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\begin{document}

\title{Techniques and Pitfalls of Coronary Arterial Reimplantation in
Anatomical Correction of Transposition}



\author[1]{Ujjwal Chowdhury}%
\author[2]{Robert Anderson}%
\author[3]{Diane E. Spicer}%
\author[1]{Lakshmi  Sankhyan}%
\author[1]{Niwin George}%
\author[1]{Niraj Pandey}%
\author[1]{Shikha Goja}%
\author[1]{Balaji Chandhirasekar}%
\affil[1]{All India Institute of Medical Sciences Cardio-Thoracic Sciences Centre}%
\affil[2]{Newcastle University}%
\affil[3]{Johns Hopkins All Children's Hospital Heart Institute}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\selectlanguage{english}
\begin{abstract}
\textbf{Background} \textbf{and Aim}: We assessed the anatomical
variations in coronary arterial patterns relative to the techniques of
reimplantation in the setting of the arterial switch operation, relating
the variations to influences on outcomes. \textbf{Methods:} We reviewed
pertinent published investigations, assessing events reported following
varied surgical techniques for reimplantation of the coronary arteries
in the setting of the arterial switch procedure. \textbf{Results:} The
prevalence of reported adverse events, subsequent to reimplantation,
varied from 2\% to 11\%, with a bimodal presentation of high early and
low late incidence. The intramural pattern continues to contribute to
mortality, with some reports of 28\% fatality. The presence of abnormal
course relative to the arterial pedicles in the setting of single sinus
origin was associated with a three-fold increase in mortality. Abnormal
looping with bisinusal origin of arteries was not associated with
increased risk. \textbf{Conclusion:} The techniques of transfer of the
coronary arteries can be individually adapted to cater for the
anatomical variations. Cardiac surgeons, therefore, need to be familiar
with the myriad creative options available to achieve successful repair
when there is challenging anatomy. Long-term follow-up will be required
to affirm the superiority of any specific individual technique. Detailed
multiplanar computed-tomographic scanning can now reveal all the
variants, and elucidate the mechanisms of late complications. Coronary
angioplasty or surgical revascularization may be considered in selected
cases subsequent to the switch procedure.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Numerous studies have assessed the complexity and variability in origin
and course of the coronary arteries when discordant ventriculo-arterial
connections are found in the setting of concordant atrioventricular, the
arrangement usually described as
transposition.\textsuperscript{1-12}Prior to the introduction of the
arterial switch procedure, such variability was mainly of academic
interest. Knowledge of the variability is now of paramount surgical
importance, with certain variations presaging a poor
outcome.\textsuperscript{8,12-14}Understanding of the variations, and
their significance, has been complicated thus far by lack of uniform
descriptions. Classifications have tended either to be
incomplete,\textsuperscript{8} or excessively
complex.\textsuperscript{4} The Leiden approach is most universally
applicable.\textsuperscript{8,9} The system does not, however, account
for all the potentially significant variables, such as
looping.\textsuperscript{12} The course of the artery to the sinus node
may also be of significance.\textsuperscript{3,15} Among the multiple
patterns, the presence of a solitary artery, the intramural variant, and
looping, have been associated with an increased risk of complications in
some surgical series, but not all.\textsuperscript{1-28} With this in
mind, we have evaluated the varied patterns relative to the early and
late outcomes of the arterial switch procedure.

\textbf{Methods}

We searched the extant literature using the Mesh term ``Transposition of
the great vessels'', and the key word ``arterial switch'', to identify
the variations in the coronary arterial anatomy as published from 1966
through 2021. The search engines used were PubMed , Google Scholar,
Cochrane Database for Systematic Reviews, Cochrane Central Register of
Controlled Trials, Ovid MEDLINE (all; 31.12.2019), ACP Journal Club,
Ovid EMBASE (1974 to 31.12.2019), Database of Abstracts of Review of
Effectiveness. We searched the literature in all languages, including
reports of mortality subsequent to the switch procedure when coronary
arterial patterns had been described. When overlapping series were
published from a single institution, we selected the studies providing
data on the largest number of patients.

\textbf{Surgical Anatomy}

With the exception of the Leiden convention,\textsuperscript{8} attempts
categorising the variations in coronary arterial patterns have foundered
either because of incompleteness or undue complexity. The Leiden
convention itself is less than perfect, failing to account for the
course of the coronary arterial stems relative to the arterial roots.
Nor does it recognise that, on occasion, the coronary arteries
themselves may be absent or duplicated. This does not mean that it
should be discarded. Nor does it necessitate the addition of new
codes.\textsuperscript{9} On the contrary, it retains its major value in
accounting adequately for the origin of the coronary arteries from the
aortic valvar sinuses. It is an easy matter then to account for
additional features in descriptive fashion.

The convention is based on the anticipated presence of the three major
coronary arteries, each with well-recognised areas of myocardial supply.
The right coronary artery supplies the right ventricular myocardium and,
when dominant, a variable portion of the diaphragmatic wall of the left
ventricle. The circumflex artery supplies the obtuse marginal wall of
the left ventricle. If dominant, this artery can supply part of the
diaphragmatic wall of the right ventricle. The anterior interventricular
artery supplies the anterior walls of both ventricles, along with the
anterior part of the ventricular septum. The variations found in the
setting of transposition can then almost always be understood on the
basis of ``marriage of convenience'' between the arteries and the aortic
valvar sinuses.\textsuperscript{6} Thus, the coronary arteries typically
arise from one or other, but usually both, of the aortic sinuses
adjacent to the pulmonary trunk (Figure 1A). The Leiden approach
distinguishes between these sinuses irrespective of the variations in
relationship between the roots themselves, and irrespective of which
sinus gives rise to which particular artery or arteries. The observer,
figuratively speaking, stands upright in the non-adjacent sinus of the
aortic root and looks towards the pulmonary root. One of the adjacent
aortic valvar sinuses is then to the right hand of the observer, and the
other to the left hand (Figure 1A). These positions are retained
irrespective of the relationships of the arterial roots (Figure 1B).

