doi: 10.1161/01.cir.0000087902.67220.2b
(Circulation. 2003;108:II-186.)
© 2003 American Heart Association, Inc.
Surgery for Congenital Heart Disease |
Coronary Events After Arterial Switch Operation for Transposition of the Great Arteries
From the Centre Chirurgical Marie-Lannelongue, 133 avenue de la Résistance, 92350 Le Plessis-Robinson, France.
Correspondence to A. Legendre, MD, Centre Chirurgical Marie-Lannelongue, 133 avenue de la Resistance, 92350 Le Plessis-Robinson, France. Phone: (33)1.40.94.28.00, Fax: (33)1.40.94.28.98, E-mail : alegendre{at}ccml.com
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Abstract |
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Background— Transfer of the coronary arteries is a crucial step during the arterial switch operation (ASO) for transposition of the great arteries. This retrospective study aims to assess the incidence and risk factors of coronary events after ASO and sensitivity of noninvasive tests in the diagnosis of the coronary obstruction.
Methods and Results— Between 1982 and 2001, 1304 newborn and infants had an ASO and the 1 198 hospital survivors had a 59-month mean follow-up. Coronary events occurred in 94 patients (7.2%; 95% CI, 6 to 9). Survival without coronary events were 92.7, 91, and 88.2% at 1, 10, and 15 years, respectively. The incidence was bimodal: high early and slow later. Multivariate analysis showed correlation with type B or C coronary pattern and major operative events (P<0.0001 and P=0.0024). In a subset of 324 patients who underwent a coronary artery angiography, lesions were observed in 22 patients (6.8%; 95% CI, 5 to 10). Multivariate analysis showed correlation with only type B or C coronary pattern (OR=20.8, P=0.0002). All of these patients had electrocardiogram and echocardiogram, 174 patients also had a treadmill test, and 115 patients had a myocardial scintigraphy. The association of these tests had the highest diagnosis sensitivity, 75%.
Conclusion— After ASO, coronary events are not rare, occurring most often early and are an important cause of death. Coronary repair can be needed lately. Noninvasive tests are not sensitive enough to detect significant delayed coronary artery stenosis and coronary artery angiography should be performed.
Key Words: transposition of the great arteries • arterial switch • coronary complications
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Introduction |
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Arterial switch operation (ASO) for transposition of the great arteries (TGA) shows better early, mid-, and long-term results than atrial switch, as has been established in several large series.1–4 Transfer of the coronary arteries during ASO may be a difficult step in the case of abnormalities of origin or distribution of these arteries. The long-term success of this intervention depends principally on the status of the coronary perfusion and the coronary events are an important cause of death.4–6 Therefore, signs of myocardial perfusion anomalies are investigated during the follow-up of the patients. The few studies regarding the capacity of noninvasive methods to predict coronary obstruction being not conclusive, and most patients remaining symptom free, an aortography or a selective coronary angiography may be proposed.7,8
In this article, we report coronary events in a population of 1 304 patients who underwent an ASO for TGA. This retrospective study was undertaken to assess the incidence and risk factors of coronary events after ASO. Then, the noninvasive diagnosis investigations of the coronary obstruction were evaluated.
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Patients and Methods |
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Between 1982 and 2001, 1 304 newborns and infants with TGA had an ASO at Marie Lannelongue’s Hospital (France). Three hundred seventy five patients had surgery before 1990 and 106 patients had a two-stage intervention. Patient characteristics are shown in Table 1. The surgical technique for ASO at Marie Lannelongue’s Hospital was standard and has been previously described.9 We used Yacoub and Radley-Smith classification for the description of coronary pattern.10 Type A is the normal distribution; type B is characterized by the presence of a single orifice; type C showed two coronary orifices originating close to each other at the facing commissure; type D is similar to type A with the exception that the circumflex artery arises from the right artery and curves posteriorly around the pulmonary trunk; and type E is defined by origin of the circumflex artery from the right posterior sinus. We grouped types B and C together because they are characterized by artery coursing between the aorta and the pulmonary trunk, usually with an intramural course and imply the same surgical difficulties for our surgeons. We did the same for the types D and E, which represent an abnormal looping of one or both arteries.
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All operative and hospital incidents noted in the hospital records were reviewed for details. Major intraoperative events included difficulties in coronary translocation, left ventricular dysfunction, cardiac arrest, and need for temporary circulatory assistance at the end of the intervention. Hospital events included myocardial ischemia or infarction and left ventricular dysfunction. A coronary event was defined as death from myocardial ischemia or infarction, sudden death, nonfatal myocardial infarction observed on the ECG, and reoperation for coronary stenosis.
After hospital discharge, five patients have been lost to follow-up. The mean follow-up of 1 198 hospital survivors was 59 months (range, 1 year to 17 years). Since 1982, all survivors had an annual examination by the referring pediatric cardiologist that included a clinical assessment, electrocardiogram (ECG), and echocardiogram with Doppler study.
