主动脉缩窄合并心内畸形的一期手术治疗

１９９３年６月至１９９４年８月为５例主动脉缩窄合并先天性心内畸形病儿施行了一期手术治疗。男４例，女１例，年龄１．５～１３岁，体重７．５～４５ｋｇ。除主动脉缩窄外，合并的心内畸形有室间隔缺损、主动脉瓣及瓣下狭窄、主动脉瓣关闭不全等。手术采用左后外侧第４肋间切口，矫治主动脉缩窄后，同期行胸骨正中切口体外循环下心内畸形矫治。本组无手术死亡和并发症，取得了满意的治疗效果。作者认为，对主动脉缩窄合并心内畸形施行一期手术矫治是完全可行的。     

婴幼儿主动脉缩窄合并心内畸形的外科治疗

目的 探讨婴幼儿主动脉缩窄合并心内畸形的外科治疗经验.方法 2000年1月至2006年12月,84例主动脉缩窄合并心内畸形患儿接受了外科手术治疗,手术年龄1个月～3岁(平均13.5个月),体重3.3～15.0 kg(平均7.3 kg).12例合并复杂心内畸形,72例合并室间隔缺损和其他简单心内畸形,23例伴有主动脉弓发育不良.一期手术62例,49例正中开胸同时矫治主动脉缩窄和心内畸形,13例左侧开胸矫治主动脉缩窄,正中开胸修补心内畸形;分期手术22例.主动脉缩窄的手术方式包括补片成形42例,切除端端吻合30例,锁骨下动脉翻转6例,血管旁路3例,球囊扩张1例.在49例正中切口一期手术中,43例应用选择性脑灌注加下半身停循环,4例应用全身低流量灌注,2例应用深低温停循环.结果 围手术期死亡8例,死亡率9.5%,其中3例为术前漏诊主动脉缩窄.结论 婴幼儿主动脉缩窄合并心内畸形的外科治疗可获得良好的近期疗效,绝大部分患儿可采取正中切口一期手术.选择性脑灌注和下半身停循环可以有效地保护脑和重要脏器.     

经胸骨正中切口一期矫治主动脉缩窄或主动脉弓中断合并心内畸形

目的 总结经胸骨正中切口一期矫治主动脉缩窄或弓中断合并心内畸形的经验.方法 2007年1月-2008年7月手术治疗24例.包括主动脉缩窄9例,主动脉缩窄合并主动脉弓发育不良12例,主动脉弓中断3例.4例合并右室双出口(Traussig-Bing型).22例合并非限制性室间隔缺损,2例不合并室间隔缺损病儿1例合并主动脉瓣下狭窄,另l例合并肺静脉狭窄.主动脉弓降部成形均在深低温低流量持续性选择性脑灌注下进行.3例主动脉弓中断及9例主动脉缩窄病儿采用端端吻合术.12例主动脉缩窄合并主动脉弓发育不良病儿中采用扩大端端吻合术8例,端侧吻合术2例,补片成形术2例.结果 死亡2例.全组病儿围术期未出现神经系统并发症及肾功能损害.术后反复呼吸道感染2例.除l例残存压差大于20mm Hg外,最长随访18个月,尚未发现再缩窄发生.结论 主动脉缩窄或弓中断合并心内畸形一经诊断即需尽早手术.经胸骨正中切口一期矫治是安全、有效的.充分切除动脉导管组织,广泛彻底游离松解胸部各血管进行无张力吻合以及选择恰当的组织一组织吻合术式是主动脉弓降部成形手术成功及减少再缩窄发生的关键.     

主动脉弓中断的外科治疗

目的 总结主动脉弓中断及合并心脏畸形的外科治疗经验.方法 1997年1月至2008年1月,36例主动脉弓中断患者进行了外科手术治疗,其中男性22例,女性14例.儿童患者36例,年龄2个月～7岁,平均年龄2.8岁.成人患者1例,年龄31岁.33例合并心内畸形,其中31例正中开胸同时矫治主动脉弓中断和心内畸形;1例左侧切口矫治主动脉弓中断,正中开胸修补心内畸形;1例采用姑息手术.3例无心内畸形的患者2例采用左后外侧切口,1例采用正中胸部加上腹部切口.术式包括16例管道连接,9例直接吻合,9例直接吻合并补片成形,1例应用左锁骨下动脉翻转.在31例正中切口一期手术中,17例应用选择性脑灌注加下半身停循环,8例采用深低温低流量灌注,6例采用全身停循环.结果 住院死亡5例,3例死于肺部感染,1例死于肺动脉高压危象,1例死于术后低心排血量.术后早期有其他重要并发症7例.31例存活患者随访3个月～5年,无远期死亡,无需要再次手术的病例.结论 合并心内畸形的主动脉弓中断患者可采取选择性脑灌注加下半身停循环或深低温全身低流量下正中一期手术同时矫治.     

