冠状动脉异常起源于肺动脉的外科治疗

目的总结冠状动脉异常起源于肺动脉的外科治疗经验及疗效随访分析。方法从1999年4月至2005年8月共对12例冠状动脉异常起源于肺动脉的患者进行了外科治疗,其中左冠状动脉起源异常8例,右冠状动脉起源异常4例。异常起源的冠状动脉直接吻合到主动脉9例,应用Takeuchi技术,即肺动脉内隧道重建冠状动脉3例。有7例左冠状动脉起源异常的患者,因中、重度二尖瓣关闭不全同期行二尖瓣成形;1例合并房间隔缺损的右冠状动脉起源异常的患者,同期在非体外循环下行房间隔缺损封堵术。结果无死亡及术后并发症,随访7~83个月,平均(32±24)个月,左冠状动脉起源异常的患者,左室舒张末径从术前的(45±7)mm减小至术后的(39±6)mm(P=0.011),左室短轴缩短率从术前的0.21±0.09增加至术后的0.35±0.06(P=0.006),7例二尖瓣成形的患者术后二尖瓣反流程度均减轻;所有患者活动能力正常,均无症状。结论外科治疗冠状动脉异常起源于肺动脉,需恢复2个冠状动脉系统供血;左冠状动脉起源异常的患者,术后左室功能明显改善,对中、重度二尖瓣关闭不全的患者,需同期行二尖瓣成形;外科治疗早、中期效果良好,远期结果需进一步随访。     

左冠状动脉起源于肺动脉的外科治疗

目的　探讨左冠状动脉起源于肺动脉的术前诊断、手术治疗的术式和疗效。　方法　1991年 8月～ 1999年 3月 ,8例患者进行了手术治疗 ,其中 7例采用肺动脉内隧道成形术 ,1例采用冠状动脉旁路移植术 ,1例患者合并二尖瓣关闭不全 ,同时进行了二尖瓣成形术。术前进行了心电图、心脏超声和心导管、心脏造影等全面检查。术后随访 7例 ,随访时间平均 (4 6 8± 10 7)个月。　结果　 8例患者无住院死亡和严重并发症 ,7例随访无晚期死亡 ,1例患者因肺动脉内隧道缝线撕脱 ,导致主动脉 主肺动脉瘘 ,二次手术修补成功。随访患者NYHA心功能Ⅰ级 ,LVED平均 (4 6 4± 3 7)mm ,较术前平均 (5 4 4± 2 8)mm明显减少 (P <0 0 1) ,EF值 (6 9 4± 2 3) %较术前 (5 9 6± 2 8) %明显提高(P <0 0 5 )。　结论　左冠状动脉起源于肺动脉是一种较为罕见的先天性心脏病 ,治疗的主要原则为重建 2支冠状动脉系统并处理好合并病变。肺动脉内隧道矫治方法 ,简便易行 ,疗效满意     

左冠状动脉异常起源于肺动脉的外科治疗

目的探讨左冠状动脉起源于肺动脉（anomalous origin of the left coronary artery from the pulmonary artery,ALCAPA）的外科手术方法及相关风险因素。方法回顾性分析北京安贞医院1993年10月至2013年9月期间手术治疗28例左冠状动脉异常起源于肺动脉患者的临床资料,男8例、女20例,年龄0.6～l 6.8（4.3±0.7）岁,其中≤1岁10例。手术方法包括左冠状动脉单纯结扎术、肺动脉内通道术（Takeuchi术）和左冠状动脉移植术。术后观察围术期死亡、并发症发生和心功能情况。结果 28例患者中行左冠状动脉单纯结扎术1例,肺动脉内通道术（Takeuchi术）7例,其中2例术后死亡;行左冠状动脉移植术20例,其中术后死亡3例。5例死亡患者的年龄（10.20±3.27）个月,术前二尖瓣中度反流3例,轻度反流2例;死亡患者术前的心功能均明显降低,射血分数与生存患者术前的射血分数相比差异有统计学意义（36.6%±8.5%vs.60.9%±10.7%,P=0.000）;死亡患者均死于低心排血量综合征。所有生存患者随访1个月至18年,1例行肺动脉内通道术的患者于术后15年因肺动脉瓣上狭窄行球囊扩张术,其余随访患者均未行二次手术;随访期间左心室收缩功能均提高,生长发育正常,二尖瓣反流无明显加重。结论年龄越小、左心功能越低,则外科手术风险越大。     

大于6月龄伴室间隔缺损合并重度肺动脉高压完全性大动脉转位患儿诊断性治疗-根治性手术策略

目的 总结年龄大于6个月的伴室间隔缺损合并重度肺动脉高压完全性大动脉转位患儿诊断性治疗-根治性手术策略的应用经验及术后效果,探讨手术指征.方法 2010年1月至2011年10月手术治疗17例伴室间隔缺损合并重度肺动脉高压完全性大动脉转位患儿,男13例,女4例.中位年龄1.2岁,其中0.5岁～＜1.0岁6例,≥1.0岁～＜3.0岁3例,≥3.0岁8例.合并动脉导管未闭6例,房间隔缺损5例,二尖瓣关闭不全2例,肺动脉瓣轻度狭窄2例.术前均行超声心动图检查,冠状动脉CT检查11例,右心导管检查3例.全组均行诊断性治疗2～4周,静吸复合麻醉低温体外循环下行大动脉调转术(ASO),术后残留肺动脉高压者继续予肺动脉高压靶向药物治疗.结果 全组无手术死亡.术前经诊断性治疗动脉氧饱和度提高10％ ～21％,肺动脉平均压下降10 ～20mmHg(1.33 ～2.67kPa).随访6～32个月,平均11.2个月.随访期间1例死于食物中毒致急性腹泻、电解质紊乱和心律失常,余患儿至最终随访日均生存.术后6例(35.29％)残余肺动脉高压,年龄均≥3岁,肺动脉高压靶向药物治疗6 ～20个月后,肺动脉压力明显下降.结论 大于6个月的伴室间隔缺损肺动脉高压完全性大动脉转位患儿经诊断性治疗后可以选择性实施根治性手术(ASO),效果良好.     