At a mean of 7 years (range, 10 days to 16.3 years, median 7 years) after ASO, 324 patients had a coronarography (selective coronary angiography or aortography), prospectively in some centers (284 patients) or after appearance of ischemia. In these 324 patients, the annual examination that included a yearly clinical assessment, ECG, and echocardiogram with Doppler study were reviewed, as well as the exercise tests and the myocardial scintigraphies done in these patients either at the time of the coronarography or just after diagnosis of the coronary obstruction to assess the degree of myocardial ischemia. An exercise test was performed in 174 patients (of 324) and a myocardial scintigraphy was performed in 115 patients. Twenty-one patients had two or three coronary angiographies, but, for statistic analysis, we studied only the first abnormal angiography or the last normal angiography when no coronary lesion was detected. All data were regularly transmitted by the referring cardiologist. Coronary stenosis was defined as 50% or greater reduction of vessel diameter in coronary angiography. Electrocardiographic evidence of ischemia included ST-T anomalies and Q wave, and echography was undertaken to study reduction or anomalies of segmental wall motion and mitral valve insufficiency, as reported by referring pediatric cardiologists.
Statistical Analysis
StatView 5.0 software (SAS Institute) was used for data analysis. Univariate analysis of continuous variables were performed with the Student t test. Univariate comparisons for categorical variables were performed with the 2-tailed 
2 test or, when necessary, the Fisher exact test. Every univariate parameter that reached the level of significance (P<0.05) was tested in a multivariate logistic regression model. Time-related events were examined by actuarial method; analyses were performed with censoring of incompletely traced patients after the time of the last follow-up, and differences between groups were calculated by the log-rank test. The hazard function regression method was used to estimate time-related freedom from and hazard function of unfavorable outcome events.11 Percentages are presented with 95% confidence intervals (CI).
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Results |
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Coronary Events
Coronary events occurred in 94 patients. Table 2 presents risk factors observed. In univariate analysis, coronary events were more frequent in patients operated on before 1990, in patients with type B or C coronary pattern, with longer cardiopulmonary bypass or reperfusion time, and with major operative events (all P<0.0001). Multivariate analysis confirmed significant correlation with type B or C coronary pattern and major operative events with OR=6.6 and 3, respectively (P<0.0001 and P<0.0024, respectively). On the contrary, other coronary relationship, ventricular septal defect, great arteries pattern, aortic cross-clamp time, and age and weight at operation had no effect on occurrence of coronary events.
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The actuarial survival free from coronary events is shown in Figure 1. Freedom from coronary events was observed in 92.7%, 92.5%, 91%, and 88.2% of the survivors at 1, 5, 10, and 15 years, respectively. Hazard function showed a bimodal pattern with a rapid declining phase approaching 0 at 3 months and slowly increased after 6 years (Figure 2).
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Eighty nine percent of coronary events were observed within the first 3 months after ASO. Of these, coronary death included 47 hospital deaths and 7 late deaths. The causes of these deaths were myocardial ischemia in 6 patients, infarctions in 45 patients, and sudden deaths in 3 patients. These data were proved at autopsy in 24 patients and on clinical grounds in the other patients (acute sudden death, echocardiography or ECG evidence). Nonfatal myocardial infarctions occurred in 34 patients (within 30 days in 31 patients). Eighteen of the patients who did not have surgery recovered a normal ECG and echocardiogram. Five patients had coronary revascularization. Two patients died after the revascularization from congestive heart failure, one immediately after revascularization, and the second 2 months later.
Concerning later coronary events, reoperations before myocardial infarction were performed in 6 patients late in the follow-up period (median 73 months), and after 10 years in 4 patients. Revascularization occurred in 11 patients and represented 5% of reoperation after ASO. Coronary revascularization was surgical ostial angioplasty in 6 patients, mammary artery graft in 3 patients, and surgical liberation of an extrinsic compression in two patients.
Coronary Obstructions
Of 324 patients who underwent a coronary angiography, one patient had a dissection of the right ostium that necessitated a stent implantation with a good result.
In those 324 patients, coronary obstruction was observed in 22 patients (6.8%; 95% CI, 5 to 10); significant lesions are given in Table 3. Other minor obstructions were observed in 14 patients but not considered as coronary obstruction in this study: minor stenosis of the left coronary in 3 patients, hypoplasia of the left coronary in 11 patients, and fistula between coronary artery and pulmonary artery in 1 patient.
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Multivariate analysis showed correlation only between coronary obstruction and type B or C coronary pattern (OR=20.8, P=0.0002).
Only one patient was symptomatic (cardiogenic failure). He had an occlusion of the right coronary and an stenosis of the left ostium.