经胸骨正中切口一期矫治小儿主动脉缩窄及合并畸形

目的探讨经胸骨正中切口一期矫治小儿主动脉缩窄(CoA)及合并畸形的手术方法和治疗效果。方法2002年6月至2005年8月手术治疗CoA及合并畸形36例,其中男27例,女9例;年龄18d~8岁,平均(14·3±9·5)个月,其中小于1岁27例,小于3月龄18例;体重3~23kg,平均(6·6±3·0)kg。有症状的婴儿型27例,无症状的大儿童型8例,经左胸切口矫治CoA后再狭窄1例;合并室间隔缺损、动脉导管未闭、房间隔缺损、主动脉弓发育不良、完全性大动脉转位及主动脉瓣下狭窄等心内畸形。36例均经胸骨正中切口以扩展端端吻合术一期矫治CoA及合并畸形。结果手术死亡1例,系术前反复心力衰竭及充血性肺炎,术后15d死于心肺功能衰竭。35例随访4~36个月,晚期死亡1例。生存34例恢复良好,无再缩窄发生。结论经胸骨正中切口一期矫治CoA及合并畸形效果良好;扩展端端吻合法是一种值得推荐的技术。     

自体肺动脉组织一期矫治主动脉弓病变合并心内畸形

目的 探讨自体肺动脉组织一期矫治主动脉弓病变合并心内畸形的手术方法和治疗效果.方法 1993年4月至2009年11月,共25例主动脉弓病变合并心内畸形的患儿接受了一期矫治手术.男性17例,女性8例;年龄26 d～6.5岁,平均11个月;体质量3.0～14.5 kg,平均12.4 kg.其中6例患儿为主动脉弓缩窄,6例为主动脉弓中断,13例为主动脉弓发育不良.手术技术包括切开肺动脉前壁,切除动脉导管,应用部分自体肺动脉壁重建主动脉弓,重建肺动脉,并同时矫治合并心内畸形.结果 24例患儿术后恢复顺利,1例患儿死于围手术期肺动脉高压危象.随访心脏超声及心脏CT检查证实主动脉弓重建及心内畸形矫治满意.术后未发生神经系统及其他并发症.随访过程中,患儿生长发育正常,主动脉弓无再狭窄.结论 自体肺动脉具有生长潜力且柔韧性好,是一种理想的重建主动脉弓的材料.一期矫治手术治疗先天性主动脉弓病变合并心内畸形可以得到满意的结果.     

新生儿主动脉弓中断合并心内畸形的一期手术矫治长期结果

目的探讨新生儿主动脉弓中断(IAA)合并心内畸形的一期手术矫治效果。方法回顾性分析2003年5月至2014年9月我院采用经胸骨正中切口下一期手术矫治IAA合并心内畸形新生儿21例的临床资料,其中男18例、女3例,年龄6~26(15.9±5.8)d。A型14例,B型7例。手术均采用胸骨正中切口,端侧吻合降主动脉及主动脉弓,同期矫治合并心内畸形。结果机械通气时间14~809(237.8±179.7)h,体外循环时间92~174(132.6±27.1)min,主动脉阻断时间48~118(70.9±18.8)min,深低温停循环时间5~60(28.8±15.5)min,住院时间4~52(28.0±12.1)d。住院期间死亡3例(14.3%),分别因手术后败血症、肺动脉高压危象、心脏骤停而死亡。18例新生儿生存,随访3个月至11年,超声检查示患儿术后心功能良好。结论新生儿IAA合并心内畸形采用经胸骨正中切口一期手术矫治减少了手术次数,提高了患儿生活质量,手术效果良好。     

