日本小児循環器学会雑誌 Pediatric Cardiology and Cardiac Surgery

Coronary artery obstructive complications after coronary transfer procedures needed for congenital heart surgery are rare but serious, and it frequently results in death or severe heart failure that requires extracorporeal membrane oxygenation (ECMO) use in the early and late phases of surgery. This complication is particularly crucial in an arterial switch operation for transposition of the great arteries (TGA), which is conducted at the newborn to infant stage when there is a low body-weight. In addition, TGA is commonly associated with various anatomic coronary abnormalities. The following two surgeries are employed to manage this complication: redo of coronary anastomosis, often with autologous patch enlargement (surgical ostial angioplasty: SOAP), and pediatric coronary artery bypass utilizing the internal thoracic artery (PCABS-ITA). Both procedures have advantages and disadvantages compared with the other, but early surgical survival results are equivalent. Based on several database analyses, I currently suggest SOAP as I(C) and PCABS-ITA as IIa(C) for a rescue operation where coronary obstruction is due to mechanical compression, kinking, and/or stretching. For late coronary complications where fibroproliferative obstruction is the main cause, PCABS-ITA as I(C)and SOAP as IIa(C). Furthermore, tight stenosis (>90%) or total obstruction extending into the bifurcation area of the left main trunk favors for PCABS-ITA, and localized left main stenosis of mild degree favors SOAP. Careful follow-up and late results are crucial. Because this is a severe but rare complication, a long-term database analysis is essential.