Arterial Switch Operation — Coronary Transfer (3D Model)

Operative Context and Objective

Following institution of cardiopulmonary bypass and myocardial arrest, the aims are to (1) divide the great arteries at the correct height with preserved rotational orientation, (2) prepare a receptive neoaortic root on the pulmonary trunk, and (3) mobilize and reimplant the coronaries with undistorted ostia, physiologic lie, and unobstructed runoff. Contemporary refinements—more distal aortic division, disciplined coronary button geometry, and tailored reimplantation strategies—have underpinned the excellent modern outcomes of the arterial switch operation (ASO) [1–5].

Stepwise Sequence

1) Landmarks and Orientation

Mark commissures and reference points on the native aortic root (the future neoaortic root is the pulmonary root). Ink the right–left (R–L) commissure and the non-facing sinus to preserve rotational orientation after translocation.
Survey coronary origins (pattern, height, take-off angle, intramural segments, proximity to commissures) and the proximal epicardial course (LM bifurcation, conal/infundibular branches). Use this survey to pre-plan button size, the need for hoods/slits, and the target sinus/height [1,2].

2) Aortic Transection

Divide the ascending aorta just above the sinotubular junction (STJ), keeping adequate length on the distal (future neoaorta) and proximal (for safe button harvest) segments. A slightly more distal division increases working room for button creation and reduces ostial distortion [1].
Inspect the cut surface. Reassess cusp symmetry, STJ diameter, and ostial proximity to refine planned button geometry and implantation height.

3) Pulmonary Transection and Neoaortic Preparation

Transect the main pulmonary artery at a level that facilitates the Lecompte maneuver later and provides a broad, healthy sinus wall for coronary reimplantation.
Fashion the neoaortic root (on the pulmonary root): trim redundant adventitia, smooth shelves, and preserve intercommissural distances. Maintain ample tissue to inset tension-free buttons [1,5].

4) Coronary Button Harvest (Mobilization Before Division)

Mobilize the proximal epicardial coronaries generously before creating the buttons so each artery can fall into a natural, torsion-free arc toward the target sinus.
Create large, round-to-oval buttons centered on each ostium; keep a broad arterial wall rim to avoid the purse-string effect without leaving bulky redundancy [1,2].
Avoid endoluminal distortion: keep the blade parallel to the ostial plane; do not “cone” the button.

5) Choosing the Reimplantation Strategy

Trapdoor (hooded) technique

Indications: low/horizontal take-off, ostia near a commissure, or when the artery must turn superiorly to reach the sinus (typical in single-ostium/single-sinus variants) [2].
Method: create a rectangular/oblique trapdoor on the neoaortic sinus; inset the button along the inferior edge; close the superior “lid” to form a roof/hood that widens the outflow and softens the exit angle [1,2].

Circular punch technique

Indications: orthogonal take-off with adequate height and a short, straight route to the sinus.
Method: punch a slightly eccentric, beveled opening; parachute the button with fine interrupted or short-running monofilament. The bevel and eccentricity help maintain round ostia and avoid a rigid ring [1].

Coronary reimplantation after neoaortic reconstruction (CRANR)

Concept: perform partial neoaortic reconstruction first, then reimplant the coronaries into the newly formed sinus geometry, an approach associated with favorable results compared with an open trapdoor in some series [3].

Hybrid tailoring

When reach/angles are marginal, convert a punch to an ellipse, add a micro-hood, or create a crescentic slit to relieve tension and prevent kinking [1–3].

6) Coronary Reimplantation (Execution)

Target sinus selection should recreate native geometry: typically left coronary button → left-facing sinus, right coronary button → right-facing sinus of the neoaortic root after the switch.
Set height first, then rotation. Seat the basal bites where the artery will lie slightly downhill into the sinus to prevent a roof kink.
Suturing principles

Use fine monofilament with equidistant, shallow bites; maintain a round/elliptic ostium without rim torque or purse-stringing.
As you tie, watch the distal epicardial segment: it should relax into a gentle S-curve with no twist, blanching, or tethering.

Final contouring

If using a hood, tailor the roof to expand the exit without redundancy. Control adventitial ooze sparingly; avoid thermal injury near the ostium [1–3].

Technical Pearls & Pitfalls

Pearls

Plan before you cut: decide implant height, target sinus, and technique (trapdoor vs punch vs CRANR) before button creation [1–3].
Over-mobilize rather than under-mobilize: extra proximal freedom upstream prevents torsion/kinks downstream [1,2].
Favor tension-free slack: if you must “place” the coronary, the geometry is wrong.
Eccentric, beveled openings better match natural ostial obliquity than perfect circles [1].
Respect commissures: keep bites off commissural pillars to preserve leaflet motion and neoaortic coaptation.

Pitfalls

High implant → roof kink. Lower the anastomosis or add/extend a hood.
Overtight sutures → ostial stenosis. Maintain lumen roundness; reassess after each quadrant.
Under-mobilization → torsion. Free more proximal epicardial length and re-evaluate the curve.
Button too small → purse-string effect. Enlarge the rim or convert to a hooded closure.
Commissural deformation. If coaptation changes, revisit height/rotation.

Special Scenarios and Adaptations

Intramural or single-ostium/single-sinus patterns: consider unroofing, slit creation, or a bifurcation-preserving hood; trapdoor is frequently advantageous in single-ostium anatomy [1,2].
High take-off/tangential origins: prefer trapdoor with generous hood and a low basal suture line to soften the exit angle [1].
Near-commissural ostia: shift slightly off the pillar and use a crescentic hood to restore flow without leaflet impingement.
Small roots or size mismatch: a short beveled slit can lengthen circumference without bulky patches that might later distort the STJ [1].

Quality Checks Before Proceeding

No tension, twist, or kink; epicardial segments are pulsatile and relaxed.
Ostia remain circular/elliptical without purse-stringing; any hood expands the exit rather than narrowing it.
Commissures symmetric; no leaflet restriction or root distortion on saline test.
Gentle tug test: distal traction does not transmit to the anastomosis.
Hemostasis without strangulation—micro-ooze acceptable; avoid over-tightening near ostia.

References

[1] Yasui H, Yonenaga K, Kado H, Nakamura Y, Fusazaki N, et al. Arterial switch operation for transposition of the great arteries: surgical techniques to avoid complications. J Cardiovasc Surg (Torino). 1992;33(4):388-395.

[2] Sung SC, Chang YH, Lee HD, Kim SJ, Woo JS, Park JJ. Arterial switch operation for transposition of the great arteries with coronary arteries from a single aortic sinus. Ann Thorac Surg. 2005;80(2):636-641.

[3] Chang YH, Sung SC, Kim H, Lee HD, Woo JS, et al. Coronary reimplantation after neoaortic reconstruction can yield better result in arterial switch operation: comparison with open trap door technique. Ann Thorac Surg. 2005;80(5):1629-1633.

[4] Dodge-Khatami A, Mavroudis C, Mavroudis CD, Jacobs JP. Past, present, and future of the arterial switch operation: historical review. Cardiol Young. 2012;22(6):717-726.

[5] Wernovsky G. Transposition of the Great Arteries and Common Variants. Pediatr Crit Care Med. 2016;17(8 Suppl 1):S337-S343.

[6] Kwon JH, Kim H, Park JA, Kim GB, Jung JW, et al. Nine-year experience with the arterial switch operation focusing on coronary transfer: outcomes and technical considerations. Ann Thorac Surg. 2022;114(3):1016-1025.