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一期手术治疗主动脉缩窄合并动脉导管未闭一例

Application of End-to-side Anastomosis for Coarctation of the Aorta with Cardiac Lesions in Neonates and Infants

Objective To compare the advantages of reconstructing the aorta by end-to-side anastomosis with extended end-to-end anastomosis for aortic coarctation （CoA） with cardiac lesions in neonates and infants. Methods There were 63 neonates and infants who underwent median full sternotomy for correction of CoA and cardiaclesions from January 2008 to July 2011 in Guangzhou Women and Children’s Medical Center. These patients were divided into two groups： extended end-to-end anastomosis was performed in 24 patients （end-to-end group, 17 males and 7 females with their mean age of 4.6±2.9 months）and end-to-side anastomosis in 39 patients （end-to-side group, 24 males and 15 females with their mean age of 3.4±2.6 months）. We compared the two groups with regard to postoperative mortality, morbidity and difference in blood pressure between the lower and upper extremities. Results The percentage of newborn patient（23.1% vs. 4.2%; χ2=3.979, P=0.045）and presence of pre-operative acidosis（15.4% vs. 0%; χ2=4.080, P=0.048）were significantly higher in end-to-side group than those in end-to-end group. There was no postoperative death in end-to-end group and 1 patient died after surgery in end-to-side group（2.6%）. The average duration of circulatory arrest in end-to-side group was significantly shorter than that in end-to-end group （18.6±2.7 min vs.23.4±3.7 min, F=14.617, P=0.000）. At the time back to cardiac intensive care unit, the percentage of patients whose difference in systolic pressure between radial and femoral artery ＜ 5 mm Hg, 5-15 mm Hg, and＞ 15 mm Hg was 20.8%, 45.8% and 33.3% respectively in end-to-end group, and 97.4%, 2.6% and 0% respectively in end-to-side group（χ2=40.380，P=0.000）. Twenty-four hours after surgery, the percentage of patients whose difference in systolic pressure between radial and femoral artery＜ 5 mm Hg, 5-15 mm Hg, and＞ 15 mm Hgwas 45.8%, 41.7% and 12.5% respectively in end-to-end group, and 100%, 0% and 0% respectively in end-to-side group （χ2=26.620, P=0.000）. All the surviving 62 patients were followed up for 2-36 months, and there was no patient with angeioma or re-stenosis needing intervention in either group during follow-up. Conclusion End-to-side anostomosis is a safe and effective method for treating CoA with cardiac lesions and eliminating residual stenosis in neonates and infants.

小儿主动脉缩窄或主动脉离断合并心内畸形的诊断与外科治疗

目的　探讨主动脉缩窄（CoA）或主动脉离断（IAA）合并心内畸形的诊断及手术方式选择。　方法　2003年1月至2010年3月济宁医学院附属医院手术治疗14例小儿CoA（9例）或IAA（5例）合并心内畸形 ［包括室间隔缺损（VSD）、房间隔缺损（ASD）、房室隔缺损（APSD）等畸形，但不包括单纯合并动脉导管未闭（PDA）］ 患者， 其中男10例，女4例；年龄0.7～12.0 （3.2±4.5）岁；体重5.5～25.5 （10.2±5.5） kg。分期手术3例，经胸骨正中切口径路一期手术矫治11例。　结果　手术死亡2例，其中1例为分期手术，二次手术行VSD修补术后死于急性左心衰竭；1例术前诊断为VSD＋PDA合并重度肺动脉高压，术前未发现IAA，术后死于急性肾功能衰竭。随访12例，随访时间6～84 （32±22）个月，患者恢复良好。复查心脏超声心动图提示：胸主动脉轻度狭窄2例，继续随访观察。　结论　多层螺旋CT和核磁共振成像是目前诊断CoA和IAA的首选检查方法。经胸骨正中切口径路一期手术治疗CoA或IAA合并心内畸形婴幼儿，可获较好的显露及疗效。

