Nguyen Stephanie N, Vinogradsky Alice V, Tao Alice M, Chung Megan M, Kalfa David M, Bacha Emile A, Goldstone Andrew B
Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY.
Section of Pediatric and Congenital Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY.
J Thorac Cardiovasc Surg. 2025 Jan;169(1):217-228.e22. doi: 10.1016/j.jtcvs.2024.07.010. Epub 2024 Jul 14.
To determine the influence of coronary anatomy on long-term outcomes of the arterial switch operation (ASO).
We retrospectively reviewed patients with transposition of the great arteries or Taussig-Bing anomaly who underwent ASO at our institution between 1992 and 2022. The primary endpoint was freedom from a composite of death, transplantation, and coronary reintervention.
A total of 632 patients (median age, 5.0 days; interquartile range [IQR], 4.0-7.0 days) underwent ASO. Coronary anatomy included the following categories: usual (n = 411; 65%), circumflex (Cx) from sinus 2 (n = 89; 14%), inverted (n = 55; 9%), single sinus (n = 46; 7%), and intramural (n = 31; 5%). Overall operative mortality was 3% (n = 16) and highest in patients with intramural cardiac anatomy (n = 3; 10%), although it dropped to 0% in this group in the most recent decade. The median duration of follow-up was 14.5 years (IQR, 6.0-20.3 years). Twenty-year freedom from the primary endpoint was 95 ± 1% for usual anatomy, 99 ± 1% for Cx from sinus 2, 90 ± 4% for inverted, 91 ± 4% for single sinus, and 80 ± 9% for intramural (P < .001). Intramurals had the highest 20-year incidence of coronary reintervention (11 ± 8%). Cox modeling identified intraoperative coronary revision (hazard ratio [HR], 20.1; 95% confidence interval [CI], 9.4-53.9; P < .001), Taussig-Bing anomaly (HR, 4.9; 95% CI, 2.2-10.9; P < .001), and an intramural coronary artery (HR, 2.9; 95% CI, 1.0-8.2; P = .04) to be risk factors for the composite endpoint.
Rare coronary artery variants-particularly intramural-are associated with increased mortality and coronary reinterventions after ASO. A low threshold for unroofing intramurals is likely associated with declining mortality and improved outcomes. Additional investigations are needed to determine the long-term fate of the coronary arteries after ASO.
确定冠状动脉解剖结构对动脉调转术（ASO）长期预后的影响。
我们回顾性分析了1992年至2022年间在我院接受ASO的大动脉转位或陶西格-宾畸形患者。主要终点是无死亡、移植和冠状动脉再次干预的复合终点。
共有632例患者（中位年龄5.0天；四分位间距[IQR]，4.0 - 7.0天）接受了ASO。冠状动脉解剖结构包括以下类别：正常（n = 411；65%）、来自窦2的回旋支（Cx）（n = 89；14%）、反位（n = 55；9%）、单窦（n = 46；7%）和壁内（n = 31；5%）。总体手术死亡率为3%（n = 16），在壁内心脏解剖结构患者中最高（n = 3；10%），尽管在最近十年该组降至0%。中位随访时间为14.5年（IQR，6.0 - 20.3年）。正常解剖结构20年无主要终点事件的发生率为95±1%，来自窦2的Cx为99±1%，反位为90±4%，单窦为91±4%，壁内为80±9%（P <.001）。壁内冠状动脉患者20年冠状动脉再次干预发生率最高（11±8%）。Cox模型确定术中冠状动脉修正（风险比[HR]，20.1；95%置信区间[CI]，9.4 - 53.9；P <.001）、陶西格-宾畸形（HR，4.9；95% CI，2.2 - 10.9；P <.001）和壁内冠状动脉（HR，2.9；95% CI，1.0 - 8.2；P =.04）是复合终点的危险因素。
罕见的冠状动脉变异——尤其是壁内变异——与ASO术后死亡率增加和冠状动脉再次干预相关。壁内冠状动脉开窗的低阈值可能与死亡率下降和预后改善相关。需要进一步研究以确定ASO术后冠状动脉的长期转归。
