Aortic Sinus Pouch Technique for Dextro-Transposition of the Great Arteries With a Single or Intramural Coronary Artery

The clinical results of the arterial switch operation (ASO) for dextro-transposition of the great arteries (d-TGA) are less than ideal when the anomaly is associated with an unusual coronary artery pattern, such as a single coronary artery or intramural coronary artery course. We developed a novel technique to deal with d-TGA with a single coronary pattern, including variations in which all the coronary arteries arise from a single aortic sinus. In this procedure, the coronary cuff is trimmed from the aorta together with the adjacent noncoronary sinus wall and is formed into a tubular pouch, which is then anastomosed with the pulmonary trunk in a side-to-side fashion. This technique not only enables extension of the length of the coronary trunk due to the thickness of the pouch, but also allows it to function as a "flexible joint," absorbing the undesired external force on the implanted coronary artery, thereby preventing kinking and distortion of the transplanted coronary artery. In addition, absence of any obstructing structure in the postoperative pulmonary outflow might support a favorable clinical course without the need for re-intervention. Although potential aneurysmal degeneration of the pouch or coronary malperfusion caused by compression of the pouch by the pulmonary trunk needs to be assessed with long-term follow-up, we believe that our technique is safe, reproducible and technically less demanding than direct coronary transplantation, making it a promising alternative technique for patients with particular coronary patterns that are difficult to deal with using the existing surgical maneuvers.