Offpump Anatomic Surgical Repair for Complex Coarctation in Adults

Abstract： Objective To investigate the clinical results of offpump anatomic surgical repair for complex coarctation in adults. Methods We retrospectively analyzed the clinical data of 7 patients with complex coarctation who underwent onestage anatomic surgical repair between January 2005 and December 2008 in Fu Wai Hospital. There were 5 males and 2 females with the age ranged from 16 to 41 years, average at 24.4 years. Among all the patients, there were 2 patients of coarctation with hypoplastic aortic arch, 1 of coarctation with aortic arch aneurysm, 3 of coarctation with descending thoracic aortic aneurysm, and 1 of coarctation with B type aortic dissection. All patients were diagnosed by color echocardiography, CT or agnetic resonance imaging（MRI）. All off-pump operations were performed under general anesthesia and ambient temperature. Median sternotomy was performed in 1 patient and left thoracotomy in 6 patients. Aortic arch patching enlargement was performed in 4 patients and descending thoracic aorta replacement in 3 patients (including 1 combined with abdominal aorta replacement and 1 case of Stanford B type aortic dissection, trunk stent was transplanted at the same time). Results There was no hospital mortality or severe surgical complications. Seven patients were followed up for a period ranged from 6 to 49 months with an average time of 20.1 months. No late death or recoarctation occurred. Hoarseness occurred in one patient and presented no improvement during the 11 months follow-up. Conclusion Onestage offpump anatomic surgical repair is safe and feasible in treating adult patients with complex coarctation, and it shows a good immediate and longterm result.

Shone’s综合征一例报告及文献复习

目的 探讨Shone’s综合征的一般规律、治疗策略及其对预后的影响因素，为临床诊治提供借鉴。 方法  2009年7月中山大学附属第一医院收治1例主动脉缩窄合并先天性二尖瓣狭窄患者，女，年龄12岁。属于广义的Shone’s综合征，包括主动脉缩窄、动脉导管未闭、二尖瓣瓣上环、二尖瓣狭窄等畸形。采用体外循环、胸骨正中切口，切除主动脉狭窄段，剪开二尖瓣下与乳头肌粘连的腱索，充分松解两组乳头肌，剪除瓣上纤维环。计算机检索PubMed（1963~2009年）、Elsevier Science（1963~2009年）、Wiley Online Library（1963~2009年）、Ovid（1963~2009年）数据库，收集有关Shone’s综合征的临床研究（前瞻性或回顾性）、病例报告和综述，分析其诊治特点。 结果 本例患者手术时间350 min，体外循环时间156 min，主动脉阻断时间48 min。手术矫治了所有畸形。患者术后2 d拔除气管内插管，3 d转出监护室，心肺功能恢复好；术后第7 d复查超声心动图提示：降主动脉与肺动脉间未见血流相通，降主动脉处未见狭窄和血流障碍，二尖瓣瓣口面积1.9 cm2，肺动脉压降至28 mm Hg；术后2周顺利出院。经检索共纳入19篇文献：其中典型Shone’s综合征回顾性研究5篇，包括112例患者；有关先天性二尖瓣狭窄或左心室流出道狭窄的临床研究14篇。各文献报道的病例类型各异，对手术策略基本达成共识：尽量矫正所有畸形。 结论 Shone’s综合征一经诊断，则应手术治疗，左心室流入道梗阻矫正是影响患者预后的重要因素。

Patch Aortoplasty for Infant Coarctation of the Aorta with Hypoplastic Aortic Arch

