Clinical implications of short-axis aortopulmonary rotation on juxtacommissural origin of the coronary artery in transposition of the great arteries and surgical strategy

Background: The relationship of short-axis aortopulmonary rotation (APR) with juxtacommissural origin of the coronary arteries (JOCA) in transposition of the great arteries (TGA) has never been elucidated. The surgical outcome of arterial switch operation (ASO) is influenced by the presence of JOCA. Methods: Fifteen patients with TGA who presented to our institution between 1988 and 1995, and 23 cases from the literature, all with documented JOCA and APR, were analyzed. Each coronary arterial type was assigned to one of five patterns, according to similarities of epicardial configuration. All our patients underwent an ASO with various techniques to deal with JOCA. Results: JOCA near the facing commissure (FC, 35 cases), were more frequent with anterior TGA (29/31, 94%) except types 5cj and 9j that were seen with posterior and right lateral TGA (4/4, 100%); whereas JOCA near the right-hand nonfacing commissure (RNC, 3 cases) were related with posterior TGA. Eta-square analysis showed significant correlation between various JOCA and short axis APR. Thirteen of our cases had JOCA near FC, two near RNC. Five of the former in whom the coronary artery was excised as a single button had a superior trapdoor; using a two-button technique three of the former had a lateral funnel and one of the latter had a medial trapdoor for the JOCA; all survived although one late noncoronary death was noted. In the remaining six cases without augmentation, only one survived (8/1 vs 1/5, p < 0.02). Conclusion: JOCA in TGA was related to short axis APR, generally near FC in anterior TGA (except types 5cj and 9j), and near the RNC in posterior TGA. A superior (lateral) or medial flap, to augment the coronary button for JOCA near FC or RNC is helpful for a successful ASO.