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SECTION 8 Coronary artery bypass graft surgery inspecial situations
requirement for dialysis, at 30days compared to conventional onpump CABG.
Surgical revascularization: newtechniques
Given the ndings of the FREEDOM trial, both overall and in the
CKD population, the burden of cardiovascular postoperative longterm complications is not insignicant. Strategies to improve outcomes have become the focus for many groups as we realize that
CABG has advantages over PCI. Perhaps the greatest technique in
improving outcomes is the use of bilateral ITA (BITA) versus single
ITA (SITA) graing. From January 1972 through January 2011 at the
Cleveland Clinic, there were approximately 938 patients who underwent BITA surgery. Follow- up in the cohort was 7.8years which
includes 104,516 patient- years. Aer adjusting for major covariates,
BITA was associated with a 21% lower rate of mortality compared
to SITA. However, there was a small but important increase in the
rate of deep sternal wound infection. e international Arterial
Revascularisation Trial (ART) addresses this more denitively in
the setting of a randomized investigation (see later in this section).
Other groups have studied the eect of multiple arterial CABG
graing in patients with diabetes.– e Mayo Clinic (Rochester,
MN, USA) 15- year experience demonstrated a clear survival benet
of MAGs over le ITA plus saphenous vein graing (64% vs 56%;
P=0.02). Most recently, a study from Japan evaluating 2618 consecutive patients with isolated CABG matched diabetic and nondiabetic patients who received single arterial gras with those who
received MAGs. is led to 431 diabetic pairs and 577 non- diabetic
pairs. Not surprisingly, by 15years diabetic patients had lower survival than the non- diabetic group, 48.6% versus 55.0% (P=0.019).
In addition, diabetic patients also had a lower MACCE- free survival, 40.8% versus 46.1% (P= 0.02). At 12years, all patients had
improved survival rate with MAG compared with those undergoing
single arterial graing, with 64.9% versus 56.8% in the diabetic cohort (P=0.0006) (Fig. 62.3). is leads to a number needed to treat
of approximately 25 patients to save one additional life at 12years
with MAG. erefore, in diabetic patients, the use of BITA graing
along with other MAGs has been associated with benets and deserves further evaluation in ongoing long- term outcome studies.
e 10- year results of ART indicate no advantage of BITA over
SITA for death or the MACCE events overall and in the intentionto- treat analysis. is has brought into question the emerging
practice of MAG. It is critical to note, however, that about 40% of
ART patients actually had a dierent treatment from that initially
proposed:there was a signicant survival benet of MAGs in the astreated analysis. is deserves further study. An in- depth analysis of
the subpopulation with diabetes is also warranted.
Conclusion
Diabetes and CKD pose an increased risk for cardiovascular end
points aer CABG surgery. More importantly, the combination of
diabetes and renal insuciency portends an even worse outcome.
Strategies to optimize medical therapy and improve the appropriate
use of BITA and multiple arterial graing are potential advances and
deserve further evaluation.
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63
Coronary artery bypass graing with
surgical ventricularreconstruction
Serenella Castelvecchio, Raffaella Molfetta, Andrea Garatti, and Lorenzo Menicanti
Introduction
Left ventricular remodelling and therationale
tosurgically reverseit
Heart failure (HF) is associated with ischaemic heart disease in
46– 68% of patients. In this population, the long- term prognosis remains poor, especially with regard to the rate of repeat
hospitalization.
The increase in left ventricular (LV) volume after a myocardial
infarction is a component of the remodelling process and it is
associated with poor clinical outcomes. Surgical left ventricular
reconstruction (SVR) has been introduced as an optional therapeutic strategy aimed to reduce LV volumes through the exclusion of the scar tissue, thereby restoring a more physiological
volume and shape and improving cardiac function and clinical
status.
is chapter will address the rationale for surgically reversing
LV remodelling, the technique, and the indications from one of the
centres with the most experience in SVR worldwide.
LV remodelling is a complex process, which may occur aer a myocardial infarction leading to chamber dilatation, altered conguration, and increased wall stress. Adverse LV remodelling results from
brotic repair of the necrotic area with scar formation, elongation,
and thinning of the infarcted zone. e increase in LV volume is
associated with stroke volume augmentation in an eort to maintain
a normal cardiac output as the ejection fraction declines. However,
beyond this early stage, the remodelling process is driven predominantly by eccentric hypertrophy of the remote, non- infarcted regions,
resulting in increased wall mass, chamber enlargement, and geometric distortion (Fig. 63.1). ese changes, along with increased
neurohormonal activation, collagen deposition, brosis, and remodelling of the extracellular matrix within the non- infarcted zone,
lead to a progressive decline in ventricular performance.