In the commonest pattern found in transposition, the right coronary
artery arises from the left-handed sinus, while the main stem of the
left coronary artery, branching into anterior interventricular and
circumflex arteries, arises from the right-handed sinus (Figure 2A). In
the second commonest pattern, the circumflex artery arises from the
left-handed sinus, taking a retro-pulmonary course (Figure 2B).
Distinguishing the sinuses in handed fashion might seem to be illogical
because the right coronary artery often arises from the left-handed
sinus. The convention, however, does no more than distinguish between
the adjacent sinuses. The approach popular amongst cardiac surgeons is
to nominate the right-handed sinus as \#1, and the left-handed sinus as
\#2. In a minority of cases, furthermore, the main stem of the left
coronary artery does arise from the left-handed sinus (\#2). It then
passes behind the pulmonary trunk to branch and fulfil its marriages of
convenience (Figure 2C). The right coronary artery in this pattern
arises from the right-handed sinus (\#1), taking an antero-aortic course
to reach the right atrioventricular groove.

When all three major arteries are present, assuming they arise from the
adjacent sinuses, there are only eight potential patterns of sinusal
origin. All have now been described. One is particularly rare, since it
breaks the concept of marriage of convenience. In this rarest variant,
two of the major arteries cross from their sinusal origin as they extend
to supply their myocardial territory.\textsuperscript{7} In all the
other variants, the arteries course from the most appropriate sinus to
their myocardial territory. On occasion, however, as shown, the arterial
stems course loop the pulmonary root, or else loop in front of the
aortic root. Such looping is a constant feature when all the coronary
arteries arise from one or other of the adjacent sinuses, with the other
adjacent sinus bereft of a coronary arterial origin (Figures 2
E,F).\textsuperscript{5} Such looping, tethering the coronary arteries
to the arterial roots, can create significant problems for the surgeon.
In presence of a significant arterial stem, however, such looping does
not necessarily produce problems (Figure 2C). A greater surgical problem
is encountered when single sinus origin (Figure 3A) is the consequence
of an intramural course of one or more of the major
arteries.\textsuperscript{16} Intramural arteries pass between the
arterial roots, extending through the wall of the aortic valvar sinus,
and usually cross the valvar commissure adjacent to the pulmonary trunk
(Figure 3B). Also of potential significance is whether the arteries take
individual origin from the valvar sinuses, or whether there is a
confluent origin and stem for two of the major branches, or for all
three in the setting of a solitary coronary
artery.\textsuperscript{5}Additional features of potential significance
are the origins of the artery to the sinus node and the infundibular
artery (Figure 2). Any of the three major coronary arteries can also be
absent or duplicated. Exceedingly rarely, one or more of the coronary
arteries can arise from the non-adjacent sinus of the aortic root. This
can be a contra-indication to the arterial switch
procedure.\textsuperscript{29}A further variation is mismatch between
the commissures of the arterial valves (Figures 2A,
F).\textsuperscript{30} If extreme, this variation can complicate safe
transfer during the arterial switch.

\textbf{Surgical techniques of transfer for usual and complex coronary
arteries}

Multiple individual modifications have been reported to allow adequate
transfer depending on the origins, branching pattern, looping course,
and intramural variations of the arteries.

The preferred current techniques for the usual patterns

\begin{itemize}
\tightlist
\item
  \emph{Coronary reimplantation following neoaortic reconstruction:}This
  was the original approach used by Jatene and
  associates,\textsuperscript{31} and subsequently advocated during the
  1980s (Figure 4A).\textsuperscript{32,E1}
\item
  \emph{The Melbourne medial flap technique:} This technique transfers
  the coronary arterial buttons to medially hinged neoaortic trapdoors
  (Figure 4B).\textsuperscript{33} The technical details of anatomical
  correction of transposition with usual coronary arrangement and Dacron
  patch closure of ventricular septal defect have been enumerated in the
  video presentation (Electronic Video 1). The coronaries were
  transferred to the neoaorta using the medially hinged neoaortic
  trapdoor.
\item
  \emph{Modified trapdoor technique:} In this modification, two buttons
  are created, each adopting the role of the trapdoor flap for the other
  button.\textsuperscript{34}
\end{itemize}

Complex coronary arteries with anterior and/or retro-pulmonary looping

\emph{The medial trapdoor technique:} A medially hinged neoaortic
trapdoor is useful in cases of significant
looping.\textsuperscript{33,39} With anterior looping, the coronary
button can be positioned at or above the neoaortic
anastomosis.\textsuperscript{33,35}

\emph{Yacoub technique:} This technique is used to relocate the right
coronary artery associated with retropulmonary looping of the circumflex
artery (Figure 4C).\textsuperscript{4}

\emph{}

Single sinus coronary arteries, juxtacommissural coronary arteries,
and/or intramural coronary arteries

