New technique for the arterial switch operation in difficult situations

New Technique for the Arterial Switch Operation in Difficult Situations Shigeyuki Takeuchi, MD, and Toshiyuki Katogi, MD Department of Surgery, School of Medicine, Keio University, Tokyo, Japan

The technique described here, a modification of the Aubert operation, avoids coronary reimplantation and also eliminates the need to use artificial material to transfer coronary circulation. (Ann Thorac Surg 1990;50:1000-1)

defect of the anterior proximal aortic wall is repaired by a patch of xenograft pericardium (Fig Id). Finally, reconstruction of the neopulmonary root is completed.

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oronary reimplantation is the most important part of the arterial switch operation for patients with transposition of the great arteries, and may contribute substantially to surgical outcome. In the case of single coronary artery and intramural coronary arteries, reimplantation can be particularly difficult. In 1977, Aubert and associates [l] reported the first successful case using the internal tunnel repair technique, eliminating coronary reimplantation from the arterial switch operation. Recently Kawada and co-workers [2] modified this technique though only for those patients who have difficulties with coronary reimplantation. Here, we propose another simple modification of this coronary rerouting procedure. The use of the viable aortic wall for partitioning facilitates the rerouting procedure without distortion, and a high patency rate and future growth can be expected [3]. With this technique, pulmonary root reconstruction is easier than in the case of coronary transfer, and compression of the coronary arteries can be avoided. Figure 1 shows this technique in detail. When transecting both great arteries at the level of pulmonary bifurcation (Fig la), a flap of the anterior aortic wall on the nonfacing sinus is joined to the distal ascending aorta like a tongue. The posterior aortic wall of the proximal ascending aorta is cut in a U-shape just above the coronary orifice, and adjacent pulmonary arterial wall is also cut in the same fashion. These two U-shaped cuts are anastomosed to form an aortopulmonary window (Fig lb). A few millimeters along the proximal aorta and the proximal pulmonary artery are sutured on either side of the U-shaped window. After the French maneuver has been done, the flap of distal ascending aorta is sutured to cover the coronary orifice and the surgically created aortopulmonary window so as to form an internal tunnel for coronary circulation (Fig lc). Then the distal aorta and the proximal pulmonary artery stump are anastornosed. The Accepted for publication Aug 10, 1990. Address reprint requests to Dr Takeuchi, Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan.

0 1990 by The Society of Thoracic Surgeons

1. Aubert J, Pannetier A, Couvelly J-P, et al. Transposition des gros vaisseaux: correction de la malformation a I'etage aortique. Chirurgie 1977;103:130-4. 2. Kawada M, Imai Y, Kurosawa H, et al. Modification of the Aubert operation. Nippon Kyobu Geka Gakkai Zasshi 1989; 37:1723. 3. Takeuchi S, Imamura H, Katsumoto K, et al. New surgical method for repair of anomalous left coronary artery from pulmonary artery. J Thorac Cardiovasc Surg 1979;78:7-11.

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Fig I . Modification of Aubert operation: (a) trunsection of both great arteries; (b) creation of aortopulmonuy window; (c) construction of coronay rerouting; (d) new aortic root and coronay pathway are completed. 0003-4975/90/$3.50