Fig.63.1 LV remodelling following an anterior myocardial infarction. (a)CMR images (four- chamber view) show marked increase in LV volumes and
chamber distortion; (b)late gadolinium enhancement indicates scar tissue in the anterior wall, septum, and apex.
432
EF = 34%, NT-proBNP = 1.722EF = 25%, NT-proBNP = 7.885
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SECTION 8 Coronary artery bypass graft surgery inspecial situations
(a) (b)
artery, starting at the middle of the scarred region and ending at the
apex. Aer careful identication of the transitional zone between
scarred and non- scarred tissue, a pre- shaped mannequin (TRISVR®,
Chase Medical, Richardson, TX, USA) is inserted into the LV
chamber and inated with saline. e mannequin is useful in giving
the surgeon the correct position of the apex and in maintaining the
long axis of the ventricle in a physiological range (7.5/ 8.5), reducing
thereby the risk of sphericalization of the new ventricle. e exclu-
Preoperatively
6 months
sion of the dyskinetic or akinetic LV free wall is performed through
an endoventricular circular suture passed in the transitional zone.
e ventricle is closed over the mannequin, respecting the longi-
Fig.63.2 (a) Preoperative and (b)postoperative CMR four- chamber
views showing the volume reduction after surgery along with an increase
of the ejection fraction (EF) and a significant decrease of natriuretic
peptides. NT- proBNP, N- terminal pro- B- type natriuretic peptide.
tudinal diameter; if the dilatation also involves the inferior wall, a
plication of the inferior wall is performed to avoid amputation of the
apex. e mannequin is deated and removed before completing the
closure of the ventricle. When indicated, the mitral valve is repaired
through the ventricular opening with a double- arm stitch running
SVR aims to exclude scar tissue from the LV cavity, thereby
reducing the volume and improving cardiac function through
reduction of LV wall tension of remote regions, in accordance
with the law of Laplace (Fig. 63.2). In 2004, our group showed that
relieving the abnormal tension by excluding the scar and reducing
the volume allows SVR to produce a mechanical intraventricular
resynchronization that improves mechanical LV performance
(Fig. 63.3).
from one trigone to the other, embedding the two arms of the suture in the posterior anulus of the mitral valve. Arestrictive mitral
annuloplasty with a ring implantation may be performed in selected
patients, when the LV opening is not big enough to have good exposure of the mitral valve.
Tailoredapproaches
e procedure, usually performed to reverse LV remodelling aer
an anterior myocardial infarction, may be tailored to approach dif-
Surgical ventricular reconstructiontechnique
Details of the technique have been previously reported. Coronary
artery bypass graing (CABG) is performed rst. e ventricle is
then opened with an incision parallel to the le anterior descending
ferent patterns of postinfarction adverse LV remodelling, varying
from the classic posterior aneurysm with a bulging of the inferior
wall to a global LV dilatation with regional wall dysfunction at the
inferior and posterior regions, according to the site of coronary occlusion. Surgery for a posterior aneurysm generally involves the
use of a patch to close the neck of the dilated region. Otherwise,
Fig.63.3 Two- dimensional speckle tracking echocardiography (STE):the analysis has been performed (a)before and (b)after surgery, showing an
improvement in LV function at 6months after surgery. Global longitudinal peak strain (GLPS), averaged from the three apical views, is a novel approach
for assessment of global LV function from two- dimensional echocardiographic images.
63 Coronary artery bypass grafting with surgical ventricularreconstruction 433
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the treatment of global dilatation of the inferoposterior wall is more
complex and varies according to the relationship between localization of the scar and the dilatation (with or without involvement of
the posterior septum).
• Predominant HF symptoms (New York Heart Association
classIII/ IV).
e indication can also be extended to patients presenting
with ventricular arrhythmias and/ or angina who need surgical
revascularization if the previous conditions are present, to avoid
Patientselection
A comprehensive echocardiographic evaluation is the rst- choice
further remodelling.