\begin{itemize}
\tightlist
\item
  \emph{Yacoub technique:} A single arterial button is turned upside
  down, and anastomosed to the neoaorta (Figure 4D).\textsuperscript{4}
\item
  \emph{Planche technique:} This modifies the ``upside-down'' technique,
  adding a U-shaped incision in the neoaortic wall and avoiding the use
  of a pericardial patch (Figure 5A).\textsuperscript{12}
\item
  \emph{Bay-window technique:} The inner half of U-shaped coronary cuffs
  are sewn into trapdoor incisions made on the neoaortic stump. (Figure
  5B).\textsuperscript{36}
\item
  \emph{Pouch technique:} This technique involves commissural
  detachment, unroofing of intramural coronary arteries, and creation of
  a long aortic pouch (Figure 5C).\textsuperscript{37,38,40}
\item
  \emph{The Double Button Melbourne technique:} This involves
  commissural detachment and unroofing of the coronary arterial orifices
  (Figure 6A).\textsuperscript{17,39}
\item
  \emph{The pericardial hood technique:} The upper edge of the coronary
  arterial button is implanted to the neoaorta at an appropriate level
  when the arterial orifices are inseparable, confluent, or
  juxtacommissural.\textsuperscript{39}
\item
  \emph{In-situ transolocation:} An aortopulmonary window is created,
  with the anastomosis completed using a tongue of aortic wall (Figure
  6B).\textsuperscript{40}
\item
  \emph{Aubert procedure:} An aortopulmonary window is completed with a
  patch to the neoaorta (Figure 7A).\textsuperscript{41}
\item
  \emph{Moat's procedure:} The aortopulmonary window is completed using
  a bovine pericardial baffle (Figure 7B).\textsuperscript{42}
\item
  \emph{Imai procedure:} The window approach for intramural arteries is
  modified by suturing a D-shaped hinged aortic cuff of the non-adjacent
  sinus. (Figure 7C).\textsuperscript{43}
\item
  \emph{In-situ arterial reallocation:} Hockey-stick-shaped incisions
  are used to transfer the coronary arteries without distortion of their
  original anatomic position (Figure 8A).\textsuperscript{44}
\item
  \emph{Reimplantation after neoaortic anastomosis:} Separate intramural
  coronary arterial buttons are transferred after completion of the
  neoaortic anastomosis.\textsuperscript{45}
\item
  \emph{Anastomosis with pericardial hoods:} The trapdoor approach is
  combined with use of pericardial hoods (Figure
  8B).\textsuperscript{46}
\item
  \emph{Cetin technique:} Coronary arterial buttons are transferred to
  the neoaorta using pericardial or pulmonary arterial hoods (Figure
  8C).\textsuperscript{47}
\end{itemize}

\textbf{Results}

Since the turn of the 21\textsuperscript{st} century, patients
undergoing the arterial switch operation have been reported with
perioperative mortalities ranging between nil and
6\%.\textsuperscript{19,48,49} In the data analysed by NICOR, for
example, which collates overall results for all centers in the United
Kingdom, 118 procedures were reported for 2019 through 2020, with 4
deaths within 30 days of the procedure.\textsuperscript{50} Some
patterns, such as the intramural variants, or those with single sinus
origin, continue to be associated with a significantly increased risk of
death, which persists over time.\textsuperscript{19-55} Even with the
commonest types of coronary arterial anatomy, transfer is not always
straight forward. In Melbourne, for example, where results have been
excellent in terms of mortality and overall outcomes, some manipulation
of the coronary arteries subsequent to transfer was required in
one-fifth of cases.\textsuperscript{33} It has emerged, nonetheless,
that certain patterns are likely to create problems. Most worrying is
the intramural arrangement. Individuals with these patterns continue to
suffer increased mortality, reported by some at 28\%, compared to 3\% in
those with usual patterns in the same hands. These individuals also
suffer an increased incidence of overall lethal and non-lethal coronary
events, at 41\% as opposed to 4.7\% for the remaining
patterns.\textsuperscript{26-28,48,51-55} The risk for single sinus
origin has decreased in institutions dealing with large volumes, such as
Marie-Lannelongue Hospital in Paris.\textsuperscript{12} These
investigators established the risk factors for coronary arterial events
in a large cohort,\textsuperscript{12,26,53,56} noting 7.2\% incidence
of events in those individuals with single sinus origin. Complex
patterns were associated with a 6.5 fold increased risk of
death.\textsuperscript{53,54} Others have also reported problems with
loooing arteries in the setting of single sinus origin, noting
significant mortality (OR 2.9, 95\% CI: 1.3-6.8). It was the intramural
arrangement, nonetheless, that still induced the greatest mortality (OR
6.5, 95\% CI: 2.9-14.2). Overall, patients with any coronary pattern
other than the usual one had nearly twice the
mortality.\textsuperscript{26}

Better indications can be found on the basis of meta-analysis. In one
large analysis,\textsuperscript{26} results were combined from 9
independent case series, providing details of almost 2,000
patients.\textsuperscript{12,13,25,26,54,56-59} Most studies had used
the Leiden classification. Complex arterial patterns were again
associated with a 6.5 fold increased risk of death. Another
meta-analysis of results from 20 institutions also showed single sinus
origin and the intramural variants to be associated with problems, in
this instance postoperative myocardial
ischemia.\textsuperscript{60}Results, perhaps not surprisingly, however,
vary markedly in difference centers. Metton and associates, for example,
described their experience with 46 patients having the intramural
arrangement from an overall cohort 919 patients.\textsuperscript{51}
They reported 11 deaths prior to discharge from hospital, with 2
additional deaths at 51 and 105 days, giving overall mortality of
28\%.\textsuperscript{51} In three other series, mortalities have been
reported at 14\% and 5\%.\textsuperscript{49,55} The Melbourne group,
nonetheless, repaired 28 individuals having the intramural pattern, with
no deaths.\textsuperscript{48} Thus, even the intramural variant is not
necessarily a risk factor in experienced hands.