Abstract: Objective To summarize the clinical experiences of resection with patch aortoplasty for infant coarctation of the aorta combined with aortic arch hypoplasia. Methods Between May 2007 and December 2009, 49 patients including 30 males and 19 females with coarctation with hypoplastic aortic arch underwent coarctation resection and patch aortoplasty in Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiaotong University. The age of the patients ranged from 23 days to 3 years and 1 month with thirtyfour patients under 6 months, ten between 6 months and 1 year old, and five more than 1 year old. The surgery under deep hypothermia cardiopulmonary bypass with selective cerebral perfusion were performed in 31 cases and circulation arrest in 15 cases; under moderate hypothermia cardiopulmonary bypass in 3 cases. Pericardia patch was used in 31 cases, pulmonary autograft patch in 14 cases and xenograft pericardia patch in 4 cases. The associated intracardiac anomalies were repaired in the same stage. Results One case died from circulation failure during the perioperative period. The operative mortality was 204% (1/49). Low cardiac output syndrome and renal failure respectively occurred in 5 cases and 1 case who were cured afterwards by correspondent treatments. No residual obstruction was detected by echocardiography after the operation. Followup was carried out in fortyeight cases for a minimum of 4 months and a maximum of 3 years. Echocardiographic examination showed that the gradient through the aortic arch was more than 40 mm Hg and computed tomography showed recoarctation in 1 case who underwent reoperation eight months after the operation; the gradient was more than 20 mm Hg in 2 cases who were under continuous observation; all the rest cases had a fine aortic arch morphology and for these patients, the blood velocity at descending aortic arch was not obviously changed during the followup period compared with that right after operation, the computed tomography showed a normal aortic arch geometry. Left bronchus compression was relieved obviously or totally disappeared in patients who suffered from left bronchus stenosis before the operation without any aortic aneurysm detected. Conclusion Coarctation resection with patch aortoplasty is considered as an optimal surgical method for management of infant coarctation with hypoplastic aortic arch.

Extraanatomic Aortic Bypass Grafting Through Median Sternotomy for Onestage Treatment of Aortic Coarctation and Associated Cardiac Diseases

Objective To summarize the experience of extraanatomic aortic bypass grafting through median sternotomy for onestage treatment of aortic coarctation and associated cardiac diseases, and to improve surgical effect of the diseases. Methods Between July 1997 and July 2008, 31 consecutive patients(20 male,11 female; age 31.9±11.7 years) with aortic coarctation and associated cardiac anomalies underwent onestage surgical repair through median sternotomy. The associated cardiac anomalies included: aortic valve insufficiency or stenosis(n=22); mitral valve insufficiency or stenosis (n=9); patent ductus arteriosus (n=5); ascending aortic aneurysm (n=4); ventricular septal defect (n=3); coronary artery disease (n=2). Extra-anatomic aortic bypass grafting was used to repair the coarctation. Routing of the grafts was: ascendingto posterior pericardial descending aorta (n=9) and ascendingtoinfrarenal abdominal aorta (n=22). Concomitant cardiac procedures included: aortic valve replacement in 16; Bentall procedures in 6; mitral valve repair or replacement in 9; ascending aortic replacement or aortoplasty in 4; patent ductus arteriosus closure in 5; ventricular septal defect closure in 3 and coronary artery bypass grafting in 2. Results One patient died of septic shock 39 days after operation with an inhospital mortality of 3.2%. Mean systolic blood pressure gradient between upper and lower extremities decreased from 64.2±25.3 mm Hg preoperatively to 13.7±10.2 mm Hg postoperatively (Plt;0.05). Twentyseven patients were followed up from 4 to 73 months, there were no late deaths，reoperations or graftrelated complications. Conclusion Extraanatomic aortic bypass grafting can be performed simultaneously through median approach in patients with aortic coarctation and associated cardiac diseases. It is an effective and safe treatment option for onestage surgical repair in adults and adolescents. Both ascendingto posterior pericardial descending aorta and ascendingtoinfrarenal abdominal aorta bypass have favorable results.

Surgical Managemen t for Coarctation of Aorta Associated with Heart Anomalies in Infan ts

Corresponding author: Y I Ding -hua, E -mail: yidh@fmmu. edu. cnAbstract: 　Objective　To investigate the optimal surgical approaches for coarctation of aorta (CoA ) associated with heart anomalies (CoA -HA ) in infants through analyzing the immediate and long-term outcome post-operation. Methods　From May 1998 to November 2006, 29 patients with CoA -HA were admitted to this institute. Subclavian flap angioplasty was performed in three patients, excision of coarctation and end-to-side anastomoses in six pat ients,and end-to-end anastomoses in the remaining 20 pat ients. Their clinical data were retrospect ively reviewed and the long-term follow -up results obtained through telephone o r letters. 　Results　Three patients died of operations, of whom one died of low cardiac output syndrome, one died of sepsis and one died of multiple organs failure. In two months’to eight years’follow -up , no later death and severe neurological complications were found. Two patients suffered from recurrent coarctation, but had no sense of symptoms and free from re-operation. In all pat ients neither systemic hypertension, nor arterial aneurysm and aortic valve regurgitation were found. 　Conclusions　Mortality of surgical corrections is accepted fo r CoA -HA in infants. Preoperative heart dysfunction and prolonged mechanical ventilation are the high risks of operative death. Recurrent coarctation is the major later comp lication.

