| Part Ⅰ Impact of Coronary Artery Anomalies in Arterial Switch Operation:Early and Midterm Outcomes[Objectives]The arterial switch operation(ASO)is the operative therapy of choice for transposition of the great arteries(TGA).Coronary transfer is a crucial point of the ASO.However,the influence of coronary artery anatomy on the prognosis of ASO is currently controversial.Furthermore,little is known about the influence of the coronary artery anatomy on ASO for TGA in the developing world;for patients with more complex anatomy and broadened hemodynamics monitoring,it is likely that the risk factors for this operation may also change.Therefore,we investigated the influence of coronary artery anomalies on the early and midterm outcomes of ASO in patients with TGA and Taussig-Bing anomaly(TBA).[Methods]All patients who underwent an ASO between January 2007 and December 2019 were included from Wuhan Union hospital databases and reviewed retrospectively.The native coronary anatomy was determined by direct visualization at the time of surgery and classified according to the modified Leiden Convention.Follow-up data were obtained by review of clinic notes as well as telephone interviews inquiring about their health status since the last visit until August 31,2021.Overall,147(86.2%)of the survivors completed the follow-up,the median follow-up time was 8.0 years(interquartile range:5.1-10.6 years).The primary outcome was all-cause mortality.The secondary outcome was coronary related complications and reoperations and left ventricular regional wall motion abnormalities.A binary logistic regression was used for models of early outcomes.Kaplan-Meier survival analyses with a log-rank test were used to analyze survival rate.Cox regression analysis was used for models of time-to-event analysis.[Results](1)A total of 206 patients underwent ASO at a median age of 33(interquartile range,20-73)days.Patients with TGA and ventricular septal defect and TBA were significantly older at the time of the ASO than patients with TGA with intact ventricular septum(62 vs.21 days,P<0.001).(2)Coronary anomalies were present in 85 patients(41.7%),the most common type of anomalous coronary anatomy was 1R-2LCx(34 patients,16.7%).Nine(4.4%)patients had a single coronary artery,and 5 patients(2.5%)had intramural coronary artery(IMCA).All the IMCA were present in coronary artery patterns with double coronary of the three main coronary arteries origin from single sinus,and 80%associated with left anterior descending artery.(3)The early mortality rate was 14.7%(30 patients).Patients with a single coronary artery had the highest early mortality rate(33.3%),and early mortality happened to IMCA.The earlier surgical era(OR:3.398,P=0.010)and longer cardiopulmonary bypass time(OR:1.021,P<0.001)were significantly associated with early mortality while single coronary artery was at the borderline of significant(OR:4.671,P=0.051).(4)There were 8(4.6%)midterm mortality,yielding an overall survival of 81.2%,81.0%,and 80.2%at 1,5,and 10 years,respectively.IMCA(HR:10.034,P=0.047)and older than 1 year of age at the time of ASO(HR:9.706,P=0.003)were independent predictors of midterm mortality.A total of eight patients(3.3%)received nine reoperations or interventions in the mid-term after ASO,but no one related to coronary complications.[Conclusion]The only modifiable anatomy risk factor for midterm mortality was IMCA,which conferred nearly 10-fold increased odds.Single coronary artery had the highest operating mortality rate,and its influence on the prognosis after ASO is required for further investigation.Part Ⅱ Influence of Coronary Artery Anomalies on Left Ventricle Function after Arteries Switch Operation:a Two-Dimensional Speckle Tracking Echocardiography Study[Objectives]Coronary transfer of the arterial switch operation(ASO)results in non-anatomical positioning of the proximal coronary arteries(CA)and suboptimal coronary perfusion.Impaired left ventricular(LV)function with reduced longitudinal strain(LS)and preserved LV ejection fraction(EF)in patients after ASO has been suggested in previous studies using two-dimensional(2D)speckle-tracking echocardiography(STE).Complex coronary lesions including the intramural course or single coronary ostium were proven to be a significant risk factor for mortality,reoperation,or reintervention after ASO.However,the impact of complexity of coronary anatomy on LV function after ASO is not fully established.This study aimed to assess the influence of CA anomalies and high-risk CA on LV function after ASO using 2D STE.[Methods]Sixty patients with transposition of the great arteries after ASO who underwent echocardiography performed between January 2007 and June 2021 at Wuhan Union hospital and thirty controls were studied.Patients after ASO were categorized into three subgroups according to the native CA anatomy and its risk to prognosis:usual CA group(n=30),low-risk CA group(n=22),and high-risk CA group(n=8).Digitally stored echocardiography was analyzed offline for the LV systolic and diastolic function.Conventional LV function parameters include peak transmitral flow velocity in early diastole(E),peak systolic(s’),peak early diastolic(e’),late peak diastolic myocardial velocities(a’),and the E/e’ ratio at the septal mitral annulus,left ventricular mass index(LVMI),and single-plane Simpson’s LV EF was calculated.LV LS at the apical four-chamber view was analyzed using 2D STE.[Results](1)Compared with controls,age at echocardiography examination(5.5±3.1 years vs.7.5±3.9 years,P=0.008)and body surface area(median 0.8 m2 vs.1.0 m2,P=0.033)were smaller in ASO group.(2)Patients of ASO group had significantly lower septal e’(10.9±1.3 cm/s vs.13.7±2.2 cm/s,P<0.001),a’(5.3±0.8 cm/s vs.7.2±1.6 cm/s,P<0.001),and s’(5.9±0.9 cm/s vs.8.4±1.5 cm/s,P<0.001),and greater E/e’(10.3±2.4 vs.8.0±1.7,P<0.001)than controls.(3)Patients of ASO group had normal LV EF and comparable(63.3±4.7%vs.63.0±5.1%,P=0.771),while LV LS were significantly lower(-20.9±2.4%vs.-24.2±2.0%,P<0.001)to controls.(4)LV EF was similar among usual,low-risk,and high-risk CA groups(64.2±4.6%vs.62.3±4.8%vs.62.9±4.8%,P=0.557),while LV LS was significantly lower in patients with high-risk CA than patients in other subgroups(-21.1±2.2%vs.-18.3±2.6%vs.-21.5±2.1%,P<0.001).(5)LV LS was negatively correlated with the level of complexity of CA anatomy(r=-0.288,P=0.026)and positively correlated with septal E/e’(r=0.268,P=0.038).[Conclusion]LV systolic and diastolic function were generally normal,however,significantly lower in patients at 5 years after ASO than healthy peers.Patients with high-risk CA are associated with greater impairment of ventricular systolic myocardial deformation.LS is a sensitive marker for early detection of the influence of CA anomalies on LV systolic function in patients after ASO. |
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