Comment
The single coronary may present technical challenges during arterial
switch operation with both early and longterm implications. (1) The
transfer of a single coronary artery from non facing sinus in
Taussig-Bing anomaly with side by side relationship of great arteries
can indeed be difficult. The distance from the non-facing sinus to
neo-aorta can be significant enough to preclude direct transfer. The
mobilisation of a single coronary artery is further limited by early
branching. Atrial switch or Damus-kaye-stansel (DKS) with Rastelli can
be considered when traditional arterial switch operation (ASO) can not
be performed. (2) However, atrial switch commits right ventricle for
systemic circulation and is bound to have poor longterm prognosis. DKS
with Rastelli is an innovative technique but the child is committed to
multiple operations for the right ventricle outflow tract (RVOT).
Therefore, pursuing ASO may still be the best option. Some of the
techniques described to facilitate ASO with “difficult to transfer”
coronary patterns are in situ coronary relocation, trap door with
pericardial hood and coronary extension using aortic autograft. (3,4,5)
Though, aortic autograft concept has an advantage of growth potential,
it may not always be feasible to obtain enough aortic tissue to create a
tube of desired length. The in situ coronary translocation is not
feasible if the coronary artery arises from the non-facing sinus. In
such circumstances, autologous pericardial tube which is viable,
non-allogenic, pliable, haemostatic and readily available is an
acceptable alternative. Animal studies have demonstrated that autologous
pericardium has better fibrinolytic activity and less sub-endothelial
fibrosis which will translate into less thrombogenicity and contracture.
(6) Though, the pericardial tube as coronary extension has remained
patent for more than two years, the longterm outcome is yet to be seen
and a cautious follow-up is recommended.