One stage operation for aneurysm of the diverticulum of the ductus arteriosus and coronary artery bypass grafting

Aneurysm of the diverticulum of the ductus arteriosus in the adult is rare. One stage operation for aneurysm of the diverticulum of the ductus arteriosis and coronary artery bypass grafting (CABG) is reported. A 61-year-old man was admitted for diagnosis of thoracic aneurysm on chest X-ray and CT. Chest CT scan showed an aneurysm above the left main pulmonary artery. An aortography showed the left vertebral artery originated directly from the aortic arch and a saccular aneurysm arising from the aortic isthmus and lesser curvature of the aortic arch. Coronary arteriography showed 75% stenosis at the right coronary artery (seg. #1) and 75% stenosis at the left anterior descending artery. Operation was performed through a median sternotomy. The aneurysm of 6 to 3 cm was located between the aortic isthmus and left pulmonary artery. Ascending aorta and right atrium were used to institute cardiopulmonary bypass (CPB). CABG (LITA to #7, SVG to #4 PD) was performed. Arterial cannulation was then switched to the left femoral artery. The proximal aorta was cross-clamped between the left vertebral artery and the left subclavian artery under the partial CPB, and the distal aorta was occluded with a occulusive balloon catheter via the right femoral artery. The selective left axillar artery cannulation was performed to perfuse LITA. The aneurysm was resected and closed with a patch. His post-operative course was uneventful.     

肺动脉闭锁合并室间隔缺损行肺动脉下拉重建右心室流出道

目的明确肺动脉闭锁合并室间隔缺损行肺动脉下拉重建右心室流出道后肺动脉发育、瓣膜反流及右心功能情况。方法回顾性分析2002年11月至2012年9月广东省人民医院31例肺动脉闭锁合并室间隔缺损患者的临床资料,其中男20例,女11例;患儿手术时14d～14．50岁（47．90±53．84）个月,均采用肺动脉下拉重建右心室流出道。随访评估其吻合口及肺动脉发育情况、肺动脉与三尖瓣反流及其与随访时间的相关关系;采用右心室应变等指标评估右心功能。结果术后早期死亡3例。随访27例（27／31,87．1％）,随访时间4～129（35．97±28．24）个月。随访期间无死亡。根治术后元吻合口再狭窄,姑息术后吻合口相对狭窄4例。吻合口及左、右肺动脉的直径均明显大于术后早期;肺动脉反流及i尖瓣反流加重,但肺动脉反流量与随访时间无相关关系。远期右心功能整体良好。结论肺动脉闭锁合并室间隔缺损行肺动脉下拉重建右心室流出道效果良好,吻合口及肺动脉分支可生长发育,术后中远期右心功能良好。     

Young child with recurrent stridor

Stridor is a serious clinical sign that warrants immediate attention. We report a young child who presented with recurrent stridor. The diagnosis was confirmed by bronchoscopy, and computed tomography of the thorax showed that tracheal compression at the lower half portion with an anomalous left pulmonary artery arising from the right main pulmonary artery formed a ‘sling’ around the trachea (i.e. left pulmonary artery sling). She had two severe episodes of noisy respiration. The acute respiratory symptoms appeared because of oedema of the airway associated with infection and was aggravated by bronchial secretions. She underwent successful surgical correction of both lesions. Early diagnosis and expert management of airway problems can reduce morbidity and mortality of this potentially lethal clinical scenario.     

Pulmonary artery sling: reimplantation versus antetracheal translocation.

