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OBJECTIVES Coronary transfer remains the most crucial part of the arterial switch operation (ASO); yet, certain coronary anatomies prohibit the use of button or trap-door transfer techniques. In the rare setting of ‘non-separable’ single sinus coronary arteries with intramural course, the modified Yacoub aortocoronary flap technique is a viable option. The aim of this study is to describe this operative technique and review its early- and mid-term outcomes. METHODS This retrospective analysis included all cases with ‘non-separable’ single sinus coronary arteries with intramural course where the modified Yacoub aortocoronary flap technique served as a bail-out option. RESULTS Of 516 patients who underwent ASO at our institution between January 1977 and April 2022, 14 underwent the modified Yacoub aortocoronary flap technique. The median age at ASO was 10 (interquartile range 7–19) days. Hospital mortality occurred in 3 patients (21.4%), all being related to coronary complications. All hospital survivors were still alive at a median of 9.1 (interquartile range 4.2–18.3) years after the ASO. None of them developed complaints of ischaemia, ventricular arrhythmias, ventricular dysfunction or exercise intolerance. Surveillance computed tomography angiography showed stable aortocoronary relationships free from stenosis, compression and kinking. No reoperations for coronary artery problems and/or neoaortic valve or root problems were needed. CONCLUSIONS Although close monitoring of early coronary events seems crucial to prevent perioperative mortality, the modified Yacoub aortocoronary flap technique may serve as a viable bail-out option in patients with ‘non-separable’ single sinus coronary anatomy with intramural course, with excellent results among hospital survivors.

Background Coronary anomalies are present in one-third of all patients with transposition of the great arteries (TGA) and have been associated with increased risk of adverse outcomes after the arterial switch operation. Therefore, knowledge about coronary anatomy remains key. Case summary A 5-day-old girl with prenatal diagnosis of Taussig–Bing anomaly (double outlet right ventricle with TGA and large subpulmonary ventricular septal defect) along with aortic arch hypoplasia and coarctation of the aorta underwent the arterial switch operation with closure of the ventricular septal defect and aortic arch repair. On preoperative echocardiography, the right (R) and left coronary artery (LCx) connected both to aortic sinus 1, suggesting 1RLCx coronary anatomy according to the Leiden Convention coronary coding system. However, intraoperative inspection led to a reclassification of the coronary anatomy: the right coronary artery and left anterior descending coronary artery connected to aortic sinus 1 (1RL) as had been observed on echocardiography, but—remarkably—the circumflex coronary artery (Cx) connected to the posterior sinus of the pulmonary trunk. As a consequence, cardioplegia was administered into both the aortic and pulmonary roots, and the circumflex coronary artery could stay in its native position without having to be transferred during the arterial switch operation. Discussion Various disruptions during embryological development can lead to unusual coronary anatomy in TGA patients. While anomalous connection of a coronary artery to the pulmonary trunk remains exceedingly rare, care should be taken to identify this pattern when present as failure to do so may result in adverse outcomes.

Background:The aim of this retrospective cohort study was to determine the incidence, potential risk factors, characteristics, and outcomes of acute kidney injury in children following the arterial switch operation for transposition of the great arteries.Methods:Retrospective review of children who underwent ASO between 2000 and 2020 in our tertiary children’s hospital in the Netherlands. Pre-and post-ASO serum creatinine levels were collected. Severe AKI was defined as 100% serum creatinine rise or estimated creatinine clearance 2according to pRIFLE criteria. Logistic regression was used to adjust for confounders.Results:A total of 242 children were included. Fifty-seven (24%) children developed severe AKI after ASO. Four patients with severe AKI were treated with renal replacement therapy. Children with severe AKI had a longer duration of mechanical ventilation 4.5 (1.0–29) versus 3 (1.0–12) days (p = 0.001), longer PICU stay 7 (2–76) versus 5 (1–70) days, (p = 0.001), higher rate of myocardial infarction 5% versus 0.5% (p = 0.001), sepsis 24% versus 9% (p = 0.002), post-operative pulmonary hypertension 19% versus 6% (p = 0.002), post-operative bleeding 9% versus 3% (p = 0.044), longer time to sternal closure 3 (1–19) versus 2 (1–6) days, (p = 0.009), and a higher mortality rate 9.0% versus 0.5% (p = 0.001) compared to children without severe AKI. Sepsis was a risk factor for developing severe AKI.Conclusions:In this single-centre cohort, 24% of our patients developed severe AKI after ASO, which is associated with increased morbidity, longer PICU stay, and higher mortality.

ObjectivesDocumentation of semilunar valve growth in fetal transposition of the great arteries (TGA) and the relationship between neo-aortic root (NAoR) dilatation, a cause for postoperative reinterventions after the arterial switch operation (ASO), and pulmonary valve (PV) annulus dimensions prenatally.MethodsThis retrospective multicenter observational study included TGA fetuses suitable for ASO. Semilunar valve annuli pre-ASO and NAoR diameters (post-ASO) were measured. Trends in annulus diameters were analyzed using a linear mixed-effects model and compared with normal values. Prenatal semilunar valve Z-scores were correlated with NAoR diameters post-ASO.ResultsWe included 137 TGA fetuses (35.8% with significant ventricular septal defects [VSDs]). One hundred twenty-one underwent ASO. Fetal TGA-PV diameters were significantly larger than control aortic valve (AoV) and PV annuli from 23 and 27 weeks, respectively, especially when a VSD was present. Fetal TGA-AoV annuli were significantly larger than control AoV and PV annuli from 26 and 30 weeks, respectively.Z-scores of fetal TGA-PV and NAoR diameter at last follow-up correlated significantly (P ConclusionFetal TGA semilunar valve annuli are larger than control annuli, especially when there is a significant VSD. Factors besides postoperative hemodynamics, including fetal anatomy, PV Z-score, prenatal flow, connective tissue properties, and genetics, may influence the risk for late reintervention in these fetuses.What's already known about this topic? Transposition of the great arteries (TGA) is treated with the arterial switch operation (ASO). Neo-aortic root (NAoR) dilatation is seen postoperatively and may require late reintervention.What does this study add? The first serial data on semilunar valve size in fetal TGA in a large cohort are provided. TGA semilunar valve diameters are larger than in normal fetal hearts, giving a larger left ventricular outflow tract. The prenatal pulmonary valve size may predispose to NAoR dilatation post-ASO.