Suggestedcontraindications
diagnostic imaging tool, providing accurate information about LV
dimensions and cardiac function. However, the feasibility of a reliable echocardiographic examination is sometime limited by poor
acoustic windows, inadequate endocardial border denition, or,
when the ventricle is particularly enlarged, by incomplete visualization of the apex. Cardiac magnetic resonance (CMR) is increasingly
Absolute:
• Severe right ventricular dysfunction.
• Restrictive diastolic pattern associated with high functional class
and mitral regurgitation.
being used for non- invasive imaging of the HF population and it is
nowadays the gold standard imaging technique to assess myocardial
anatomy, regional function, and global function. e use of CMR
with late gadolinium enhancement for detection of myocardial scar
Surgical treatment ofischaemic heart failure
beyondmyocardialrevascularization
has a major role in patient selection, allowing the exclusion of those
patients for whom the nal result is expected to be unfavourable.
Our group has recently reported that the presence of late gadolinium
enhancement in the proximal anterior LV segments is associated
with a lower likelihood of reaching a target volume (LV end- systolic
volume index (LVESVI) <60 mL/ m) or improving N- terminal proB- type natriuretic peptide levels (2512 ± 1242 ng/ L vs 2492 ± 1848;
P=0.971) and portends poor survival. Furthermore, CMR oers the
opportunity to assess thickness and function of the remaining nonenhanced viable myocardial tissue (‘the remote regions’). ese may
be hibernating (ischaemic but viable myocardium which is likely to
display functional recovery aer CABG) or non- ischaemic but dysfunctional because of the high local tension that reduces shortening
and which is likely to demonstrate functional improvement aer
volume reduction obtained through SVR. Finally, our group has
recently outlined the importance of plasma concentrations of natriuretic peptides for risk stratication before surgery and aer surgery. Lower BNP values— probably reecting lesser neurohumoral
activation— are associated with a higher probability of event- free
survival, while higher values are associated with a lower event- free
probability.
In the last two decades, the indications for revascularization in patients with ischaemic HF were limited to patients with angina and
signicant coronary artery disease. e management of patients
with ischaemic HF without angina has been a challenge because of
the lack of randomized data with patients who predominantly had
HF symptoms. Until recently, coronary revascularization as sole
therapy has been supported for this population. However, only approximately 40% of patients with ischaemic HF show improvement
in LV ejection fraction aer revascularization. Bax et al. showed
that the change in LV ejection fraction aer revascularization
was inversely and linearly related to the baseline LV end- systolic
volume, with a higher end- systolic volume being associated with a
low likelihood of functional recovery aer revascularization despite
the presence of substantial viability. e possibility to combine
myocardial revascularization with SVR to reverse LV remodelling
has been addressed in the Surgical Treatment for Ischemic Heart
Failure (STICH) Hypothesis 2 trial that compared CABG alone with
the combined procedure of CABG with SVR. e trial failed to
show an additional survival benet in the SVR group, although the
combined procedure resulted in a signicant greater reduction in
LVESVI. Nevertheless, the relative small percentage of ESVI reduction observed in the combined group raised concerns on the ex-
Suggestedindications
e choice to perform SVR should be based on careful evaluation
of HF symptoms, which should be predominant over angina, on
accurate measurements of LV geometric and haemodynamic
parameters, on careful evaluation of mitral valve function, on the
assessment of the transmural extent of myocardial scar tissue, and
on the viability of regions remote from the scar. SVR should perhaps
be performed only in centres with a high level of surgical expertise
dedicated to this challenging patient population.
According to our experience, we consider the following to be the
indications for SVR:
• Previous anterior or posterior myocardial infarction, as evaluated
by electrocardiogram or CMR.
• LVESVI greater than 60 mL/ m.
tent of the SVR procedure that was applied in this trial. Our group
hypothesized that the lack of observed benets in the STICH trial
might be due to inadequate volume reduction, which le the patients in the two arms at identical risk. Later, a post hoc analysis
from the STICH trial reported a postoperative LVESVI of 70 mL/
m or lower resulted in improved survival compared with CABG
alone. Indeed, even the STICH trial, beyond the neutral results,
showed that the baseline LVESVI is the strongest predictor of poor
outcome (hazard ratio 2.73, 95% condence interval 1.50– 4.98;
P=0.0010) in patients with severe LV dysfunction and ischaemic
HF. It remains unclear how the volume reduction did not improve
the outcome in the trial. One of the most plausible explanations is
the mixed population (more representative of real- world ischaemic
patients independently of HF, with small volume, without clear evidence of scar tissue— late gadolinium enhancement/ MRI was not
mandatory) in which SVR was applied.
