Mechanisms of coronary complications after the arterial switch for transposition of the great arteries Phalla Ou, MD, PhD, Diala Khraiche, MD, David.

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Mechanisms of coronary complications after the arterial switch for transposition of the great arteries Phalla Ou, MD, PhD, Diala Khraiche, MD, David S. Celermajer, PhD, FRACP, DSc, FAA, Gabriella Agnoletti, MD, PhD, Kim-Hanh Le Quan Sang, MD, Jean Christophe Thalabard, MD, PhD, Mathieu Quintin, MS, Olivier Raisky, MD, PhD, Pascal Vouhe, MD, PhD, Daniel Sidi, MD, PhD, Damien Bonnet, MD, PhD The Journal of Thoracic and Cardiovascular Surgery Volume 145, Issue 5, Pages 1263-1269 (May 2013) DOI: 10.1016/j.jtcvs.2012.06.009 Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Determination of the coronary angles. The commonest positioning of the greats arteries and the coronaries after ASO are representing here. The coronary angles were determined as follows: (1) The aortopulmonary centerline that passes through the center of both the aorta and the pulmonary artery was drawn; (2) the perpendicular of the aortopulmonary centerline that passes through the center of the aorta is the reference line (0°); (3) the angle between the coronary ostia (red cross, left ostium; green cross, right ostium) and the reference line correspond to the coronary angle. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1263-1269DOI: (10.1016/j.jtcvs.2012.06.009) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Significant stenosis of the ostium of the left coronary artery by anterior compression by the pulmonary artery. The reimplantation is too anterior, as confirmed by the left coronary angle (green curve) almost equal to 90°, corresponding to a reimplantation at 12 o' clock. PA, Pulmonary artery; Ao, aorta. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1263-1269DOI: (10.1016/j.jtcvs.2012.06.009) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Tight stenosis of the LAD in the Yacoub type D. The reimplantation of the LAD (black arrow on the left panel) is to anterior as indicated by the left coronary angle almost equal to 90° (green curve on the left panel), and also too high above the left coronary sinus, as identified by the short coronary–pulmonary bifurcation distance (red arrow on the right panel) equal to 5 mm. PA, Pulmonary artery; Ao, aorta; LAD, left anterior descending artery. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1263-1269DOI: (10.1016/j.jtcvs.2012.06.009) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Mechanism of lesion of the circumflex artery in Yacoub type D. The reimplantation of the right ostium was too far under the right sinus, as evidenced by the long coronary–pulmonary artery distance (red arrow on the right panel). Thus, the course of the circumflex toward the left atrioventricular groove is increased, causing a stretching of the coronary artery (black arrow on the left panel). Ao, Aorta; LV, left ventricle. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1263-1269DOI: (10.1016/j.jtcvs.2012.06.009) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Lesion of the right coronary artery. The reimplantation of the right sinus is too high above the right sinus, as evidenced by the short coronary–pulmonary artery bifurcation distance (red arrow). The right ostium was then compressed by the pulmonary artery. This patient had a long “olasty” of the ostium and proximal segment of the right coronary artery using saphenous vein. See the difference in caliber between the saphenous vein in the proximal segment and the native distal segment, which is thinner. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1263-1269DOI: (10.1016/j.jtcvs.2012.06.009) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 6 Delayed on first-pass perfusion (black arrow, and see Video 1). Magnetic resonance imaging sequence involving the anteroseptobasal segment in a patient with a tight stenosis in the left anterior descending artery (Yacoub type D) owing to a compression by the pulmonary artery. Ischemia was also confirmed on myocardial scintigraphy. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1263-1269DOI: (10.1016/j.jtcvs.2012.06.009) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions