Influence of coronary artery anatomy during transposition of great arteries on reimplantation technique - is it possible to simplify standard classification?

Transposition of the great arteries (TGA) is “cyanotic” congenital heart disease, which leads to certain death in 100% of patients. The modern standard of treatment is radical correction - arterial switch. One of the most important aspects of successful arterial switch is the anatomy of coronary arteries and its influence on the reimplantation technique. Many complex classifications of coronary anatomy during transposition were offered, however, we can see the tendency to their simplicity in practical work. Coronary anatomy of 120 consecutive patients with simple transposition of great vessels TGA and TGA with ventricular septal defect was evaluated. In the most cases (n=105, 93.1%) we observed 3 variants of coronary anatomy: usual (1LAD,Cx,2R - 65.9%), circumflex artery from RCA (1LAD,2R,Сх - 20.4%), separate origin of circumflex artery from aortic sinus (1LAD,R,2Сх - 6.8%). In 65 patients we used classical “open” methods of reimplantation of coronary arteries (U-shaped with “buttons”, J-shaped “trap-door” or their combination), the median time of myocardial ischemia was 83±22.5 min (78-126 min), and median blood loss 120±30 ml (75-245 ml). We used “close” technique in 52 patients. The median time of myocardial ischemia was 34±9.3 min (31-62 min), median intraoperative blood loss 20±20 ml (10-50 ml). The necessity in postponed approximation of sternum decreased from 60% (2010) to 6% (2015). It resulted in reduced time of inotropic myocardial support, reduced frequency of adrenaline usage and combined inotropic support up to 5.6% in 2015. Postoperative mortality reduced from 18% (2010) up to 6% in 2015. Coronary anatomy does not influence on the method of reimplantaion of the coronary arteries. The only real exception is an intramural coronary artery, the way of its reimplantation may differ in each individual case. “Close” technique of reimplantation reduces the period of myocardial ischemia and artificial circulation. The sinotubular zone is formed by means of circular anastomosis while creating of neoaorta, it may reduce the risk of neoaortal valve insufficiency. Continuous locking stitch of coronary anastomosis is haemostatic, this fact was proved by more than twice reduced blood loss.