arterial switch with abnormal coronariesaz9194.vo.msecnd.net/pdfs/120401/11.07.pdf · arterial...
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Arterial SwitchArterial Switch
with Abnormal Coronarieswith Abnormal Coronaries
ASO, Cx. Coronaries AATS, SF 2012
with Abnormal Coronarieswith Abnormal Coronaries
Francois LacourFrancois Lacour--Gayet, MDGayet, MDProfessor and Chief Professor and Chief Pediatric Cardiac SurgeryPediatric Cardiac Surgery
Montefiore Children’s Hospital, Montefiore Children’s Hospital,
Einstein College of Medicine, Einstein College of Medicine,
New York CityNew York City
DisclosureDisclosure
• None
ASO, Cx. Coronaries AATS, SF 2012
Yacoub Classification
ASO, Cx. Coronaries AATS, SF 2012Yacoub MH, RadleyYacoub MH, Radley--Smith R.M. Smith R.M. Thorax. 1978;33:418. Thorax. 1978;33:418.
C C PlanchePlanche, F , F LacourLacour--GayetGayet et al et al Pediatric Cardiology 1998; 19: 297Pediatric Cardiology 1998; 19: 297--307307
Marie Lannelongue Classification
Based on the Course of the Coronaries
��Normal course:Normal course: 60%60%
��Looping courses: Looping courses: 35%35%
ASO, Cx. Coronaries AATS, SF 2012
��Looping courses: Looping courses: 35%35%
-- posterior posterior 20%20%
-- anterioranterior 1%1%
-- double loopingdouble looping 14%14%
��IntraIntra--mural course:mural course: 5%5%
C C PlanchePlanche, F , F LacourLacour--GayetGayet et al et al Pediatric Cardiology 1998; 19: 297Pediatric Cardiology 1998; 19: 297--307307
Marie Lannelongue Classification
Based on the Course of the Coronaries
��Normal course:Normal course: 60%60%
��Looping courses: Looping courses: 35%35%
ASO, Cx. Coronaries AATS, SF 2012
��Looping courses: Looping courses: 35%35%
-- posterior posterior 20%20%
-- anterioranterior 1%1%
-- double loopingdouble looping 14%14%
��IntraIntra--mural course:mural course: 5%5%
Right SinusRight Sinus Left SinusLeft Sinus
Normal Course: 60%
ASO, Cx. Coronaries AATS, SF 2012
Not applicable to situs inversusNot applicable to situs inversus
Posterior Looping Course: 20%
ASO, Cx. Coronaries AATS, SF 2012
19%19% 1%1%
Anterior Looping Course: 1%
ASO, Cx. Coronaries AATS, SF 2012
Double Looping Course: 14%
Taussig Bing
ASO, Cx. Coronaries AATS, SF 2012
Kinking of
Posterior Vessel
Risks Depending on CourseRisks Depending on Course
ASO, Cx. Coronaries AATS, SF 2012
Stretching of
Anterior Vessel
Single OstiumSingle Ostium
ASO, Cx. Coronaries AATS, SF 2012
Anterior
Looping
Posterior
Looping
Double
Looping
Nearly ALL CASESNearly ALL CASES
ASO, Cx. Coronaries AATS, SF 2012
Intramural Course: 5%
Most Complex Form
Single ostium
ASO, Cx. Coronaries AATS, SF 2012
Yacoub type C Yacoub type B
ASO TechniquesASO TechniquesClosed aortaClosed aorta
��Opened aorta: Opened aorta:
-- TrapTrap--doordoor
�� No trapNo trap--doordoor
ASO, Cx. Coronaries AATS, SF 2012
�� CustodiolCustodiol cardioplegiacardioplegia
�� No circulatory arrestNo circulatory arrest
��LecompteLecompte ManeuverManeuver
��PA reconstruction: PA reconstruction:
PantaloonPantaloon autologous pericardiumautologous pericardium
Aorta
High
Division of the Great VesselsDivision of the Great Vessels
Shorten the NeoShorten the Neo--AortaAorta
ASO, Cx. Coronaries AATS, SF 2012
PA
Low
LargeLarge coronary buttonscoronary buttons
ASO, Cx. Coronaries AATS, SF 2012
The more complex, the more dissection The more complex, the more dissection
LeftLeft buttonbutton
ASO, Cx. Coronaries AATS, SF 2012
No trap-door
RightRight buttonbutton
ASO, Cx. Coronaries AATS, SF 2012
Right button in high positionRight button in high position
ASO, Cx. Coronaries AATS, SF 2012
IntraIntra--mural coursemural course
ASO, Cx. Coronaries AATS, SF 2012
Yacoub Type C
Yacoub Type BYacoub Type B