主动脉缩窄或主动脉弓中断合并心内畸形一期修复

目的 探讨采用经胸骨正中切口一期修复主动脉缩窄(CoA)或主动脉弓中断(IAA)合并心内畸形的治疗效果.方法 2002年7月至2009年6月,经胸骨正中切口行降主动脉远端和主动脉弓下缘端侧吻合术一期修复CoA或IAA合并心内畸形病儿43例,其中CoA 34例,IAA 9例(A型6例、B型3例),合并心内畸形包括室间隔缺损42例、动脉导管未闭34例、房间隔缺损12例、主动脉瓣下隔膜狭窄5例、二尖瓣关闭不全2例,右心室双出口1例.结果 手术死亡1例,为术后肺动脉高压和严重低心排血量综合征者.术后并发症包括严重低心排血量综合征3例,低氧血症6例,肺部炎症11例,肺不张14例,声音嘶哑19例,室上性心动过速23例.8例失访.34例随访3个月～5年,生活质量明显改善,心脏超声心动图和CT检查显示吻合口无明显再缩窄发生.结论 经胸骨正中切口,采用主动脉远端和主动脉弓下缘端侧吻合技术一期修复CoA或IAA合并心内畸形的手术早、中期效果良好,能明显减少术后再狭窄.     

先天性主动脉缩窄合并心内畸形的外科矫治

目的 探讨先天性主动脉缩窄(CoA)合并心内畸形的外科治疗方法。方法 1994～2001年共收治45例CoA合并心内畸形患者,其中一期手术组26例,分期手术组19例。23例合并有中～重度肺动脉高压(平均肺动脉压56mmHg)：心内畸形以室间隔缺损(VSD)最常见(36例,80％),一期组选择单纯正中切口21例,左外侧和正中双切口5例。分期手术组平均间隔105d行二期手术矫正心内畸形。结果 两组分别死亡2例。24例术后上下肢动脉压差消失,10例平均动脉收缩压差均小于10mmHg平均随访29个月。患者生活质量有明显提高。超声心动图检查提示无假性动脉瘤或主动脉再狭窄。结论 选择一期或分期手术矫治CoA合并心内畸形,手术结果无明显差异,一期手术中选择左外侧和止中双切口方法安全有效。     

降主动脉-升主动脉吻合术矫治婴儿期主动脉缩窄合并心内畸形15例

目的探讨降主动脉-升主动脉吻合术治疗婴儿期主动脉缩窄合并主动脉弓发育不良及心内畸形的疗效。方法选取2011-05—2015-05间治疗的主动脉缩窄合并主动脉弓发育不良、心内畸形的患儿15例。患儿均采用胸骨正中切口、开胸后先游离出主动脉弓、头臂干、动脉导管、弓降部等血管。建立体外循环、选择性脑灌注下行降主动脉-升主动脉端侧吻合术,恢复全身灌注后完成心内畸形的矫治。体外循环时间86~132 min,主动脉阻断时间51~94 min。结果术后早期死亡2例,低心排出量综合征6例,室上性心动过速6例,肺炎7例。13例患儿随访2个月~3 a,无死亡及再次主动脉狭窄。结论降主动脉-升主动脉吻合术治疗婴儿期主动脉缩窄合并主动脉弓发育不良及心内畸形的临床效果满意。     

Indications and techniques for midline approach to aortic coarctation in infants and children

A variety of techniques have been described for the repair of aortic coarctation. Most of these use operative exposure through a left thoracotomy. There are, however, instances when a median sternotomy provides a more versatile approach and allows for equally acceptable repair. Twelve patients (age, 2 days to 16 years) with coarctation of the aorta serve to illustrate the value of the technique. All but 3 patients were under 3 years old. Five patients had repair of coarctation combined with repair of other congenital cardiac anomalies (atrial and ventricular septal defects, 2 patients; atrial septal defects, 2 patients; and valvular aortic stenosis, 1 patient). Six patients had complicated recurrences of previously repaired coarctations and 1 patient had a primary coarctation that involved the aortic arch. All repairs were accomplished through a median sternotomy with the use of cardiopulmonary bypass and periods of (1) total circulatory arrest (6 patients); (2) reduced flow (4 patients); or (3) normal flow with multiple sites of arterial inflow (2 patients). All patients did well with no operative mortalities and no sequelae to date (8 weeks to 4 years). Examples of various techniques are provided to demonstrate the flexibility obtainable with this method. Median sternotomy can provide a viable approach to difficult problems involving coarctation of the aorta.     