\textbf{Discussion}

Accurate reimplantation of the coronary arteries is the key component in
the success of the arterial switch procedure. This must be achieved
without creating undue tension, torsion, or kinking of the stems of the
coronary arteries or their proximal branches. During the evolution of
the procedure, certain patterns have been identified as problematic. Of
particular concern are the so-called intramural variants, and the
arrangements when all arteries arise from a single sinus. During the
evolution of the operative procedure, so-called ``looping'' was
considered a potential problem, as was juxta-commissural origin of the
arterial orifices. Presence of associated defects also created
additional problems, as did side-by-side arterial trunks in the
so-called Taussig-Bing variant.\textsuperscript{4,12,31,47} With ongoing
experience, many of these potential problems have been mitigated. It is
now generally considered that translocation is feasible for all variable
patterns, although origin from the nonadjacent sinus may now be
considered a contra-indication.\textsuperscript{29}

In the initial technique as described by Jatene, the coronary arteries
were not transferred to the new aorta until after anastomosis of the
aorta to the initial pulmonary root.\textsuperscript{31} Translocation
to a distended root was then recognised as helpful in avoiding the need
for prolonged myocardial ischemia, preventing recurrent reperfusion
injuries, and permitting visualization of the newly implanted buttons
and suture lines prior to reconstructing the new pulmonary
trunk.\textsuperscript{21,22,31,47,E1-E4} The approach, however, posed
the risk of damaging the neoaortic valvar leaflets when creating the
required openings in the neoaortic root. Placement of a marking stitch
at the facing neoaortic commissure was proposed to mitigate this
difficulty.\textsuperscript{E5} The essence of the technique is to punch
appropriately sized holes, and then to anastomose the mobilized buttons
to these openings.\textsuperscript{13} A key point is to bring the
initial pulmonary root towards the buttons, rather than stretching the
buttons towards the new root.\textsuperscript{E6} Good midterm results
were reported using this strategy.\textsuperscript{59}

Despite the success of the initial
technique,\textsuperscript{31}advantages came to be recognised of the
trapdoor technique.\textsuperscript{33,39} In this modification, the
arterial buttons are translocated to the neoaortic root prior to
reconstruction of the neoaorta. This approach was considered of
particular value in the setting of retropulmonary looping of the
circumflex artery, which is the second commonest pattern, or the main
stem of the left coronary artery. These variations create a shorter
distance, and an acute turn, between the coronary artery and its new
sinus, with potential kinking or distortion during translocation.
Similar advantages were suggested for the trapdoor approach in the
setting of anterior looping,\textsuperscript{12} which has the potential
risk of stretching or bowstringing during translocation
.\textsuperscript{4,13,E4} Further advantages were suggested if the
arterial buttons were placed at or above the neoaortic
anastomosis.\textsuperscript{33,35} Since reports of its success were
published by the group working at Marie Lannelongue during the
mid-1990s, the technique has gained significant
popularity.\textsuperscript{12,52,54,E6} Some suggested changes,
however, were not without their own problems. In the modification
proposed by Vouhe, for example, with each button playing the role of the
trapdoor flap for the other button, arterial obstruction within one year
occurred in over one-quarter of patients. These findings understandably
led to the abandonment of the modification.\textsuperscript{34} Another
modification was to create trapdoor flaps in both arterial
roots.\textsuperscript{44} Good short-term results then accrued for five
consecutive individuals found to have looping in the setting of single
sinus origin.\textsuperscript{44} Yet another successful modification
was to augment the relocated coronary artery using a patch of autologous
or treated pericardium or pulmonary artery.\textsuperscript{4,46} All of
these modifications are designed to avoid kinking or stretching
subsequent to transfer. It follows that identification of the optimal
location for each anastomosis remains crucial. As yet, however,
long-term results of these individual techniques are not available so as
to determine which might be preferable.\textsuperscript{4,34,36,44,46}

Problems were encountered initially when looping patterns were found in
the setting of origin of coronary arteries from each of the adjacent
sinuses. The techniques as described above have resolved most of the
difficulties. Problems still remain when all arteries arise from the
same aortic sinus,\textsuperscript{6} a finding in up to one-sixth of
individuals in some series.\textsuperscript{40-43} The difficulties
relate to the limited mobility when a short main stem feeds the looping
artery or arteries. Comparable limited mobility is found should the
arteries arise from the same sinus through double or triple
orfices.\textsuperscript{2,4,5,8,10,12,19,27,28,52} Specific techniques
have also been proposed to mitigate these problems. Thus, when arising
from a solitary main stem, a button can be detached and inverted using
the technique proposed by Yacoub,\textsuperscript{4} or else anastomosed
to the neoaortic root using the trapdoor
technique.\textsuperscript{33,39} When there are multiple orifices
within the sinus, then as is the case for juxtacommissural origin from
both adjacent sinuses, creation of an aortopulmonary window is a good
option.\textsuperscript{40-43} The group working at Marie Lannelongue,
however, had initially modified the technique of Yacoub as suggested
above, only to abandon it because of kinking. Instead, they promoted the
dual button trapdoor transfer as described by Asou and
Mee.\textsuperscript{11,12,17,33,39} An additional high risk of direct
implantation had been identified in specific situations when the angle
between a line drawn between the centres of the arterial roots and that
drawn from the neoaorta to the coronary arterial orifice exceeds 75
degree.\textsuperscript{20} In this setting, augmentation using a
pericardial hood was shown to maintain a natural lie of the transferred
coronary artery, and to produce a good long-term
result.\textsuperscript{46} Others had suggested using a short
autologous pericardial tube,\textsuperscript{E3} but this risks the
formation of thrombus, as well as extrinsic compression by the newly
constructed pulmonary pathways. Problems also occurred subsequent to
augmentation using a pulmonary arterial flap, with the coronary artery
being abnormally positioned even after successful
translocation.\textsuperscript{21,44,E2,E3}

It is the intramural arrangement, nonetheless, that still poses the
greatest risk to the patient. If undetected prior to the procedure, the
artery may inadvertently be transected during the initial aortotomy. The
aortotomy should be performed in a safe area, revealing the location of
all the arterial orifices before the aorta is
transected.\textsuperscript{E7,E8} If the intramural artery is
para-commissural, or inseparable from the other arterial orifice arising
from the same sinus, the commissure itself should be detached,
permitting harvesting of the button as a single disc. If the intramural
component is stenotic, it must be completely unroofed prior to
resuspending and reconstructing the neopulmonary
valve.\textsuperscript{11,17,39,46,47,E7-E9}