BACKGROUND: We compared two repair techniques for pulmonary artery sling. The first comprised detachment of the aberrant left pulmonary artery from the right pulmonary artery and its implantation into the main pulmonary artery, and the second, translocation of the left pulmonary artery anterior to the trachea (without implanting it into the main pulmonary artery), resection of tracheal stenosis, and end-to-end reconstruction of the trachea. METHODS: Five symptomatic infants (3 boys and 2 girls; median age 5 months; range, 3 weeks to 11 months) with pulmonary artery sling were operated on through a median sternotomy with aid of cardiopulmonary bypass. In 3 patients, the left pulmonary artery was transected from the right pulmonary artery and implanted into the main pulmonary artery. In addition, the anterior trachea was augmented with a pericardial patch (n = 2). In the remaining 2 patients, associated tracheal stenosis was resected, the left pulmonary artery was translocated anterior to the trachea, and the trachea was reconstructed. RESULTS: All 5 infants survived the operation. The 3 patients in whom the left pulmonary artery was implanted into the main pulmonary artery had an uncomplicated postoperative course. All 3 patients, at a follow-up of 10 months to 7.9 years, were free of symptoms; the left pulmonary artery was documented to be widely patent. The remaining 2 patients in whom the left pulmonary artery was translocated anterior to the trachea could not be extubated. In both patients the distal trachea was compressed anteriorly by the left pulmonary artery. One of these patients died at 1 week postoperatively secondary to tracheal dehiscence. In the other patient, the left pulmonary artery was implanted into the main pulmonary artery with good result; at a follow-up of 3.9 years, mild residual stridor has persisted. CONCLUSIONS: In pulmonary artery sling, implantation of the aberrant left pulmonary artery into the main pulmonary artery, if necessary combined with anterior tracheoplasty, reliably eliminates tracheal and esophageal compression and maintains antegrade flow into the left pulmonary artery. Translocation of the left pulmonary artery anterior to the trachea without implanting it into the main pulmonary artery is not favored because that might result in anterior compression of the trachea. In addition, we are concerned about growth of the circumferential tracheal anastomosis in neonates and infants.     

Improvement in right ventricular function by mitral valve closure in hypoplastic left heart syndrome

A male neonate presented with the aortic/mitral stenotic variant of hypoplastic left heart syndrome, wherein the suprasystemic left ventricular pressure and relatively large left ventricle had shifted the intraventricular septum. Despite bilateral pulmonary artery banding, the stroke volume was difficult to maintain owing to the compressed right ventricle, causing heart failure symptoms. Percutaneous balloon aortic valvuloplasty decreased the left ventricular pressure, restoring the right ventricular function. Norwood procedure with mitral valve closure after catheter intervention reduced the left ventricular size and improved the right ventricular function. This paper refers to the potential of mitral valve closure for hypoplastic left heart syndrome.     

Pulmonary sling. Case report and collective review.

The eighteenth survivor of correction of an anomalous left pulmonary artery arising from the right pulmonary artery is reported. This is the first case in which postoperative angiography demonstrated patency of the left pulmonary artery. The onset of symptoms in infancy, predominance of expiratory rather than inspiratory stridor, anterior indentation of the esophagus, and lethal progression of symptoms during the first year of life are peculiar to this anomaly. Operation through a left thoracotomy is advocated, with division of the proximal left pulmonary artery and implantation into the main pulmonary artery posterior to the phrenic nerve. Previously reported cases are collectively reviewed.     

Primary chondromatous osteosarcoma of the pulmonary artery

Primary pulmonary sarcoma is an extremely rare malignancy, pulmonary osteogenic sarcoma is even more rare and has a poor prognosis. We present a report of a 58-year-old woman with primary pulmonary osteosarcoma occupying the right main pulmonary artery and extending to the main pulmonary artery. Right pneumonectomy was performed with total right main pulmonary artery resection under cardiopulmonary bypass. Microscopic examination demonstrated that tumor cells contained mainly chondromatous components and were atypical cells that became osteoid. There is no sign of recurrence 24 months postoperatively. The present case is the only case yet reported with even an intermediate-term survival without recurrence.     