正中切口解剖外旁路移植术一期治疗主动脉缩窄合并心脏畸形

目的总结正中切口解剖外旁路移植术一期治疗主动脉缩窄合并心脏畸形的外科治疗经验,以提高手术疗效。方法1997年7月至2008年7月,采用正中切口解剖外旁路移植术一期治疗主动脉缩窄合并心脏畸形31例,其中男20例,女11例;年龄31．9±11．7岁。合并的心脏畸形包括：主动脉瓣狭窄或关闭不全22例,二尖瓣狭窄或关闭不全9例,动脉导管未闭5例,升主动脉瘤4例,室间隔缺损3例,冠心病2例。解剖外旁路移植术包括升主动脉-腹主动脉旁路移植术22例,升主动脉-心包后降主动脉旁路移植术9例。同期手术包括主动脉瓣置换术16例,主动脉根部置换术6例,二尖瓣成形或置换术9例,升主动脉置换或成形术4例,动脉导管未闭缝合术5例,室间隔缺损修补术3例,冠状动脉旁路移植术2例。结果住院死亡1例（3．2％）,术后39d死于感染性中毒性休克。术后上、下肢收缩压压差较术前明显下降（13．7±10．2mmHg vs．64．2±25．3mmHg,P〈0．05）。随访27例,随访时间4～73个月,无晚期死亡、与人工血管相关的并发症和再次手术患者。结论正中切口解剖外旁路移植术是一期治疗成人及青少年主动脉缩窄合并心脏畸形的一种安全有效的手术方法。升主动脉腹主动脉旁路移植术及升主动脉-心包后降主动脉旁路移植术均可获得满意疗效。     

Repair of Coarctation of the Aorta in Neonates and Young Infants

Abstract In repair of coarctation in neonates or young infants, inadequate removal of ductal tissue, failure to address hypoplasia of the aortic arch, and suture line tension have been reported to be important factors of residual or early recurrent stenosis at the coarctation repair site. In a consecutive series of neonates and young infants with coarctation, who were all operated without delay with extended resection, the clinical outcome regarding the development of restenosis and hypertension was studied. In addition, the resected specimens were investigated regarding the completeness of resection of ductal tissue. Twenty-five consecutive neonates and young infants (median age 22 days, range 5 to 39 days) who underwent surgical correction of coarctation were reviewed; the resected specimens were examined histologically to document the extent of ductal tissue in the aortic wall. Fifteen patients had a preductal coarctation with associated cardiovascular anomalies including a hypoplastic aortic arch (n = 11). The remaining 10 patients had a paraductal coarctation without associated intracardiac anomalies. In all patients, the isthmus was bypassed and an end-to-side anastomosis was constructed between the descending aorta and the undersurface of the proximal aortic arch (n = 13) or the distal ascending aorta (n = 12). In 13 patients without marked hypoplasia of tbe aortic arch, the coarctation repair was performed through a left thoracotomy. In the remaining 12 patients, the coarctation was repaired through a median sternotomy with CPB and hypothermic circulatory arrest, on the basis of an associated hypoplastic aortic arch (n = 4), hypoplastic aortic arch with intracardiac anomalies (n = 7), or a “bovine” innominate artery (n = 1). There was no perioperative or late mortality. At a median follow-up of 15 months, 1 patient (4%) developed a recurrent stenosis at the coarctation repair site; in the remaining 24 patients, echocardiograpby showed a widely patent anastomosis with no evidence of a hemodynamically significant gradient. None of the patients had hypertension. Histologic examination of the resected specimens demonstrated the presence of ductal tissue in the descending aorta with maximal extension into its lateral wall (mean 5.2 mm). In all specimens of the paraductal subtype, there was also extension of ductal tissue into the lateral wall of tbe isthmus (mean 3.9 mm). We conclude that: (1) in the absence of marked hypoplasia of the proximal aortic arch, coarctation can be repaired with low mortality and morbidity via a left thoracotomy; (2) in the presence of marked hypoplasia of the proximal aortic arch and/or if associated intracardiac defects also need to be repaired, we advocate repair of the coarctation and associated defects through a median sternotomy with circulatory arrest; (3) in view of the absence of postoperative hypertension in this series, early repair of aortic coarctation is recommended; and (4) because ductal tissue may extend not only into the descending aorta but also into the isthmus, complete excision of the coarctation and bypass of the isthmus are valuable techniques to avoid secondary constriction of the aorta by ductal tissue.     

