A Saddlebag Rescue Patch Osteoplasty for High-Risk Coronary Artery Transfer During an Arterial Switch

A 3-week-old, 2.6-kg infant with d-transposition of the great arteries and an intact ventricular septum had an abnormal left coronary artery (LCA) originating from the left-facing sinus with ostial stenosis and an intramural retro-commissural course. The patient presented with profound cyanosis and persistent pulmonary hypertension, which required 3.5 days of veno-arterial extracorporeal membrane oxygenation, followed by recovery before an elective arterial switch operation (ASO) with Lecompte maneuver. 

After transection of both great vessels and identification of an unexpected coronary pattern along with pulmonary commissural malalignment, the intramural LCA was unroofed to create a wide ostium. During exploratory probing to confirm patency, a half-circumferential perforation occurred at the mid-LCA segment. Immediate repair was achieved by extending the unroofing ostium longitudinally and connecting it with the perforation site to prepare for patch reconstruction—a rescue patch osteoplasty. 

A single composite coronary button containing both ostia was sutured onto the pre-constructed neo-aorta using a closed technique. A triangular perfusion window was created on the distal neo-aorta, and the entire defect—including the lay-open LCA segment—was patched with a glutaraldehyde-treated autologous pericardium in a saddlebag configuration. Reperfusion yielded prompt cardiac contraction, and pulmonary outflow reconstruction was performed on a beating heart. 

Epicardial echocardiography confirmed laminar phasic flow in both coronaries, good biventricular contractility, and no valvular or outflow obstruction. The patient successfully came off the bypass and was transferred with a closed sternum to the intensive care unit before subsequently being discharged home without support. A coronary computer tomography angiography at three months post-ASO confirmed satisfactory results. 

Conclusions  

Rescue patch osteoplasty enables reliable repair of iatrogenic coronary perforation while preserving geometry and unobstructed flow. This approach broadens the surgical armamentarium for managing high-risk coronary and intraoperative coronary injuries during ASO. 

Figure 1: This is an illustrated image of the procedure.  

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