Coronary re-implantation after completion of neo-aortic reconstruction in arterial switch operation: accurate intraoperative assessment for the optimal re-implantation site.

The arterial switch operation (ASO) has evolved into the treatment of the choice for most forms 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 a nd 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 great arteries 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 are left 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 we have to pursue further technical refinement of coronary artery transfer in ASO.