Stent-graft repair of an aortic rupture caused by invasive hemangiopericytoma

A 2.6 kg female with the diagnosis of type "B" interruption of the "right" aortic arch and mitral atresia underwent stage I palliation with translocation and anastomosis of the distal right carotid artery to the descending aorta. The distal main pulmonary artery was anastomosed to the under surface of the neoaortic arch. A modified Blalock-Taussig shunt was constructed between the left side innominate artery and the left pulmonary artery. The child awaits stage II palliation.     

Surgical repair for pulmonary artery sling on a 46-day-old infant

Surgical repair on a 46-day-old girl with pulmonary artery sling is reported. She was suffered from dypnea and admitted to a hospital on 12 days after her birth. On chest roentgenogram atelectasis of right lung was found. She had been on respirator since 21 days after her birth. On bronchogram and pulmonary arteriogram, the trachea and right bronchus were compressed and shifted with the anomalous origin of left pulmonary artery which originated from the right pulmonary artery and passed between the trachea and esophagus. These results confirmed the diagnosis of pulmonary artery sling. Hence, she was referred to our hospital for surgical treatment. She underwent surgical repair on 46-day-old. In operation, we chose a mid-sternal splitting incision, and excised 5 mm of ductus arteriosus. Under extracorporeal circulation, the left pulmonary artery was amptated from the right pulmonary artery and pulled back to left side between the trachea and the esophagus. The left pulmonary artery was anastomosed to the main pulmonary artery at the anterior to the left bronchus. She weaned from respirator, and was extubated on the 3rd day after procedure. She recovered uneventfully in post-operative course. On the 24th day after operation she discharged from hospital. On pulmonary perfusion scanning and pulmonary arteriography performed one year after operation, the left pulmonary artery was patient with slightly decreased perfusion in the left lung. Surgical repair for pulmonary artery sling was recognized as high mortality because of frequently associated tracheobronchial anomalies. In the Japanese literature, only 4 patients survived surgically and lived in late stage.(ABSTRACT TRUNCATED AT 250 WORDS)     

先天性心脏病合并右位主动脉弓的诊断与治疗

目的 探讨先天性心脏病合并右位主动脉弓的诊断与治疗。 方法 回顾性分析2012年1月1日至2013年4月1日北京儿童医院小儿心脏中心27例先天性心脏病合并右位主动脉弓行外科手术治疗患儿的临床资料,其中男20例,女7例;年龄（10.96±12.08） 个月,体重（7.70±3.13） kg。法洛四联症14例,室间隔缺损9例,动脉导管未闭1例;肺动脉吊带1例;单纯双主动脉弓2例;均合并右位主动脉弓。其中13例合并血管环畸形,包括迷走左锁骨下动脉畸形和双主动脉弓畸形。所有患儿均接受手术治疗,在矫治心内畸形的同时,进行左锁骨下动脉移植,矫治迷走左锁骨下动脉畸形,双主动脉弓主要是切断一侧非优势弓。 结果 围术期死亡3例,其中1例术后无法停体外循环死亡,1例未合并血管环的患儿术后7 d死亡,1例合并双主动脉弓患儿术后并发急性呼吸窘迫综合征（ARDS） 死亡;1例放弃治疗。随访23例,随访时间3～17个月,心脏超声心动图提示心内畸形矫治满意,恢复良好,双侧上肢动脉波动良好。 结论 对先天性心脏病合并右位主动脉弓患者行外科矫治时应慎重,术前尽量完善相关检查,选择增强CT、磁共振成像检查,明确诊断,制定手术计划。一期同期矫治血管环畸形及其它先天性心脏病,手术效果满意,近期效果良好。     

