Outcomes of the modified Yacoub aortocoronary flap technique for 'non-separable' single sinus coronary arteries with intramural course in the neonatal arterial switch operation

Abstract

Objectives: Coronary transfer remains the most crucial part of the arterial switch operation (ASO); yet, certain coronary anatomies prohibit the use of button or trap-door transfer techniques. In the rare setting of 'non-separable' single sinus coronary arteries with intramural course, the modified Yacoub aortocoronary flap technique is a viable option. The aim of this study is to describe this operative technique and review its early- and mid-term outcomes.

Methods: This retrospective analysis included all cases with 'non-separable' single sinus coronary arteries with intramural course where the modified Yacoub aortocoronary flap technique served as a bail-out option.

Results: Of 516 patients who underwent ASO at our institution between January 1977 and April 2022, 14 underwent the modified Yacoub aortocoronary flap technique. The median age at ASO was 10 (interquartile range 7-19) days. Hospital mortality occurred in 3 patients (21.4%), all being related to coronary complications. All hospital survivors were still alive at a median of 9.1 (interquartile range 4.2-18.3) years after the ASO. None of them developed complaints of ischaemia, ventricular arrhythmias, ventricular dysfunction or exercise intolerance. Surveillance computed tomography angiography showed stable aortocoronary relationships free from stenosis, compression and kinking. No reoperations for coronary artery problems and/or neoaortic valve or root problems were needed.

Conclusions: Although close monitoring of early coronary events seems crucial to prevent perioperative mortality, the modified Yacoub aortocoronary flap technique may serve as a viable bail-out option in patients with 'non-separable' single sinus coronary anatomy with intramural course, with excellent results among hospital survivors.

Keywords: Arterial switch operation; Congenital heart disease; Intramural coronary artery; Single coronary artery; Transposition of the great arteries.

Figure 1:

Major coronary patterns involving ‘non-separable’ single sinus coronary artery with intramural course in transposition of the great arteries anatomy. According to the Leiden Convention coronary coding system (figures derived from and modified after ref [11]). (A) 2LCx*,R = separate coronary ostia from sinus 2 with intramural (*) LCA; 2LCx*R = common coronary ostium from sinus 2 with intramural (*) LCA. (B) 2R*,LCx = separate coronary ostia from sinus 2 with intramural (*) RCA. (C) 1L*,2CxR = 2 ostia located very close to each other, each on 1 side of the commissure between the 2 facing sinuses. Note that, in reality, the ostia would lie closer to each other than might be suggested based on the diagrams. LCA: left coronary artery; RCA: right coronary artery.

Figure 2:

Schematic stepwise representation of the modified Yacoub aortocoronary flap technique. Right anterior-related position of the aorta compared to the pulmonary artery with aligned commissures of the semilunar valves and coronary artery with intramural course. A surgical incision is made around both coronary ostia to create a coronary flap (A). Rotation of the the coronary flap to align the ostia with the neo-aorta in the horizontal plane (maximum 45°) with anastomosis of the basis of the coronary artery button to the neo-aorta (B). The aorta is positioned above the pulmonary valve and pulmonary trunks and a small longitudinal aortic incision has been made (C) for the creation of the aortocoronary flap using a pericardial hood to connect the coronary flap to the neo-aorta (D) and to accomplish the arterial switch (E).

Figure 3:

Representative examples of conventional coronary CTA images and CTA-based 3D reconstructions showing the neo-aorta with modified Yacoub aortocoronary flap and coronary arteries. (A) Axial view CTA of patient Nr. 2 (2LCx*,R coronary anatomy) at the 35.9 post-ASO. (B) Sagittal view CTA of patient Nr. 7 (2LCx*,R coronary anatomy) at 2.7 years post-ASO. (C) CTA-based 3D reconstruction of patient Nr. 9 (1L*,2CxR coronary anatomy) at 7.0 years post-ASO. (D) CTA-based 3D reconstruction of patient Nr. 13 (2LCx*,R coronary anatomy) at 2 months post-ASO. (E) CTA-based 3D reconstruction of patient Nr. 2 (2LCx*,R coronary anatomy) at the 35.9 post-ASO. ACF: modified Yacoub aortocoronary flap; Ao: neo-aorta; ASO: arterial switch operation; CTA: computerized tomography angiography; Cx: circumflex coronary artery; L: left coronary artery; PT: neo-pulmonary trunk; R: right coronary artery.