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SECTION 8 Coronary artery bypass graft surgery inspecial situations
Waiting for further analysis of the STICH data, the 2018 European
Society of Cardiology/ European Association for Cardio- oracic
Surgery Guidelines still recommend the SVR at the time of CABG
in selected patients operated in centres with a high level of surgical
expertise.
Conclusion
SVR, routinely combined with myocardial revascularization, was
introduced as a therapeutic strategy aimed to reduce LV size through
the exclusion of scar tissue in selected HF patients. e STICH trial
has been strongly criticized and its several limitations have led to
substantial clinical uncertainty in making such results widely generalizable. Accordingly, the choice to add SVR to CABG may still be
considered, and should be based on a careful evaluation and selection of patients. SVR should perhaps be performed only in centres
with a high level of surgical expertise and a dedicated focus on the
challenging management of ischaemic cardiomyopathy.
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64
Coronaryanomalies
Indications and technique, including anomalous
coronary arteries and coronary artery fistulas
Anita Nguyen, Ramachandra C. Reddy, and Hartzell V. Schaff
Anomalous coronaryarteries
Anomalous coronary arteries occur in 1.3% of the general population. Although most coronary anomalies do not cause any symptoms
and are considered benign, for example, origin of the circumex
from the proximal right coronary artery, approximately 20% can
cause life- threatening conditions. is chapter will focus on surgical treatment of two pathologically signicant coronary anomalies, anomalous aortic origin of a coronary artery (AAOCA) and
anomalous origin of the coronary artery from the pulmonary artery
(ACAPA).
Anomalous aortic origin ofa coronaryartery
AAOCA is a congenital anomaly characterized by a main coronary
artery arising from the wrong sinus of Valsalva. e two pathologically important types are an anomalous right coronary artery arising
from the le sinus of Valsalva (ARCA) and an anomalous le coronary artery arising from the right sinus of Valsalva (ALCA). e
incidence of AAOCA in the general population is estimated at 0.1–
0.3%, with ARCA considered to be six to ten times more frequent
than ALCA.
ere are many dierent anatomical variations of AAOCA. e
anomalous coronary artery may arise from a single ostium or from
separate ostia; it may take an interarterial course between the aorta
and the pulmonary artery (PA) and/ or an intramural course in the
wall of the aorta. e intramural course has a variable relationship
to the commissure between the right and le coronary cusps of the
aortic valve; it may run at the level of, superior to, or inferior to the
commissure. Coronary arteries with an interarterial course which
arise from the opposite sinus of Valsalva (ARCA and ALCA) are
considered potentially malignant as they have been associated with
sudden cardiac death (SCD). Other possible courses that an anomalous coronary artery may take include origin from the wrong sinus
and coursing posterior to the aorta (retroaortic), anterior to the PA
(prepulmonic), or in the ventricular septum (transseptal). ese
variants are not associated with SCD and are considered benign.
e risk of SCD associated with ALCA is relatively high (2– 5%),
but is considerably lower with ARCA (0.1– 0.2%). Death usually
occurs in young athletes during or aer strenuous activity. Several
theories explaining the coronary ischaemia and resulting SCD have
been proposed, including expansion of the great vessels during exercise leading to compression of coronary arteries with an interarterial
course. Alternative theories postulate an increase in aortic wall tension causing a reduction in coronary artery ow during exercise.
Other features that may contribute to ischaemia are a slit- like orice
that may narrow with an increase in aortic pressure during physical
activity and an acute take- o angle of the coronary artery.
e only known risk factor associated with SCD is age less than
30years. Anatomical variations, including the length of the intramural segment, take- o angle, and luminal diameter, are not predictive of SCD and a negative stress test does not predict freedom
from SCD.
Patients with AAOCA are oen asymptomatic, and physical
examination is usually unremarkable. Transthoracic echocardiography is particularly useful in the paediatric population, where
diagnosis of AAOCA is oen made based on transthoracic echocardiography alone. In adult patients, computed tomography angiography and magnetic resonance angiography can establish the
anatomical diagnosis. Standard tests, such as electrocardiography
and exercise stress testing are oen normal, but positive functional
tests such as stress echocardiography and myocardial perfusion
studies may be helpful in establishing the presence of myocardial
ischaemia in patients with non- specic chest pain.