螺旋CT增强扫描在诊断和治疗肺动脉栓塞中的应用

目的 评价螺旋CT在诊断和治疗肺动脉栓塞（肺栓塞）中的作用。方法 对16例（年龄35－74岁）行螺旋CT检查的肺栓塞病人进行回顾性分析。使用PQ6000型单层螺旋CT机,连续容积增强扫描。结果 共计分析176支肺动脉分支,受累89支,占50．2％;双侧下叶主支受累最多（达31．5％）;累及左、右肺动脉主干者为16％,累及肺叶以下分支达84％,未见累及主肺动脉的病例。肺动脉栓塞螺旋CT增强扫描的直接征象为肺动脉腔内偏心性、类圆形充盈缺损,附壁性类环形充盈缺损,管腔闭塞,血栓位于管腔中央的“轨道症”;并存的间接征象包括主肺动脉增宽、局限性肺纹理稀疏、肺梗死和胸腔积液。结论 在肺动脉栓塞的诊断,螺旋CT增强扫描是一种有效的无创性检查手段,且安全、快速。在肺栓塞的定性定量诊断和指导选择治疗方法上,可以起到重要作用。     

Coronary to pulmonary artery collaterals in patients with pulmonary atresia and ventricular septal defect

BACKGROUND: The frequency, distribution, and surgical importance of coronary artery to pulmonary artery (CAPA) collaterals have not been established. The aim of this study was to establish prevalence, anatomical pattern, and significance of CAPA in patients with pulmonary atresia and ventricular septal defect (PA/VSD). METHODS: We reviewed cardiac catheterization and operative data of 87 consecutive, unselected patients who underwent one-stage complete unifocalization for PA/VSD and assessed major systemic to pulmonary collaterals from July 1992 to June 1998. RESULTS: CAPA collaterals were diagnosed in 9 of 87 patients (10%). The collaterals originated from the left coronary artery system in 7 patients and the right in 2. Collaterals from the left coronary system arose from the left main coronary artery in 3 patients and the circumflex in 4. All collaterals joined the central pulmonary artery, which bifurcated and supplied both lungs. One collateral from the right coronary system joined the stump of the main pulmonary artery and the other gave origin to a true left pulmonary artery, which was the sole supply to 75% of the left lung. Coronary artery enlargement was seen in 2 patients only. No patient had evidence of myocardial ischemia. Coronary collaterals comprised a dual source of pulmonary blood flow in all but 1 patient. During unifocalization, the CAPA collaterals were ligated at its origin in all cases, and the collateral from the right coronary to the left pulmonary artery was unifocalized. CONCLUSIONS: The prevalence of CAPA collaterals in patients with PA/VSD is approximately 10%. The diagnosis may be missed without appropriate angiograms. We recommend selective ascending aortogram or selective coronary angiogram in all patients.     

Pulmonary artery sling. Results of surgical repair in infancy.

Pulmonary artery sling is a rare congenital vascular anomaly in which the left pulmonary artery originates from the right pulmonary artery and encircles the right main-stem bronchus and distal trachea before entering the hilum of the left lung. This causes compression of the trachea and right main-stem bronchus, and most infants with this anomaly have severe respiratory distress within the first year of life. Between 1953 and 1990 12 infants (nine male, three female) underwent surgical repair of pulmonary artery sling. Ages ranged from 8 days to 9 months (mean age 5 months). Bronchoscopic examination was performed in all patients. Complete tracheal rings were the most common associated lesion (five patients). Nine patients had pulmonary angiography. Most recently, computed tomography and magnetic resonance imaging have been used to diagnose pulmonary artery sling and associated complete tracheal rings when present. Surgical repair consisted of transection of the left pulmonary artery at its origin and implantation into the main pulmonary artery anterior to the trachea via right thoracotomy (one), left thoracotomy (six), or median sternotomy (five). Three patients had simultaneous pericardial patch tracheoplasty for complete tracheal rings. There were no operative deaths. Two late deaths occurred, at 7 months and 2.5 years postoperatively. Of 10 long-term survivors nine have had postoperative studies to determine the patency of the left pulmonary artery. Seven anastomoses were patent (78%). Pulmonary artery sling can be repaired in infancy with low operative mortality and excellent long-term patency of the left pulmonary artery by dividing the left pulmonary artery and implanting it into the main pulmonary artery anterior to the trachea. Simultaneous pericardial patch tracheoplasty should be performed if complete tracheal rings are associated. We recommend repair at the time of diagnosis with median sternotomy and extracorporeal circulation.     