Once recognised, two methods have evolved to mitigate the problems of
the intramural arrangement. The first is to separate the orifice of the
intramural artery from its sinus, either as a confluent button
containing the other artery, or as separate buttons. The second method
is to leave both arteries within the sinus, and to create an
aortopulmonary window roofed by a patch or autologous tissue. Each
technique has advantages and
disadvantages.\textsuperscript{11,17,39,46,47,E7-E9} If two buttons are
to be successfully created, there should be more than 2 millimeters
between the orifices. Each button can then be handled using the trapdoor
approach.\textsuperscript{33,39} This technique, however, is technically
demanding. An insufficient cuff of sinusal wall has been found to lead
to more angled rotation of one or both
buttons.\textsuperscript{11,17,33,39,48} Transfer of a confluent button
can be achieved using a medially based trapdoor supplemented by
pericardial or pulmonary hood augmentation, with this approach avoiding
turbulent flow within the neopulmonary
system.\textsuperscript{47}Creation of an aortopulmonary window, in
contrast, by maintaining the native geometry, is claimed to reduce the
possibility of tension, torsion, kinking or
overstretching.\textsuperscript{37,38,40-44} Use of a hinged aortic
sinus pouch and flap in the latter approach is also claimed,
irrespective of the location of the arteries, to reduce the risks of
thrombosis, shrinkage, distortion, late obstruction, compression, and
neopulmonary arterial stenosis.\textsuperscript{37,38,40-44}

The commonest reason for early mortality following anatomical correction
has proved to be postoperative ventricular
dysfunction.\textsuperscript{19,48,49,60} Reports on etiology, however,
are limited and conflicting.\textsuperscript{E8-E10} Studies conducted
to date have been hindered by the small number of included patients, and
hence their limited statistical power ranging between 20\% to
35\%.\textsuperscript{25,26,53,54} We were able to identify nine
retrospective, one prospective, and one meta-analysis specifically
addressing the relationship between coronary arterial patterns and short
and long-term
outcomes.\textsuperscript{12,13,25,26,30,34,36,57-59,E11-E13} Reported
events have varied from 2\% to 11\%, with a high early and low late
incidence. Most have been related to kinking, torsion, or
stretching.\textsuperscript{12,13,25,26,30,34,36,57-59,E11-E13} As with
the operative problems, the events are associated with the intramural
arrangement, retropulmonary looping, and single sinus origin with
multiple orifices. Residual stenosis due to intimal proliferation is
commonly reported.\textsuperscript{47,51-54,57,E14,E15} Complications
occurring with favourable arterial patterns have been less well
explained. One meta-analysis,\textsuperscript{26} for
example,\textsuperscript{26} found looping in the setting of a single
sinus origin to be associated with a 3 fold increase in mortality,
whereas looping when each adjacent sinus supported a coronary artery was
not associated with increased risk. The underlying problem is again
considered to be kinking or stretching of the looping coronary
arteries.\textsuperscript{26,53,E13-E15} In up to one-tenth of cases,
evidence has been found of extensive lengths of stenosis, or even
occlusion, explaining well some catastrophic clinical
consequences.\textsuperscript{12,33,39} A small number of individuals
suffer late events, either death or myocardial infarction, following
anatomical correction,\textsuperscript{54,56,59,E4,E12} with myocardial
revascularization reported at periods of between three months and three
years after the switch.\textsuperscript{53,54,E15,E16} The causes were
again mostly related to stretching of the translocated coronary arteries
with ongoing somatic growth, and progressive fibrocellular-intimal
hyperplasia..\textsuperscript{E12,E14,E15} Studies assessing the
capacity of non-invasive methods to predict such obstruction have thus
far been inconclusive.\textsuperscript{E12-E20} With the increased
resolution of three-dimensional clinical techniques, nonetheless, it is
becoming much easier specifically to identify the postoperative coronary
arterial anatomy, thus offering hope that the reasons for complications
will soon become obvious.\textsuperscript{E21-E23} Already, when using
coronary angiography, the group working at Marie Lannelongue had
identified postoperative lesions in two-thirds of their patients at a
median of 7 years of follow-up.\textsuperscript{53} Another angiographic
study, however, identified problems in less than one-twentieth of their
patients after a median follow-up of just over one
year.\textsuperscript{E12} Others have demonstrated long term problems
in between one-twelth and one fifth of patients, mostly in the setting
of single sinus origin, with the findings considered an important cause
of late death.\textsuperscript{E13-E15} The optimal management of the
lesions, once identified, remains to be determined. Percutaneous
coronary angioplasty, or surgical revascularization, have thus far been
performed with satisfactory mid-term
results.\textsuperscript{51-53,E13,E15,E17-E19,E24,E25}

\textbf{Conclusions}

Even in the current era, an intramural arrangement, or origin of the
three major arteries from the same sinus, remains associated with
adverse events following the arterial switch procedure. Optimizing the
technique for translocation of these challenging variants be crucial to
reducing these ongoing problems. The creation of the International
Congenital Heart Surgery Registry to address the issues of
reimplantation, having categorised the patterns present used an
all-inclusive system such as the original Leiden
convention,\textsuperscript{8} may now provide the data needed to answer
the persisting questions.