One-stage Repair of Coarctation of Aorta and Associated Intracardiac Malformation in Infants

Abstract: Objective To summarize onestage repair of coarctation of the aorta(CoA) with intracardiac malformation in infants. Methods From January 2001 to January 2006, 28 patients with CoA and associated intracardiac malformation underwent onestage repair. There were 18 patients with preductal and another 10 patients with juxtaductal CoA. Six patients were accompanied by diffuse hypoplasia of aortic arch and 22 patients were associated with patent ductus arteriosus (PDA). Associated cardiac malformation included ventricular septal defect in 16 patients, ventricular septal defect and atrial septal defect in 5 patients, atrioventricular canal defect in 3 patients, transposition of great artery and ventricular septal defect in 2 patients and double outlet right ventricle in 2 patients. Left posterolateral thoracotomy combined with median sternotomy were used in 12 patients and single median sternotomy was used in 16 patients. End to end anastomosis of aorta with removal of the coarctated segment were performed in 20 patients, Gore-Tex patch graft aortoplasty were performed in 4 patients and aortoplasty with left subclavain flap were performed in 4 patients. Results There was no death.The lasting time of intubation was 7h to 13d, and intensive care unit (ICU) staying time was 3 to 18d. Four patients received delayed sternal closure in 48 to 72h after surgery because of cardiac dilatation. Three patients received peritoneal dialysis for acute renal failure following cardiac surgery. Three patients received inhalation of nitric oxide for treatment of postoperative pulmonary hypertension. The systolic pressure difference between lower limb and upper limb measured after operation was 10 to 20mmHg in 18 patients.There were no obvious systolic pressure difference between arm and leg in 8 patients.The systolic pressure of upper limb was higher than that of lower limb in 2 patients, and the pressure difference was 15mmHg and 20mmHg. All patients were followed up from 3 to 50 months. They were all survival except one died of severe tricuspid regurgitation, pulmonary infection and respiratory failure 3 months after surgery which diagnosis was transposition of great artery and ventricular septal defect. The results of other 27 patients were satisfactory. Recoarctation occurred in 1 patient with end to end anastomosis and 1 patient with Gore-Texpatch graft aortoplasty. The pressure difference through the measurement of echocardiography was 25mmHg and 28mmHg. No reoperation were undergone. Conclusion CoA with intracardiac malformation can be repaired by single median sternotomy or left posterolateral thoracotomy combined with median sternotomy in onestage. This operative approach is beneficial, not only with shorten period of therapy and less operative cost, but also advantageous for the recovery of cardiac and pulmonary function.

成人主动脉缩窄的临床特点和外科矫正

目的探讨成人主动脉缩窄的临床特点和外科治疗方法。方法40例成人主动脉缩窄患者行手术矫治，其中心脏不停跳手术28例，常规体外循环下手术12例。行主动脉狭窄段切开、人工血管补片扩大术12例，人工血管置换术15例，锁骨下动脉降主动脉旁路移植术1例，采用人工血管行胸一腹主动脉旁路移植术9例，经心包后径路行升主动脉一降主动脉旁路移植术3例。结果全组无手术死亡，几种术式术后均无脑部和脊髓等神经系统并发症。术后36例得到随访，平均随访12个月。36例患者上、下肢血压差均小于10mmHg（1kPa－7．5mmHg）。超声心动图和超高速CT检查提示人工血管血流通畅，无假性动脉瘤形成。结论成人主动脉缩窄的外科术式有多种选择，掌握好手术适应证，根据患者的具体病理生理状况选择合适的手术方式可获得满意的治疗效果。