Surgical anatomy of the coronary circulation in hearts with discordant atrioventricular connections

We examined the arrangement of the coronary arterial and cardiac venous systems in 46 specimens with discordant atrioventricular connections so as to identify any structural abnormalities and to consider their surgical implications in terms of anatomical biventricular repair. Grossly abnormal arterial courses were seen in 11 hearts (24%). A substantial branch supplying the morphologically right ventricular outflow tract, which could restrict a ventriculotomy, was found in 61% of cases. The coronary sinus received all the morphologically right ventricular veins, as well as the posterior interventricular vein, in 40 hearts, this pattern being in contrast to the pattern in the normal heart. The morphologically left ventricular and anterior interventricular veins, all of which drain via the coronary sinus in the normal heart, were frequently connected independently to the morphologically right atrium in the specimens with discordant connections, the drainage occurring through the spaces between the pectinate muscles. These direct drainages are at risk of potential damage either by extensive intra-atrial maneuvers or by postoperative intraatrial thrombosis. It is predicted, therefore, that surgical results can be improved still further when account is taken of this vascular anatomy of the heart itself.