\textbf{Authors' contributionS}\selectlanguage{english}
\begin{longtable}[]{@{}lllllllll@{}}
\toprule
Author's name & Concept/ design & Data analysis/ interpretation &
Drafting article & Critical revision & Approval of article & Statistics
& Funding & Data Collection\tabularnewline
\midrule
\endhead
Ujjwal Kumar Chowdhury & ? & ? & ? & ? & ? & ? & - & ?\tabularnewline
Robert H. Anderson & ? & ? & ? & ? & ? & ? & - & ?\tabularnewline
Diane E. Spicer & ? & ? & ? & ? & ? & ? & - & ?\tabularnewline
Lakshmi Kumari Sankhyan & ? & ? & ? & ? & ? & ? & - & ?\tabularnewline
Niwin George & ? & ? & ? & ? & ? & ? & - & ?\tabularnewline
Niraj Nirmal Pandey & ? & ? & ? & ? & ? & ? & - & ?\tabularnewline
Shikha Goja & - & ? & ? & ? & ? & - & - & ?\tabularnewline
Balaji Chandhirasekar & - & ? & ? & ? & ? & - & - & ?\tabularnewline
\bottomrule
\end{longtable}

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\textbf{Figure Legends}

Figure 1 : If the observer stands in the non-adjacent sinus of the
aortic root, and looks towards the pulmonary root (Panel A), one of the
sinuses of the aortic root is to the right hand of the observer (\#1),
whilst the other is to the left hand (\#2). The system retains its
ability to distinguish between the sinuses being right handed and left
handed irrespective of the relationship between the arterial trunks
(Panel B).

Figure 2 : The commonest variant is for the right coronary artery to
arise from the left-handed sinus, and the main stem of the left coronary
artery from the right-handed sinus (Panel A). In the second most common
pattern, the retropulmonary circumflex artery also arises from sinus
\#2. The main stem of the left coronary artery can arise from sinus \#2
(Panel C), with the antero-aortic right coronary artery arising from
sinus \#1. All coronary arteries can arise either from sinus \#1 (Panel
E) or from sinus \#2 (Panel F). Panels A and F also show commissural
mismatch (white arrows with red borders).

Figure 3 : Panel A shows the sinus \#2 in a heart in which the main stem
of the left coronary artery is intramural. An intramural anterior
interventricular artery originating from sinus \#2 is shown in panel B,
with a retropulmonary circumflex artery also arising from this sinus.

Figure 4 : The steps, I and II, showing coronary reimplantation after
neoaortic reconstruction in panel A. Panel B showing transfer to
medially hinged trapdoors with panel C showing the technique of for
transfer of the retropulmonary circumflex artery. Panel D shows steps I
and II for transfer of a single coronary artery.

Figure 5 : In Panel A, steps I and II show a technique of relocation of
a single coronary artery. In Panel B, the two steps are shown for the
``bay window'' transfer. Panel C shows the two steps of the aortic sinus
pouch technique for transfer of an intramural coronary artery.

Figure 6 : In Panel A, steps I through IV illustrate the two-button
technique for transfer of intramural coronary arteries. Steps I through
III in Panel B show the modification of the initial creation of an
aortopulmonary window.

Figure 7 : In Panel A, steps I through III show the initial technique
proposed for anatomical correction without arterial
translocation.\textsuperscript{41} Steps I and II in panel B show the
modification using a bovine pericardial patch,\textsuperscript{42} while
steps I and II in panel C show the modification using a D-shaped hinged
aortic cuff from the aortic non-adjacent sinus.\textsuperscript{43}

Figure 8 : Panel A shows steps I and II of in-situ relocation using
hockey-stick incisions.\textsuperscript{44} Panel B shows steps I and II
of the augmentation of the button using a pericardial
hood.\textsuperscript{46} Panel C shows steps I and II of the technique
using a pulmonary arterial patch.\textsuperscript{47}

\textbf{References (Electronics)}

E1. Bove EL. Current techniques of the arterial switch procedure for
transposition of the great arteries. J Cardiac Surg 1989; 4: 193-199.

E2. Ugurlucan M, Sayin OA, Surmen B, Tireli E. Coronary reimplantation
after neoaortic reconstruction in arterial switch operation. Ann Thorac
Surg 2006; 82: 382.

E3. Scheule AM, Jonas RA. Management of transposition of the great
arteries with single coronary artery. Semin Thorac Cardiovasc Surg
2001;4:34--57.

E4. Suzuki T. Modification of the arterial switch operation for
transposition of the great arteries with complex coronary artery
patterns. Gen Thorac Cardiovasc Surg. 2009; 57: 281-92.

E5. Chang AC, Wernovsky G, Kulik TJ, et al. Management of the neonate
with transposition of the great arteries and persistent pulmonary
hypertension. Am J Cardiol 1991;68:1253--5.

E6. De Leval MR, François K, Bull C, et al. Analysis of a cluster of
surgical failures. J Thorac Cardiovasc Surg 1994; 107: 914--24.

E7. Cleuziou J, Horer J, Henze R, et al. Surgical management of single
intramural coronary artery in Taussig-Bing anomaly detected at arterial
switch operation. Thorac Cardiovasc Surg 2008; 56: 170-172.

E8. Moll M, Michalak KW, Sobczak-Budlewska K, Moll JA, Kopala M,
Szymczyk K, Dry\selectlanguage{polish}ż\selectlanguage{english}ek P, Moll JJ. Coronary Artery Anomalies in Patients
With Transposition of the Great Arteries and Their Impact on
Postoperative Outcomes. Ann Thorac Surg. 2017 Nov;104(5):1620-1628.

E9. Mavroudis C. Anatomical repair of transposition of the great
arteries with intact ventricular septum in the neonate: guidelines to
avoid complications. Ann Thorac Surg 1987; 43: 495-501.

E10. Murthy KS, Coelho R, Kulkarni S, et al. Arterial switch operation
with in situ coronary reallocation for transposition of great arteries
with single coronary artery. Eur J Cardiothorac Surg 2004; 25: 246-9.

E11. Krian A, Kramer HH, Quaegebeur J, et al. The arterial
switch-operation: early and midterm (6 years) results with particular
reference to technical problems. Thorac Cardiovasc Surg
1991;39:160--165.