Of 324 patients, 38 had myocardial ischemia evidence with at least one ECG, echocardiography, exercise test or myocardial imaging positive. In this group, 14 patients had coronary lesions (36.8%). Of 286 patients who did not show evidence of ischemia, 8 patients had coronary obstructions (P<0.0001) (Table 3). Individually, each of the tests (ECG, echocardiography, exercise test, and myocardial scintigraphy) had a low sensitivity (less than 50%; Table 4). The association of these tests was then analyzed. Sensitivity was higher, reaching 75% but still three lesions were mixed (Table 5).
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Of 22 patients with coronary obstruction, 6 patients underwent two or three coronary angiographies. One patient had an early normal angiography and an abnormal angiography 8 years later. In another patient with an early coronary obstruction, myocardial ischemia appeared a few years later. In all cases, myocardial ischemia on ECG, echocardiography, and myocardial scintigraphy disappeared after revascularization.
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Discussion |
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In previous ASO studies, coronary events were often reported with early mortality and morbidity.1–3 Specific reports on coronary events or lesions are scarce, with two studies being retrospective8,12 and one study prospective,7 although they included only a small number of patients. Coronary events were frequent in our population with a prevalence of 7% as seen in earlier reports in which prevalence varied from 2% to 11%.5,13–16 This prevalence was close to that observed for pulmonary stenosis or aortic regurgitation in a comparable population4 but the time of occurrence during the follow-up was different. The coronary events most often occurred immediately after the ASO and were the main cause of death1,4,5,14–18 or morbidity.19 In the early postoperative period, coronary events were related to coronary anatomy and to surgical technique difficulties as shown in this population and by others.1,5,13,14,16,17,19 As it could be expected, the prevalence of coronary events decreased with surgical experience.5,14,16,19 Causes were probably anatomical kinking or torsion and extrinsic compression by biological glue that necessitated immediate coronary revision or reoperation. The use of biological glue dramatically decreased with surgical experience in the last 10 years. After postoperative myocardial infarction, the majority of our patients who had angiography did not have coronary lesions, as previously reported.7,8 Late coronary mortality and myocardial infarction were rare, not observed in this study and had a prevalence of less than 2% in other populations.5,6,12–14,16,17,20 In our population, the only coronary events observed after 3 months were reoperation for coronary lesions. Coronary revascularizations occurred late, at least 1 year after ASO and most often after 3 years in other reports.8,12,17 Late coronary events were not related to intraoperative problems or early ischemic symptoms.8,12 Causes were probably progressive fibrocellular intimal thickening or stretching of the coronary artery with growth.7
Coronary lesions were not rare in this population although prevalence was difficult to assess. Coronary lesions were observed in 6.8% of the 324 patients who had aortography or coronarography a median 7 years after ASO, this exploration being done electively in 88%. A large study with prospective aortography performed in 64% of the population showed a prevalence of 3.3% but aortography was performed earlier, at a median 13.2 months after ASO.12 In a small prospective study selective, coronarography at a median 7.6 years after ASO showed a prevalence of 7.5%.7
A higher prevalence, 18.2%, has been reported, but in theses studies specific technique or coronary artery translocation was used.8
Diagnosis of coronary lesion is important as it is not rare and has been the cause of late death in previous study.6,8,12 Symptoms cannot be relied on because they were most often absent in our population, as seen in other studies.7,8,12 Lesions can appear late, probably related to growth, as in one of our patients who had an early normal coronarography. As previously observed,7,8,12 we found that noninvasive techniques, such as ECG and echocardiography, had a low sensitivity and thus cannot be used safely to diagnose a potentially severe disease. Unfortunately, other noninvasive tests of the myocardial perfusion were not sensitive enough, even when all tests were used in conjunction, because retrograde perfusion from collateral circulation protects the myocardium, but can become insufficient with growth, as observed in one of our patients. Indeed, 5% of the patients in this study with all negative tests had coronary artery lesions and 25% of the patients with significant lesions were not detected in another study.8 Thus, aortography and/or coronary artery angiography should be widely performed. We proposed a yearly follow-up with a clinical examination, and ECG and an echocardiography every 3 years associated with myocardial scintigraphy and exercise testing, because the association of the three studies has the best sensitivity (Table 5). Nevertheless, this sensitivity is too low for a rare but potentially dangerous lesions that can develop later. We suggest coronarography at 5, 10, and 15 years.
The strengths of the present study is that a large number of patients were included and there was a long period between ASO and angiography. The only previously published study7 was a prospective one with late coronarography, but it included only a small number of patients. Nevertheless, the results of these study for incidence and noninvasive sensitivity were in agreement with the present data. However, only a small proportion of patients (n=324) had angiography and there was a nonprospective collection of angiographic data.
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Conclusions |
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Coronary events are not rare and the incidence had a bimodal pattern: a high early incidence but decreasing with surgical experience and a low late incidence. Coronary lesions have a prevalence of 6.8% and they may be late in the follow-up. They are associated with type B or C coronary pattern and are not completely diagnosed by noninvasive techniques. Because they can have serious consequences, long-term follow-up and systematic coronary artery angiography should be performed.
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References |
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