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Vol. 40. Issue 10.
Pages 713-714 (October 2021)
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Vol. 40. Issue 10.
Pages 713-714 (October 2021)
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Arterial switch operation for transposition of great arteries: Is coronary artery circulation evaluation necessary?
Switch arterial: a avaliação da circulação coronária é necessária?
António Marinho-da-Silva
Referal Center for Congenital Cardiology, Coimbra Hospital and University Center, Portugal
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Arterial switch operation (ASO) for transposition of great arteries (TGA) was first performed by Jatene in the late 70s.1 To achieve a normal spatial arterial relationship, the excision of the coronary artery buttons and their implantation in the new aorta is required. The difficulty of this step is related to the type of coronary origin and distance to the new insertion site. As this anatomical normalization step is completed, cardiac functional normalization is sought. Post-surgical sequelae are mostly related to the original complexity of TGA-associated anomalies (ventricular septal defect, coarctation, etc.) and acquired stenosis, related to Lecompte maneuver or neo-vessel suture sites. Also, well known, late complications of congenital or acquired coronary circulation may occur too, with variable incidence (8-27.5%) and related to different mechanisms.2,3

Since the beginning of the year 2000, coronary computed tomography angiography (CCTA) has assumed an increasingly important role in the assessment of coronary anomalies, especially after TGA correction using the Jatene procedure.4 Most coronary problems and events described so far, tend to occur in childhood in the first few years after surgery where complaints are difficult to assess. Looking for coronary artery abnormalities despite apparent “normality”, was a task we did in the past using conventional angiography with unnecessary patient exposure to radiation and catheterization complications. Nowadays, new imaging tools that are less or noninvasive are available to assess functional and anatomical coronary abnormalities. Examples of these are: new Doppler echocardiography techniques of the heart or dual-energy computed tomography myocardial perfusion imaging.5–7 The role of CCTA in coronary anatomy interrogation is less validated in children than in adults.8 The paper from Abreu et al. published in this issue of the Journal9 seeks to reinforce the importance of this diagnostic imaging method in this setting. Despite a small number of analyzed patients, a high prevalence of lesions was found (39%). This corresponds to half of the patients presenting lesions “suggestive of myocardial ischemia”, which shows there is some disagreement between previous fundamental complaints/imaging tools.

Since this is a retrospective study, it has several limitations, which are well explained by the authors. However, the paper is not a mere academic exercise, as it demonstrates the need for additional therapeutic measures (including surgery) to preserve cardiac function.

Owing to lack of symptomatology, how to identify patients with coronary abnormalities and a disease that may ultimately compromise their lives is the challenge that this paper poses. In the future, the use of more accessible techniques, such as stress echocardiography or modalities of tissue Doppler imaging may help in risk stratification and, therefore, support the rationale to use CCTA in a productive way. But, clearly, the published results reinforce the need for universalization of the technique (CCTA) and as it can prevent the need for general anesthesia and aggressive invasive methods, in almost all studies, it is of great importance in this small patient population. Although some international guidelines support this view,10 others do not.11 Of course, if clinical symptoms (arrhythmia, thoracic pain, or excessive fatigue) or abnormalities in the standard exams are present, cardiac assessment using coronary computed tomography (or Dual-CT) should be performed immediately at any time. However, should one basal evaluation of coronary circulation in all post-operative ASO patients be reasonable too?12 The general reported low incidence of coronary related problems makes it questionable. The article from Abreu et al. warns us of the limitations that most methods, such as standard exercise testing, have for the identification of ischemia. Furthermore, the paper gathers information that may be useful in the future design of guidelines, which may include CCTA as a fundamental tool in the follow-up of these patients.

Conflicts of interest

The author has no conflicts of interest to declare.

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Successful anatomic correction of transposition of the great vessels. A preliminary report.
Arq Bras Cardiol, 28 (1975), pp. 461-464
P. Ou, et al.
Mechanisms of coronary complications after the arterial switch for transposition of the great arteries.
J Thorac Cardiovasc Surg, 145 (2013), pp. 1263-1269
T. Tsuda, et al.
Coronary artery problems late after arterial switch operation for transposition of the great arteries.
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V. Wijk, et al.
Sudden death due to coronary artery lesions longterm after the arterial switch operation: a systematic review.
Can J Cardiol, 33 (2017), pp. 1180-1187
D. Ibrahim, et al.
Dual-energy computed tomography for detection of coronary artery disease.
Expert Rev Cardiovasc Ther, 13 (2015), pp. 1345-1356
R.J.C. Maia, et al.
Global longitudinal strain predicts poor functional capacity in patients with systolic heart failure.
Arq Bras Cardiol, 113 (2019), pp. 188-194
S. van Wijk, et al.
Evaluation of left ventricular function long term after arterial switch operation for transposition of the great arteries.
Pediatr Cardiol, 40 (2019), pp. 188-193
C. Veltman, et al.
Variation in coronary anatomy in adult patients late after arterial switch operation: a computed tomography coronary angiography study.
Ann Thorac Surg, n96 (2013), pp. 1390-1397
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Acquired anomalies of the coronary arteries after arterial switch operation. Usefulness of CT coronary angiography and impact on follow up.
Rev Port Cardiol, 40 (2021),
K. Stout, et al.
2018 AHA/ACC guidelines for the management of adults with congenital heart disease.
Circulation, 14 (2019), pp. 698-800
H. Baumgartner, et al.
2020 ESC guidelines for the management of adult congenital heart disease.
Eur Heart J, (2020), pp. 1-83
K. Szymczyk, et al.
Usefulness of routine coronary CT angiography in patients with transposition of the great arteries after an arterial switch operation.
Pediatr Cardiol, 39 (2018), pp. 335-346
Copyright © 2021. Sociedade Portuguesa de Cardiologia
Revista Portuguesa de Cardiologia (English edition)
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