E12. Tanel RE, Wernovsky G, Landsbreg MJ, et al. Coronary artery
abnormalities detected at cardiac catheterization following the arterial
switch operation for the transposition of the great arteries. Am J
Cardiol. 1995; 76: 153-157.

E13. Bonnet D, Bonhoeffer P, Piechaud JF, et al. Long-term fate of the
coronary arteries after the switch arterial operation in newborns with
transposition of the great arteries. Heart. 1996; 76: 274-279.

E14. Tsuda E, Imakita M, Yagihara T, et al. Late death after arterial
switch operation for transposition of the great arteries. Am Heart J
1992; 124: 1551-1557.

E15. Bonhoeffer P, Bonnet D, Pi\selectlanguage{ngerman}échaud J, et al. Coronary artery
obstruction after the arterial switch operation for transposition of the
great arteries in newborns. J Am Coll Cardiol 1997; 29: 202-6.

E16. Ou P, Khraiche D, Celermajer DS, et al. Mechanisms of coronary
complications after the arterial switch for transposition of the great
arteries. J Thorac Cardiovasc Surg 2013; 145: 1263-9.

E17. Sarris GE, Chatzis AC, Giannopoulos NM, et al. The arterial switch
operation in Europe for transposition of the great arteries: a
multi-institutional study from the European Congenital Heart Surgeons
Association. J Thorac Cardiovasc Surg 2006; 132: 633-9.

E18. Spray TL. Transposition of the great arteries. In: Kaiser LR, Kron
IL, Spray TL, editors. Mastery of cardiothoracic surgery. Lippincott,
Williams and Wilkins; 2006. p. 855-64.

E19. Pedra SR, Pedra CA, Abizaid AA, et al. Intracoronary ultrasound
assessment late after the arterial switch operation for transposition of
the great arteries. J Am Coll Cardiol 2005; 45: 2061-8.

E20. Tamisier D, Ouaknine R, Pouard P, et al. Neonatal arterial switch
operation: coronary artery patterns and coronary events. Eur J
Cardiothorac Surg 1997; 11: 810-817.

E21. Taylor AM, Dymarkowski S, Hamaekers P, et al. MR coronary
angiography and late-enhancement myocardial MR in children who underwent
arterial switch surgery for transposition of great arteries. Radiology.
2005; 234: 542-7.

E22. Oztunc¸ F, Baris¸ S, Adaletli I, et al. Coronary events and anatomy
after arterial switch operation for transposition of the great arteries:
detection by 16-row multislice computed tomography angiography in
pediatric patients. Cardiovasc Intervent Radiol. 2009;32: 206-12.

E23. Manso B, Castellote A, Dos L, et al. Myocardial perfusion magnetic
resonance imaging for detecting coronary function anomalies in
asymptomatic paediatric patients with a previous arterial switch
operation for the transposition of great arteries. Cardiol Young. 2010;
20: 410-7.

E24. Kampmann C, Kuroczynski W, Treubel H, et al. Late results after
PTCA for coronary stenosis after the arterial switch procedure for
transposition of the great arteries. Ann Thorac Surg. 2005; 80: 1641-6.

E25. Raisky O, Bergoend E, Agnoletti G, et al. Late coronary artery
lesions after neonatal arterial switch operation: results of surgical
coronary revascularization. Eur J Cardiothorac Surg 2007; 31: 895-9.

\textbf{Legend of Video Presentation (Electronics)}

We report here-in a 20 days-old male child diagnosed with
D-transposition of the great arteries of the ventricular septal defect,
Yacoub's type A coronary arterial pattern undergoing anatomical
correction at the arterial level using medially hinged trapdoor
technique with Dacron patch closure of the ventricular septal defect
under moderately hypothermic cardiopulmonary bypass and St. Thomas (II)
based cold blood cardioplegia. Postoperative recovery was uneventful.

\textbf{Surgical Techniques}

\textbf{The operation: Surgical planning and the position}

\begin{itemize}
\tightlist
\item
  Following median sternotomy, the thymus was subtotally excised taking
  care not to expose the brachiocephalic vein. The pericardium was
  incised about 5-6 mm in front of and parallel to the phrenic nerve,
  thus exposing the two great arteries, the right atrium and the
  superior vena cava. The pericardium was opened using scissors and not
  cautery to avoid inadvertent cautery-induced ventricular fibrillation.
  A rectangular segment of pericardium was harvested and fixed in 10\%
  glutaraldehyde for 10 minutes for later use of right ventricular
  outflow tract reconstruction.
\item
  The position and size of the great arteries, as well as the site of
  origin and distribution of the coronary arteries was determined. All
  four chambers were inspected and pressures recorded. Note the
  anteroposterior disposition of the aorta and the main pulmonary artery
  with the left main coronary artery arising from the left posterior
  aortic sinus and the right coronary artery arising from the right
  posterior aortic sinus. The left main coronary artery giving origin to
  the left anterior interventricular coronary artery and circumflex
  coronary artery.
\item
  The operation was performed with moderately hypothermic
  cardiopulmonary bypass at 32°C. Angled venous cannulas were inserted
  into the superior and inferior caval veins and with distal aortic
  cannulation. Measures were taken to avoid excessive manipulation.
\end{itemize}

\textbf{Dissection and division of the ductus arteriosus}

The persistent ductus arteriosus was dissected on the superior surface
of the pulmonary artery by McGoon's technique, transfixed at both aortic
and pulmonary arterial ends using 6-0 polypropylene suture (Johnson and
Johnson Ltd., Ethicon, LLC, San Lorenzo, USA) and was divided.

\textbf{Mobilization of the aorta and the pulmonary arteries}

The two great arteries were separated from each other by dividing the
pericardial reflection and between them, starting from the level of the
top of the commissures and pulmonary artery till the level of pulmonary
arterial branching on either side. Low voltage cautery (10-15 mv) was
used during dissection. The aorta, right and left pulmonary arteries
were looped using elastomer vessel loops.