ASO, Cx. Coronaries AATS, SF 2012
IntraIntra--mural coronarymural coronaryYacoub type B
ASO, Cx. Coronaries AATS, SF 2012
C Planche C, F Lacour-Gayet et al. JTCVS 1988; 96: 354-63
Yacoub Type BRotation 180Rotation 180ºº
Yacoub type B,
No coronary relocation
ASO, Cx. Coronaries AATS, SF 2012
P Aubert et al, British Heart Journal 1978; 40: 204-10
Yacoub type B,
No coronary relocation
ASO, Cx. Coronaries AATS, SF 2012
N Moat et al JTCVS 1992, 103, 872-6
S Takeuchi, 1990; 50: 1000-2
Infundibular coronary branchInfundibular coronary branch
ASO, Cx. Coronaries AATS, SF 2012
VERY FREQUENTVERY FREQUENT
Excentric OstiumExcentric Ostium
ASO, Cx. Coronaries AATS, SF 2012
Malaligned CommissuresMalaligned Commissures
ASO, Cx. Coronaries AATS, SF 2012
Important
AortoAorto--Pulmonary Diameter MismatchPulmonary Diameter Mismatch
ASO, Cx. Coronaries AATS, SF 2012
Side by side vesselsSide by side vessels
ASO, Cx. Coronaries AATS, SF 2012
ExampleExample
ASO, Cx. Coronaries AATS, SF 2012
TGA-IVS
Double looping + Intra Mural + Side by Side
Harvesting common buttonHarvesting common button
ASO, Cx. Coronaries AATS, SF 2012
Incising the stenosed left ostiumIncising the stenosed left ostium
ASO, Cx. Coronaries AATS, SF 2012
Creating two buttonsCreating two buttons
ASO, Cx. Coronaries AATS, SF 2012
Results Results
ASO, Cx. Coronaries AATS, SF 2012
Results Results
Denver Children’s, 2002-2010
101 consecutive Arterial Switch, 49% cx ASO
Hospital Mortality : 0%
ATS, June 2012ATS, June 2012
ASO, Cx. Coronaries AATS, SF 2012
Hospital Mortality : 0%
• Coronary Failure: 2 patients
•1 transplantation, single ostium
•1 late death, DORV, Malaligned commissure
• 3 angioplasty
• No late reoperation
Survival Curve, 101 ASO
90%
95%
100%
99%
ASO, Cx. Coronaries AATS, SF 2012
50%
55%
60%
65%
70%
75%
80%
85%
90%
1 2 3 4 5 6 7 8 9 100 6M 1Y 2Y 3Y 4Y 5Y 6Y 7Y 8Y
ATS, June 2012ATS, June 2012
Mean LOS:13D
Complications: 25%
Most frequent in complex forms
No AV block
Failure to rescue: none
101 Arterial Switch101 Arterial Switch
ASO, Cx. Coronaries AATS, SF 2012
Failure to rescue: none
Risk Factor for Morbidity:
Malaligned commissures
Aortic arch repair
Coronary anatomy no more a risk factor
1198 ASO, 1198 ASO,
Mean follow up 59MMean follow up 59M
324 coronary angiograms324 coronary angiograms
2% coronary reoperation2% coronary reoperation
Intra mural coronary p=0.002Intra mural coronary p=0.002
Late Coronary Complications after ASOLate Coronary Complications after ASO
Coronary events after arterial switch operation for TGA. Legendre A, Losay J, Serraf A et al. Coronary events after arterial switch operation for TGA. Legendre A, Losay J, Serraf A et al.
Circulation 2003, Suppl 1:II 186Circulation 2003, Suppl 1:II 186--9090
ASO, Cx. Coronaries AATS, SF 2012
Intra mural coronary p=0.002Intra mural coronary p=0.002
��Late Coronary Control in complex coronaryLate Coronary Control in complex coronary(CT Scan, MRI, coronarography)(CT Scan, MRI, coronarography)
Late dilation of the neoLate dilation of the neo--aortaaorta
A Baruteau, V Lambert, Marie Lannelongue, Paris
2026 ASO2026 ASO, 1982-2012
118 Adult > 18Y with complex ASOMean Follow up 21.2 Y
�60% dilatation of the neo-aortic root
�8% reoperation for aortic regurgitation
ASO, Cx. Coronaries AATS, SF 2012
�8% reoperation for aortic regurgitation
�1,5% coronary reoperation
ASO: They do wellASO: They do well
ASO, Cx. Coronaries AATS, SF 2012
WilliamWilliam, 20Y, French Junior Formula 1 Champion., 20Y, French Junior Formula 1 Champion.
Arterial Switch, Oct. 1991
William, 20YWilliam, 20Y
Arterial Switch, 1991
ASO, Cx. Coronaries AATS, SF 2012
William
ASO, Cx. Coronaries AATS, SF 2012
ASO, Cx. Coronaries AATS, SF 2012