Surgical repair should be considered in all patients with ALCA
with an interarterial course, regardless of symptoms and in patients with ARCA who have symptoms of myocardial ischaemia.
An anomalous le main coronary artery or le anterior descending
artery arising from the right sinus and coursing anteriorly and inferiorly (transseptal course) has a more benign outlook and surgery
is not necessary in the absence of symptoms or denite narrowing.
436
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SECTION 8 Coronary artery bypass graft surgery inspecial situations
e management of asymptomatic ARCA remains controversial,
and the very low risk of surgery may outweigh the risk of SCD in this
population., However, asymptomatic ARCA should be repaired in
patients with a positive stress test who lead a very active lifestyle.
Other patients may choose to proceed with operation because of the
unknown subsequent risk of SCD and desire to maintain full activities. Postoperatively, patients with negative stress test and no ostial
compromise on imaging studies may be allowed to participate in
sports. Lifelong surveillance is advised in all patients with AAOCA.
Surgicaltechniques
Unroofing
Unroong is the most commonly used surgical technique in patients with an intramural course of the anomalous coronary artery
and separate coronary ostia. e operation is simplied if the intramural course is above the level of the commissure between the right
and le aortic valve cusps. Aneo- ostium is created in the correct
sinus by opening the aorta, placing a probe into the anomalous coronary artery, and opening the intra- aortic coronary artery to create
a new ostium. Typically, four to six individual 7- 0 or 6- 0 polypropylene sutures are used to tack the coronary artery to the aortic wall
(Fig. 64.1a,b). If the intramural course is at or below the level of the
aortic commissure, it may be necessary to detach the commissure
and reattach it to the aortic wall at its original level aer creating
the neo- ostium. However, this creates some risk of deformation of
the aortic valve and aortic insuciency. In such instances, we prefer
using a modied unroong procedure (limited unroong/ fenestration), where only the portion of the anomalous coronary artery in
the correct sinus is opened. is eectively enlarges and translocates
the ostium to the correct sinus (Fig. 64.1c,d).,,
Coronary artery translocation andreimplantation
Coronary artery reimplantation achieves an anatomical repair and
is the method of choice in patients with separate coronary ostia
Fig.64.1 Intraoperative images demonstrating unroofing (a, b) and limited unroofing (c, d) in patients with ARCA. Panel (a)shows unroofing of ARCA
with an intramural segment above the commissural level. The aorta has been opened (large arrowheads) and the right sinus of Valsalva is shown on
the right (between the two large arrows). The intramural segment has been unroofed (small arrows) and a new coronary ostium has been created
(small arrowheads). Panel (b)shows unroofing of ARCA with a tunnel below the commissural level. The aorta has been opened (large arrowheads)
and the commissure between the right and left aortic cusps is seen (large arrow). The incised intramural course (small arrowheads) and tacked down
edges around the new orifices are shown (small arrow). Panels (c)and (d)show limited unroofing in the same patient. Panel (c)shows the anomalous
coronary ostium at the level of the commissure with a probe placed inside. Panel (d)shows limited unroofing performed only in the correct coronary
sinus without detaching the commissure. The attached edge of the new coronary ostium in the right sinus of Valsalva is seen with a probe placed in the
new coronary ostium.
Copyrighted and used with permission of Mayo Foundation for Medical Education and Research.
64 Coronaryanomalies 437
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and no intramural course. An intramuscular course in the septum
makes reimplantation dicult because of the extensive mobilization required. e ostium of the anomalous coronary artery is
excised as a button. e anomalous coronary artery is then mobilized and reimplanted into the correct sinus. e risks of coronary
reimplantation include stretching and kinking the coronary artery,
as well as stenosis of the anastomosis. It can be performed only if the
coronary artery is sucient in length.,
Pulmonarytranslocation
PA translocation is useful in patients in whom unroong or
reimplantation is not possible (i.e. anomalous coronary arteries
with a single ostium and no intramural course). e PA is transected proximal to its bifurcation and translocated laterally and/ or
anteriorly. is reduces the risks of compression by the great vessels
without manipulating the anomalous coronary artery itself.