完全型房室间隔缺损人工瓣膜置换一例-站在“单心室循环共瓣成形或换瓣”分岔路口的思考

1例12岁女性患者因“左上腔静脉-肺动脉连接术后,完全型房室间隔缺损,右室双出口,肺动脉瓣狭窄,左异构,单心房,下腔静脉-半奇静脉引流”入院。术前超声显示共同房室瓣增厚、卷曲,对合不良,中大量反流,以左侧房室瓣为主;主肺动脉发育差。手术保留房室瓣,取31#二尖瓣机械瓣,以2/0 Prolene线连续缝合于二尖瓣瓣环。横断主肺动脉,5/0 Prolene线连续缝合近端,远端与20#Gore-tex人工血管端端吻合。将肝静脉自右房壁切下,与人工血管另一端吻合。术后血氧饱和度95%~100%之间。出院前复查超声、CT示人工瓣膜功能良好、心功能正常。虽然,共同房室瓣成形是瓣膜处理的首选,但当瓣膜功能障碍过于严重、成形很可能失败的情况下,勉强进行瓣膜成形术将使手术的风险骤然提升。此时,人工瓣膜的置换为最佳选择。     

Gore-Tex片作单瓣重建右心室流出道的早、中期疗效

目的评价0.1mm厚的Gore-Tex片作肺动脉单瓣重建右心室流出道(RVOT)的早中期临床效果。方法2002年6月至2006年7月,对48例合并肺动脉狭窄或闭锁的先天性心脏病患者施行矫治手术,术中采用0.1mm厚的Gore-Tex片作肺动脉单瓣的Dacron血管片重建RVOT,其中包括法洛四联症合并肺动脉狭窄33例、型肺动脉闭锁8例、肺动脉瓣缺如3例,右心室双出口合并肺动脉狭窄2例,永存动脉干1例,完全型大动脉错位、室间隔缺损、肺动脉狭窄1例。结果本组无手术死亡。术后血氧饱和度达1.00,右心室/左心室收缩压比值0.22~0.65,右心室与左、右肺动脉压差<10mm Hg。所有患者(100%)均随访3~48个月,无死亡和并发症。彩色多普勒超声心动图检查提示:无肺动脉狭窄,肺动脉瓣轻度反流13例,中度反流5例,Gore-Tex膜具有活动功能40例。结论采用0.1mm厚的Gore-Tex片作单瓣重建RVOT,其早中期临床结果显示有较满意的血流动力学效果。     

Traumatic occlusion of the extracranial internal carotid artery. Report of two cases

Two cases of tapered occlusion of the unilateral internal carotid artery after head and facial injury are reported. The first was a 42-year-old male admitted because of left hemiparesis 3 hours after receiving blows to the face. Computed tomography (CT) scan obtained 10 hours after injury showed an area of slight low density in the right frontotemporal region. Carotid angiography demonstrated tapered occlusion of the right cervical internal carotid artery. A large cerebral infarction had developed in the right hemisphere and the patient died 10 days after the traumatic incident. The second case involved a 45-year-old male hospitalized with aphasia and right hemiparesis about 1 month after incurring a depressed fracture of the left temporal bone. CT revealed two small low-density areas in the left corona radiata, and carotid angiography disclosed tapered occlusion of the left cervical internal carotid artery. The neurological signs gradually improved after anticoagulant therapy. Early diagnosis of traumatic cervical carotid artery occlusion may be difficult in the absence of apparent cervical trauma with focal cerebral symptoms appearing after a lucid interval. No definitive management has been established and the prognosis is poor. It is emphasized that unusual neurological symptoms following head or cervical trauma should provoke suspicion of carotid artery injury, which, on diagnosis, should be promptly treated.     

