Intraoperative coronary revision but not coronary pattern is associated with mortality after arterial switch operation

OBJECTIVES: We sought to determine differences in baseline characteristics and clinical outcomes in a consecutive series of patients undergoing arterial switch operation (ASO), assessing the effect of coronary anatomy on postoperative mortality, both overall and adjusted for surgical era. METHODS: From January 2000 to May 2015, 283 consecutive patients underwent ASO for transposition of the great arteries. A total of 103 patients (36.4%) had an associated ventricular septal defect and 23 (8.1%) had an aortic arch obstruction. Coronary anomalies were present in 119 (42%) patients. RESULTS: Overall survival was 93.0±1% at 15 years (19 events). Intraoperative revision of the coronary anastomosis was required in 8 patients (2.8%) due to inability to wean from cardiopulmonary bypass (CPB) or post-CPB myocardial ischaemia. Surgical revision was neither related to the underlying coronary anatomy (χ²=0.681, P=0.4091) nor to the surgical era (χ²=0.682, P=0.4090). Univariable analysis suggested decreased mortality rate for infants who underwent surgery during 2008 or later (P=0.01). In multivariable analysis, intraoperative coronary button revision was the only predictor of mortality [P<0.001, hazard ratio (HR) 12.01, 95% confidence interval (CI) 3.85-37.49], whereas surgical era (before 2008) failed to achieve statistical significance (P=0.057, HR 2.19, 95% CI 0.96-12.04).CONCLUSIONS: In the recent era, unusual coronary patterns do not affect survival following ASO, whereas intraoperative coronary button revision is a predictor of mortality. Preventive strategies aimed towards intraoperative detection of impaired coronary perfusion are useful tools that might be considered for all patients in order to improve outcomes.