Coronary artery bypassgrafting
Coronary artery bypass graing is another treatment option in patients with a single coronary ostium, in whom reimplantation or
unroong cannot be considered. Conduit choices include the internal thoracic artery or a saphenous vein gra, with the internal
thoracic artery slightly favoured due to better patency. However,
concerns regarding competitive ow and resulting gra failure have
been raised. is can be addressed by ligating the native coronary artery, but this manoeuvre essentially creates a circulation completely
dependent on the bypass gra and a patent anastomosis. For these
reasons, coronary artery bypass graing is only recommended in
elderly patients or those with concomitant coronary artery disease
or extensive calcication of the aortic wall.,,
Othermanagement
Restriction of exercise and abstaining from participating in any
competitive sports is advised in all patients prior to surgery. Medical
management with beta blockers has been proposed. Percutaneous
intracoronary stenting has been used to treat the narrowed origin
and intramural portion of an anomalous coronary, but the approach
leaves the patient with risk of in- stent restenosis that has been reported to be as high as 13%, as well as need for long- term antiplatelet
therapy.
chest pain. If ALCAPA is le untreated, death will occur in 90% of
patients within the rst year of life. ALCAPA is usually diagnosed
in infancy. It rarely becomes manifest in adults but can occur in patients who develop a signicant collateral circulation from the right
coronary artery. Adult patients may present with myocardial infarction, le ventricular dysfunction, valvular abnormalities, and malignant arrhythmias.
Patients with ARCAPA are usually asymptomatic and frequently
the diagnosis is made due to an incidental nding of a murmur.,
If ACAPA is suspected, diagnosis can routinely be made with
angiography. Non- invasive diagnostic modalities including
electrocardiogram- gated multidetector computed tomography
angiography and magnetic resonance imaging can further help
establish the diagnosis.
Surgical correction is necessary in all patients with ALCAPA. e
aim is to create a two- coronary system, which can be achieved by
coronary button transfer, the Takeuchi procedure, or coronary artery bypass graing. Surgical correction of ARCAPA is more controversial, but the risk of sudden death in this population warrants
surgical intervention.
Surgicaltechniques
Simpleligation
Simple ligation of the anomalous coronary artery originating from
the PA theoretically should improve ow in the le coronary system
by eliminating shunting into the low- pressure pulmonary circulation. is leaves the patient with a one- coronary system and has
been associated with high early mortality rates in children. ere is
also a risk of late SCD. erefore, simple ligation is only advocated in
emergency situations, and in most patients a two- coronary system
should be established during repair.,
Coronary buttontransfer
Coronary button transfer is recommended as it achieves an anatomical correction and is the preferred treatment modality in paediatric
patients. e anomalous coronary artery is excised with a cu of
PA and reimplanted into the correct coronary ostium (Fig. 64.2).
e defect in the PA is closed using a pericardial/ homogra patch.
Direct implantation may be more dicult in adults due to friability
of vessels and decreased elasticity. An interposition gra, using
Anomalous origin ofthe coronary artery
fromthe pulmonaryartery
In ACAPA, the anomalous coronary artery arises from the PA. e
most signicant morphologies are anomalous origin of the le coronary artery from the pulmonary artery (ALCAPA; Bland– White–
Garland syndrome) and anomalous origin of the right coronary
artery from the pulmonary artery (ARCAPA).
ALCAPA is more common with an incidence of 1 in 300,000 live
births and accounts for 0.25– 0.5% of all congenital cardiac diseases.
ARCAPA occurs less frequently (approximately 0.002% of the general population). e main complication of ACAPA is shunting of
the coronary circulation from the le to the right resulting in myocardial ischaemia due to the steal phenomenon.
ALCAPA causes myocardial ischaemia and mitral insuciency
in infancy, leading to failure to thrive, profuse sweating, pallor, and
either the saphenous vein or a polytetrauoroethylene tube can be
used to overcome the reduced mobility of the coronary artery.
Takeuchiprocedure
is procedure may be useful if a coronary button transfer is not
achievable due to a short coronary artery or other unfavourable anatomy. An aortopulmonary window is created and a
transpulmonary bae tunnels blood from the aortopulmonary
window to the coronary ostium. A potential complication of the
Takeuchi procedure is supravalvular pulmonary stenosis.,
Coronary artery bypassgrafting
Coronary artery bypass graing with ligation of the native coronary
artery is another treatment option, and this may be preferred in patients with xed coronary disease and in older patients with friable
tissues that would complicate coronary ostial transfer or creation of
a transpulmonary bae.
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