A case of tracheo-bronchial stenosis after extended end-to-end aortic arch anastomosis for interrupted aortic arch treated with suspension of the ascending artery and pulmonary artery

A 9-day-old boy had pulmonary artery banding and extended end-to-end aortic arch anastomosis for ventricular septal defect (VSD) and type A interrupted aortic arch. Severe dyspnea gradually developed. At 3 months of age, intracardiac repair of VSD was performed. Weaning from the ventilator was difficult. Endoscopic examination and chest CT revealed stenosis of the right and left main bronchi and compression of tracheal bifurcation and the right and left main bronchi by the ascending aorta and pulmonary artery. Suspension of the ascending aorta and pulmonary artery was performed 15 days after VSD closure. Nine days after this procedure, the patient was weaned from respirator. Postoperative course was uneventful. Bronchial stenosis may be caused from extended end-to-end aortic arch anastomosis.     

Large cell carcinoma with chest wall infiltration combined with contralateral giant bulla

A 48-year-old male consulted the department of respiratory medicine for right precordial pain occurring from the beginning of May 2004. Chest X-ray indicated a tumorous shadow in the right upper lung field and a large left lung cyst. Although chest wall infiltration was suspected based on computed tomography (CT) demonstrating a mass lesion in the right S2, there was no significant swelling of the mediastinal lymph node. On the left side, the lung was markedly compressed by a large cyst in the left upper lobe. Since bronchoscopy failed to establish a definitive diagnosis, the patient was referred to our department for surgery based on a suspicion of malignant pulmonary tumor. Considering both the risk of perioperative complications due to the left cystic lesion at surgery for right lung lesion and the improvement of respiratory function by removing cystic lesion of the left lung, the left side operation was preceded by the right side. Although postoperative examinations of respiratory function did not demonstrate any particular improvement, the results of selective right pulmonary artery obstruction test supported the possibility of pulmonary lobectomy. Therefore, the right upper lobectomy and ND 2a mediastinal dissection combined with chest wall resection was subsequently performed. Postoperative pathological diagnosis revealed that the tumor was a stage IIB large cell carcinoma of pT3N0M0 with costal infiltration.     

Isolated Left Thoracic Isomerism with Lung Cancer: Report of a Case

Thoracic isomerism, or symmetric morphology, is frequently associated with cardiac and abdominal anomalies. We report an unusual case of isolated left thoracic isomerism with lung cancer. A 67-year-old woman was referred to our hospital for investigation of an abnormal shadow on a chest X-ray. Chest computed tomography (CT) showed bilateral hyparterial bronchi, and bronchofiberscopy showed bifurcation of the right main bronchus into two branches. Pulmonary arteriography subsequently revealed that the right pulmonary artery bifurcated at the hilum and that it was not a mirror image of the left pulmonary artery. No other malformations were found on echocardiography or abdominal CT scan. We performed segmental resection of right S¹⁺² and S³ for lung cancer and the patient had an uneventful postoperative course. It is important to clarify the anatomy of patients with thoracic isomerism before surgical manipulation.     

A case report of anomalous origin of right pulmonary artery from innominate artery associated with left sided unilateral pulmonary hypertension

A 7-year-old girl, who was diagnosed as anomalous origin of right pulmonary artery from innominate artery associated with left sided unilateral pulmonary hypertension due to left patent ductus arteriosus, was reported. The right pulmonary artery had a stenotic segment of it's origin containing ductal tissue. Operation was performed without the aid of cardiopulmonary bypass. The continuity between main and right pulmonary arteries was established by a pericardial roll graft. The postoperative course was uneventful and she is very well three years after correction. To our knowledge, this is a very rare case with such combination of congenital anomalies as anomalous origin of right pulmonary artery and left sided unilateral pulmonary hypertension to be reported in the literature in Japan.