Off pump repair of aortic arch anomalies with concomitant intracardiac defects via anterior approach

BACKGROUND: The authors evaluated the surgical treatment of aortic arch anomalies associated with intracardiac pathologies, through median sternotomy on beating heart without using cardiopulmonary bypass (CPB). METHODS: A consecutive series of 10 patients with aortic coarctation were operated upon. Median age at repair was 3.5 months (range, 5 days to 72 months), median weight was 4 kg (range, 2.2 to 30 kg). All aortic obstruction repairs were done via midsternotomy without using CPB and it is used only for repair of intracardiac defects. The aortic reconstruction included resection and end-to-side anastomosis in six patients and pulmonary autograft patch aortoplasty in four patients. RESULTS: There was no operative mortality. Mean follow-up value was 17.6 +/- 8.07 months. There was no restenosis. CONCLUSION: Most of the aortic coarctation and interrupted aorta type A can be well-treated surgically through median sternotomy without using CPB. Thus, the need for profound hypothermia and circulatory arrest and its potential neurological and other side effects are removed and CPB is reserved only for associated intracardiac defects, if present.     

Concurrent single stage repair of coarctation of aorta and associated cardiac pathology in adult patients

Background Thoracic aortic coarctation and associated intracradiac pathology including a concomitant valvular lesion or coronary artery disease is an uncommon combination in adult patients. The simultaneous operative management of both lesion is preferred to avoid a second redo surgery and the risks associated with it. Methods We describe a simultaneous operative management of six adult patients with coarctation of aorta and associated cardiac lesion. All six patients had heterotopic bypass (Dacron tube implanted between the ascending and descending aorta) to repair the coarctation and concomitant repair of the cardiac lesion. The associated procedures were aortic valve replacement in 3 patients, coronary artery bypass grafting in 2 patients and mitral valve replacement in 1 patient. Results There were no operative deaths and all patients are doing well on follow up with patent coarctation of aorta bypass graft at a mean follow up of 18 months. No graft related complications occurred, and there were no instance of stroke or paraplegia. All patients had an uneventful post operative course and are on routine out patient follow up. Conclusion A median sternotomy for repairing adult coarctation of aorta with concomitant cardiac lesion can be performed safely and readily managed as an excellent single stage approach.     

Single-stage repair of adult aortic coarctation and concomitant cardiovascular pathologies: a new alternative surgical approach

Background  

Coarctation of the aorta in the adulthood is sometimes associated with additional cardiovascular pathologies that require intervention. Ideal approach in such patients is uncertain. Anatomic left-sided short aortic bypass from the arcus aorta to descending aorta via median sternotomy allows simultaneuos repair of both complex aortic coarctation and concomitant cardiac operation.     

Mitral valve replacement with the beating heart technique in a patient with previous bypass graft from ascending to descending aorta due to aortic coarctation

BACKGROUND AND AIM: Conventional mitral valve replacement (MVR) is carried out under cardioplegic arrest with cross-clamping of the ascending aorta during cardiopulmonary bypass. In this case, MVR was performed with on-pump beating heart technique without cross-clamping the aorta because of the diffuse adhesion around the ascending aorta, and tube graft presence between ascending and descending aortas. METHODS: A 47-year-old female patient had aorto-aortic bypass graft from ascending aorta to descending aorta with median sternotomy and left thoracotomy in single stage because of aortic coarctation 2 years ago in our cardiac center. She was admitted to the hospital with palpitation and dyspnea on mild exertion. Transthoracic echocardiography revealed 4th degree mitral insufficiency. RESULTS: MVR was carried out through remedian sternotomy with on-pump beating heart technique without cross-clamping the aorta. CONCLUSIONS: MVR with on-pump beating heart technique offers a safe approach when excessive dissection is required to place cross-clamp on the ascending aorta.     

Late results of ascending aorta-descending aorta bypass grafts for recurrent coarctation of aorta

Ten patients between the ages of 10 and 17 years underwent ascending aorta-descending aorta bypass grafts for recurrent coarctation at the Oregon Health Sciences University from 1975 to 1984. The combined approach through a left thoracotomy and median sternotomy was used in all the patients. This operation was used when the segment of recoarctation was long, dense adhesions were present, collaterals were inadequate, or when a cardiac operation was necessary for an associated lesion. All the patients survived the operation, and the long-term results to date have been satisfactory.