Surgical Approaches to Coronary Arteries Crossing the Subpulmonary Infundibulum in the Setting of Tetralogy of Fallot

BackgroundMultiple techniques have been described to surgically address the presence of an anomalous coronary artery crossing the subpulmonary infundibulum in patients with tetralogy of Fallot, with perioperative mortality and ventricular dysfunction both being higher than for those patients without this complication.AimsBased on our analysis of previous publications, we used our own experience to illustrate the diagnostic accuracy of computed-tomographic angiography in demonstrating the pertinent anatomical features of the complication. Based on our own surgical experience, we then assessed the efficiency and outcomes of the different surgical strategies designed to mitigate the threat posed by the anomalous coronary arteries.ResultsReported perioperative mortality for these patients continues to remain between 3% and 15%, being 3% at our center. Deaths, when occurring, have been the result of inadvertent injury to the coronary arteries, residual right ventricular outflow tract obstruction, and conduit-related problems. There are varying reports of reoperation following corrective surgery for these patients.ConclusionsComputed-tomographic interrogation is now fully capable of delineating all the pertinent anatomic details of anomalous coronary arteries crossing the subpulmonary infundibulum. With regard to treatment, we suggest that staged palliation will remain a requirement in select instances. Our experience confirms that the trans-tricuspid and trans-pulmonary surgical approach displays the best long-term outcomes by reducing the risks for infundibular obstruction. If feasible, it should be preferred to implantation of a conduit. Translocation of the pulmonary trunk is useful in patients with severely hypoplastic pulmonary ventriculoarterial junctions. In cases where this approach cannot be used, turn back of the pulmonary trunk, or Bonchek's procedure, are additional surgical options.