\textbf{Placement of marking sutures at the proposed neoaortic location
of coronary transfer}

Two marking sutures were placed over the pulmonary artery at the
proposed neoaortic location. Note the site of neoaortic coronary button,
little above the sinuses to avoid waisting/kinking of the coronaries.

\textbf{Cross-clamping of the ascending aorta and administration of
cardioplegia}

The aorta was cross-clamped. Antegrade St. Thomas based (1:4) cold blood
cardioplegia and topical cooling was used for myocardial preservation.

\textbf{Venting of the left ventricle}

Right atriotomy was done after snugging the inferior caval vein and left
heart was vented through the atrial septal defect using a No.13 DLP
suction vent (Medtronic Inc., Medtronic Parkway N.E., Minneapolis, MN,
USA).

\textbf{Dacron patch closure of the ventricular septal defect}

The ventricular septal defect was closed using an appropriately sized
Dacron polyester patch (Bard® Savage® filamentous knitted polyester
fabric, Bard Peripheral Vascular Inc., Tempe, AZ, USA) and pledgeted 5-0
polypropylene sutures (Johnson and Johnson Ltd., Ethicon, LLC, San
Lorenzo, USA). The tricuspid valve was checked for competence injecting
cold saline through the tricuspid valve into the right ventricle.

\textbf{Administration of second dose of cardioplegia}

Second dose of antegrade root cardioplegia was administered after
closing the ventricular septal defect.

\textbf{Dissection of the aorta and pulmonary trunk}

The aorta was divided in between stay sutures at the level of pulmonary
arterial bifurcation. Two stay sutures of 6-0 polypropylene were placed
on the top of each coronary buttons for retraction and mobilization. The
transected distal aortic end was retracted superiorly for optimal
visualization and uncluttering of surgical field.

The pulmonary trunk was next divided about 1-2 mm below the level of
pulmonary arterial bifurcation. The vessel loops on right and left
pulmonary arteries were placed on traction for the LeCompte manoeuvre.

\textbf{Inspection of the pulmonary valve}

The pulmonary valve and subpulmonary region were inspected through the
transected end of the pulmonary artery.

\textbf{Identification of the coronary arteries}

The position of the coronary ostia and their relation to the sinuses of
valsalva of the aortic and pulmonary valves were determined. Note the
origin of both coronary arteries from the left and right posterior
sinuses respectively. Additionally, the course and mode of branching of
the proximal 5-6mm of each artery was inspected.

\textbf{Mobilization of coronary buttons}

The left and right coronary ostia were mobilized with a surrounding rim
of aortic wall including almost the full thickness wall of the sinus of
valsalva without causing injury to the valve leaflets. The process was
started at the edge of the transected aortic wall for the left coronary
ostium followed by the right coronary ostium. Low voltage cautery (5-6
mv) was used for hemostasis at the harvested site.

\textbf{Creation of medially-based arterial flaps for coronary artery
translocation}

A site on the pulmonary artery for the left and right coronary
anastomoses were chosen. This neoaortic location was higher than the top
of the sinus of valsalva, to avoid tension/kinking/waisting of the
coronary arteries and to avoid distortion of the aortic valve. Two
medially based pulmonary arterial flaps as described by Roger Mee were
created accordingly. The sites chosen allowed for rotation of the
mobilized coronary buttons through an angle not more than 30°. No
portion of the pulmonary arterial wall was excised.

\textbf{Coronary anastomoses}

The coronary anastomoses were performed using 6-0 polypropylene suture,
taking care not to injure the coronary ostia and distortion of the
mobilized disc.

\textbf{The LeCompte manoeuvre}

The pulmonary arterial bifurcation, right and left pulmonary arteries
were mobilized beyond the site of the divided ductus into the pulmonary
hilum on the left side and behind the superior vena cava to the
branching of the right pulmonary artery on the right side. The distal
transected end of the aorta was then threaded behind the mobilized
pulmonary arterial bifurcation by LeCompte manoeuvre and the second
aortic controlling clamp was transferred onto the aorta at its new site
behind the pulmonary artery bifurcation.

\textbf{Reconstruction of the aorta}

The small distal end of the aorta was matched to the larger proximal end
for anastomosis using 6-0 polypropylene suture.

\textbf{Repair of the defects in the aortic sinus}

Two defects which was produced in the facing sinuses of the pulmonary
trunk were repaired using a single patch of the autologous pericardium
and 6-0 polypropylene suture. The size of the patch is approximately one
and a half times the size of the defect, thus enlarging the diameter of
the proximal aorta to match the size of the distal pulmonary artery.

\textbf{Release of the aortic cross-clamp and restoration of myocardial
perfusion}

The aortic cross-clamp was released, thus restoring myocardial
perfusion. Note the distended left and right coronary arteries perfusing
the myocardium without any kinking or torsion.

\textbf{Reconstruction of the pulmonary artery}

The last stage of the LeCompte manoeuvre consists of direct anastomosis
between the reconstructed proximal aorta and the distal pulmonary artery
using a 6-0 polypropylene suture. Precautions were taken to anastomose
the two ends without compressing the proximal parts of the coronary
arteries, without causing narrowing of the right and left pulmonary
ostia and without stretching the branches of both pulmonary arteries.

\textbf{Closure of the right atriotomy}

The atrial septal defect was directly closed using 5-0 polypropylene
suture. The right atrium was closed in two layers using 5-0
polypropylene suture. The child was weaned-off cardiopulmonary bypass
with stable hemodynamics on dobutamine and nitroglycerine infusion.

Postoperatively, the child was in normal sinus rhythm, and recovery was
uneventful. At the 24-months follow-up, the child was asymptomatic, in
normal sinus rhythm, normal ventricular function with no
echocardiographic evidence of regional wall motion abnormality.\selectlanguage{english}
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