilizing this technique, particularly in the 21st century.
Shukla, et al. reported no surgical mortalities in neonateswith coronary arteries stemming from a single aortic sinus when a coronary button was translocated after the
neo-aortic anastomosis was performed.14 Brown and colleagues also showed that the technique of completing the
neo-aortic anastomosis before selecting the ideal position
for a mobilized coronary button significantly decreased
the incidence of unsuccessful coronary transfer. They
found that coronary artery pattern ceased to be an independent risk factor for surgical mortality after switching
to this technique.2 Chang and Sung, et al. reported thecomparison of the results between the technique of coronary re-implantation after neo-aortic reconstruction andthe open trapdoor technique. 1 5 They emphasized that
coronary re-implantation after neo-aortic reconstruction

minimizes coronary artery transfer-related mortality or
morbidity. They also emphasized that the technique isparticularly beneficial in the management for variationsof a single sinus coronary artery.16 Recently, the University of Michigan group reported the midterm results ofcoronary re-implantation after neo-aortic reconstructionin 168 patients. They found that the coronary anatomy
did not influence surgical mortalities.1
We have employed this technique as our standard procedure for ASO since 2003. Although our experiences
are still restricted to a small number of cases, we also believe that the technique is a safe and promising method
to reduce the prevalence of coronary problems after
ASO. The technique is indicated for almost all types of
the coronary anatomy, even for variations with abnormallooping and/or a single coronary orifice. In posterior
looping, we usually twist the coronary button with amodest counterclockwise angle (10~15 degree), so thatthe coronary artery is medially rotated, and then re-implant the button to more distal and higher position thanusual. The maneuver prevents kinking of the transferredcoronary artery; however, it may cause another technicalproblem in that the appropriate implantation site of the
buttons would lie at or above the neo-aortic anastomosis.
When we encounter the situation, Ugurlucant’s modification is utilized.17 Three to 4 mm suture line of the neoaortic anastomossi is left unsutured. This open area is
occluded with two fine forceps, while the aortic crossclamp is removed to distend the neo-aorta, so that whether the optimal place for the coronary button is either at or
above the neo-aortic anastomosis can be accurately determined. Then the open area is used for attaching the

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Suzuki T, et al: Coronary Re-implantation in Arterial Switch Operation

coronary button. We successfully utilized this modification in two patients with single coronary ostium of LAD
and Cx originating from the right sinus. By using thismodified technique, we have not had any concerns about
the placement of the coronary button after neo-aortic reconstruction even if the best position was on or above
the neo-aortic anastomosis.
An augmentation of transfer distance in anterior looping is generally solved with placing the button in a lower
position. However, we were compelled to employ theopen trap-door procedure in a child with anterior looping. This patient had double loops (1RL; 2Cx) with sideby-side great vessels relationship and commissural malalignment. The complex anatomical arrangements that
may have caused far transfer distance were not amenable
to our standard technique. Therefore we selected theopen trap-door technique in order not to insult neo-aortic
valve, and a generous neo-aortic wall flap was createdsafely. Commissural malalignment is prevalent in sideby-side great vessels,1 8 and it is commonly associatedwith a variety of anomalous looping courses. The complicated combinations entail a variety of technical modifications to preclude distortion of the transferred coronary arteries.
As mentioned before, the alignment of the commissures of the two arterial valves is also of major surgicalsignificance. Several authors draw special attention tocommissural malalignment in TGA. Gittenberger-deGroot, et al. reported that the alignment was perfect in
two-thirds of cases, and slightly deviated, but adequate
for coronary arterial transfer in one-sixth. Major malalignment was found in 19.4% of cases.19 Kim and colleagues2 0 reported that longer transfer distances due tocommissural malalignment demanded a variety of techniques to accomplish safe re-transplantation. They werecompelled to accomplish more extensive dissection of
the coronary arteries than usual in all patients, to re-implant the coronary button to a supra-commissural or juxta-commissural site in some patients, and to transfer twocoronary artery systems to the same sinus in others. We
experienced one patient with major commissural malalignment, and had to move the right coronary button
more distally than usual together with a counterclockwise twist. In this case, our standard method was quite
beneficial to decide the optimal height and twist angle ofthe coronary button. We were able to find out this unusual arrangement easily before implantation during neoaortic root dilatation. Our standard method would warrant being suitable for variety of commissural malalignment of great arteries.
There are few patients whose anatomical variations of
the coronary arteries do not allow our standard techniqueas well as the conventional re-implantation procedures,and do demand special technical modifications. The
variations are abnormal courses of one or more of the
major coronary arteries running between the great ves-sels, which are commonly associated with ostia close toan aortic commissure and/or intramural course. In particular, the coronary artery variations of Yacoub type B or
type C enforce the difficult management. Mee commented that if the ostia are 2 mm or more apart from eachother, creation of two separate coronary buttons is feasible, usually requiring taking down the commissure between the facing sinuses. Both coronary arteries can thenbe handled in the usual way.4 Inseparable ostia in Yacoub
type C as well as a single ostium in Yacoub type B canbe managed in two different ways, i.e., transferring asingle coronary button upside down2 1, 2 2 or the methodof coronary artery left in situ.4, 23-25 In 1978, Aubert, etal. first reported a unique method, in which the coronary
arteries are left in situ and coronary circulation is restored with creating an aortopulmonary window and suturing a pericardial patch around the coronary ostia.23 A
modification of Aubert’s procedure is the Imai method,wherein hinged non-facing aortic sinus wall is used as abaffle instead of pericardial patch. These “coronary arteries left in situ procedures” lessen early surgical mortality. However, late right ventricular outflow tract obstruction due to an oversized intra-arterial baffle and lateostial stenosis, especially in cases of the intramuralcourse, remain theoretical hazards that may require future revision. The abnormal course of the coronary arteries left untreated remains as a potential risk for mortality
as the child grows. In the case of dividable coronary orifices, the coronary buttons should be translocated in theusual fashion after unroofing the intramural course. Ourseries included one patient with Yacoub type C coronary
arteries, in whom we were compelled to perform the
Imai method. In this particular case, the distance between the two coronary orifices was too short to separate
them into two buttons. However, we would have performed our standard method if the distance between theorifices were separable enough. Recently, Padalino andcolleagues reported on successful coronary transfer in apatient with an intramural origin of both left and rightcoronary arteries. They created two separated coronary
buttons and transferred them after completion of neoaortic anastomosis.2 6 Qamar, et al.1 also successfully
treated 12 patients with intramural coronary arteries withusing the same technique.
Conclusion
In this manuscript, we reported a simple but uniform
technique that permits relocation of the coronary arteries
irrespective of their sinusal origin or their epicardial
course. The neo-aortic distension maneuver after neo-aortic reconstruction described so far facilitates intraoperative
assessment for the optimal positions for coronary button
transfer, and our technique enables to minimize majorcomplications in most ASO cases. Although our method issuitable for most ASO cases, various modifications of cor-

Keio J Med 2009; 58 (4): 227－233

onary transfer are required in a few variations of the coronary anatomy and we have to pursue further technical refinement of coronary artery transfer in ASO.
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