The Arterial Switch Procedure: Closed Coronary Artery Transfer

The typical coronary artery pattern seen in d-TGA as viewed from the superior aspect (surgeon's view). Note the symmetrical orientation of the aortic and pulmonary valve commissures. LAD = left anterior descending coronary artery; LCX = left circumflex coronary artery; RCA = right coronary artery.

The aorta is divided 5 to 7 mm distal to the level of the pulmonary artery bifurcation and the precise locations of the coronary artery ostia and valve commissures are noted (A). A LeCompte maneuver is performed (B, C). Ao. = aorta; LPA = left pulmonary artery; MPA = main pulmonary artery; RPA = right pulmonary artery.

After marking the precise locations of the superior extent of each neo-aortic valve commissure with an external suture, the neo-aorta is reconstructed and the clamp removed. Ao = aorta; MPA = main pulmonary artery.

The coronary artery buttons are removed with as wide a rim of aortic tissue as possible. Dissection of the branches is avoided or minimized until the extent of mobilization needed for a tension-free anastomosis is determined. Ao = aorta.

After removing the cross-clamp, distending the root, and closing the neo-aortic valve, the incision for the left coronary button is made within the facing sinus of Valsalva (A). The oblique orientation helps in achieving the proper orientation of the coronary artery (B, C), avoiding kinking of the vessel. The right coronary artery button is transferred using the same technique (D). Ao. = aorta; MPA = main pulmonary artery.

The neo-pulmonary artery is reconstructed using a pantaloon-shaped patch of autologous pericardium.