ctga

CASE PRESENTATION CABG IN A PATIENT WITH CORRECTED TRANSPOSITION OF GREAT ARTERIES : 

CASE PRESENTATION CABG IN A PATIENT WITH CORRECTED TRANSPOSITION OF GREAT ARTERIES Dr.C.Ganapathy Arumugam

Case history : 

Case history AGE/SEX :69 yrs/ M C/O : chest pain – 1 wk P/H/O : Old IWMI, Type 2 DM and HTN. BIOCHEMISTRY – normal ECG: SR, PVC, LAD, anterior fascicular block, old IWMI CXR: Situs inversus totalis ECHO : dextrocardia with corrected TGA CAG : Dextrocardia, triple vessel disease, adequate LV, separate origin of LMCA

Case history : 

Case history Anesthesia induction and maintenance: usual and uneventful Monitoring: ECG, IBP, PA, SPO2,ETCO2 and TEE Elective CABG x 3 vein grafts to LAD, OM, PDA. No arterial conduits due to abnormal situs of the heart. Intraoperative and postoperative course: uneventful Discharged on the 4th postoperative day.

TGA : 

TGA Failure of Truncus arteriosus to spiral aorta arising from the anterior portion of the right ventricle and pulmonary artery arising from the left ventricle Complete separation of the pulmonary and systemic circulation Survival possible only if VSD, ASD or PDA present

CORRECTED TGA : 

CORRECTED TGA Atrioventricular discordance with ventriculoarterial discordance Usually associated with other anomalies

Discussion : 

Discussion INCIDENCE: 0.5- 1.4% of congenital heart disease cases. Pathophysiology: with no other defects present , the path of the blood flow is physiologic. Blood from the left atrium enters the RV and then directed to the aorta and on the right side the deoxygenated blood from the venacava enters the left ventricle then to the pulmonary artery

Discussion : 

Discussion Pathophysiology: Associated anomalies VSD 80%, pulmonary stenosis 50%, tricuspid stenosis, TR, coarctation of aorta, AS, complete AV block, and other rhythm problems like WPW syndrome, SVT, AF and atrial flutter. Clinical: Abnormal ECG and radiography with no symptoms for 3-4 decades. Rhythm disturbances, TR, impaired RV function and CCF develops after 50 years of age. Patients with associated anomalies present in infancy.

ECG in CCTGA : 

ECG in CCTGA P wave- normal. Abnormal AV conduction prolonged PR intervals to complete heart block (incidence 75%) QRS- (inverted right and left bundle branches): septal activation proceeds from right to left, so Q waves in lead V1 and absent Q waves in other left precordial leads. The deep S waves in the right precordium and the tall R wave in lead aVL Left Axis Deviation (mechanism unsettled) T wave patterns: positive in all precordial leads. The T waves are taller in right precordial leads.

CXR IN CCTGA : 

CXR IN CCTGA Great arteries side by side with ascending aorta to the left of medially positioned pulmonary trunk. (narrow vascular pedicle) pulmonary trunk when even enlarged does not alter left cardiac silhouette. Ventricular silhouettes determined by coexisting malformations.

Discussion : 

Discussion 2D echo criteria for determining ventricular chamber and atrioventricular valve morphology: Relative levels of attachments of AV valve to ventricular septum, AV valve leaflet configuration (bileaflet or trileaflet), the papillary muscle arrangements, the presence or absence of chordal attachments to the septum (tricuspid valve) or to the ventricular free wall (mitral valve), the type of ventricular trabeculations (moderator band in morphologic RV), the ventricular shape and the presence or absence of fibrous continuity between mitral valve and the great artery. The aortic root and pulmonary trunk are parallel to each other. The pulmonary trunk is confirmed by its right and left branches and the aorta is confirmed by its brachiocephalic arterial branches.

Review of literature : 

Review of literature Coronary arterial revascularization in an adult with congenitally corrected transposition of great arteries and dextrocardia. Baltalarli A, Tanriverdi H, Gökşin I, Onem G, Rendeci O, Saçar M: J Card Surg. 2006 May-Jun;21(3):296-7 a 47-year-old man with isolated congenitally corrected transposition of great arteries, dextrocardia, and athersclerotic coronary artery disease. The patient underwent coronary artery revascularization with cardiopulmonary bypass. The free left internal mammary artery (LIMA) was grafted to the tiny left anterior descending artery (LAD), and the reversed saphenous vein Y graft was anastomosed to the posterior descending and posterolateral branches of the morphologic right coronary artery. RESULTS: The patient recovered uneventfully.