左冠状动脉异常起源于肺动脉的临床治疗

目的总结左冠状动脉异常起源于肺动脉的手术治疗经验。方法回顾性研究总结近年9例左冠状动脉异常起源于肺动脉的患者,对4例于肺动脉起始部结扎左冠状动脉,5例于体外循环下行肺动脉内隧道成形术(Takeuchi术),合并的心脏畸形同时予以纠治。结果全组9例术后无心肌缺血或梗死、残余分流和晚期死亡,心功能恢复到I级。结论左冠状动脉异常起源于肺动脉畸形一旦确诊,主张手术治疗。     

冠状动脉畸形的外科治疗

目的 总结先天性冠状动脉畸形的手术治疗经验。方法 11例冠状动脉畸形患者中冠状动脉窦8例, 冠状动脉起源异常3例,合并法洛四联症1例,风湿性心瓣膜病2例。右冠状动脉瘘均在心肺转流术下经心腔修补内瘘口或经扩张的冠状动脉修补外瘘口或同时修补内,外瘘口;左冠状动脉－肺动脉瘘支动脉结扎术或在心肺转流术心脏不停跳下经肺动脉修补;左冠状动脉－左心室瘘伴主动脉瓣关闭不全经左冠状动脉修补外瘘口及主动脉瓣成形术。左冠状动脉起源于肺动脉畸形行左冠状动脉根部结扎或冠状动脉旁路移植术。合并的心脏疾病的同时纠治。结果 本组无手术死亡,术后心脏杂音均消失,10例术后症状缓解。结论 先天性冠状动脉畸形一旦确诊,主张手术治疗。     

单心房外科治疗的临床分析

目的总结单心房的外科治疗经验。方法自1984年8月至2004年8月共手术治疗单心房患者33例。其中30例二尖瓣关闭不全,行二尖瓣成形术;18例三尖瓣关闭不全,行三尖瓣成形术;3例仅为房间隔完全缺如。合并永存左上腔静脉14例。单心房均采用补片分隔。合并畸形同期矫治。术中采用2种缝合技术防止房室结和传导束的损伤,二尖瓣成形至无关闭不全。结果本组术后无死亡。术后无传导阻滞发生。除1例术后轻度二尖瓣关闭不全,其余无二尖瓣关闭不全。随访25例患者3个月～11年,均恢复正常工作学习。结论单心房一旦诊断明确应尽早手术;手术关键在于防止房室结和传导束的损伤、彻底矫正二尖瓣关闭不全以及合并畸形;单心房用补片分隔,自体心包补片为首选。     

婴幼儿一侧肺动脉起源异常的外科治疗

目的总结婴幼儿一侧肺动脉起源异常的外科治疗经验。方法回顾性分析2005年3月至2010年5月第四军医大学西京医院11例一侧肺动脉起源异常合并心血管畸形患者行外科手术治疗的临床资料,手术时平均年龄11.5(2～36)个月;平均体重7.1(4～13)kg。右肺动脉起源于升主动脉7例,左肺动脉起源于升主动脉4例。11例患者均合并其它心血管畸形及中度以上肺动脉高压。全组患者均在低温体外循环下经胸骨正中切口径路行一期手术矫治。结果手术时间169～293(231±55)min,体外循环时间87～210(138±47)min,主动脉阻断时间45～133(86±28)min。围术期死亡1例,病死率9.1%,为法洛四联症合并右肺动脉起源异常患者术后死于低心排血量。生存患者术后超声心动图提示:左、右肺动脉均经右心室肺动脉发出,无狭窄、残余漏,畸形矫治满意。随访10例,随访率100%,平均随访13.5(3～32)个月。超声心动图提示:肺动脉连接均通畅,9例患者的肺动脉压均明显下降。结论一侧肺动脉起源异常应尽早外科手术治疗,婴幼儿一侧肺动脉起源异常行外科手术治疗可获得良好的近期疗效,年龄较大肺动脉压力不可逆增高者外科治疗应谨慎;术中充分游离异常起源的肺动脉及升主动脉,并视具体情况横断主动脉可获得较好的手术显露;自体肺动脉补片加宽修补主动脉缺损可有效避免术后动脉瘤的发生。     

主动脉窦瘤破裂的外科治疗及远期疗效

目的 总结主动脉窦瘤破裂的临床特点及外科疗效,讨论对合并感染性心内膜炎及主动脉瓣关闭不全患者的处理.方法 回顾性分析1997年9月至2007年9月43例主动脉窦瘤破裂患者的临床资料.其中男性32例,女性11例;年龄11～50岁,平均年龄(29.0±11.5)岁.破口源于右冠状动脉窦34例,无冠状动脉窦9例.破入有心室30例,右心房8例,右心室及右心房3例,破人室间隔2例.合并室间隔缺损26例,主动脉瓣关闭不全15例,感染性心内膜炎8例,三尖瓣反流6例,房间隔缺损4例,二尖瓣反流2例,动脉导管未闭2例,肺动脉赘牛物1例.全部患者于心肺转流下行窦瘤修补及合并畸形矫治术.结果 无围手术期死亡.并发症5例,包括急性左心功能衰竭3例,Ⅲ度房室传导阻滞2例.随访6～120个月,平均(68.0±17.7)个月;2例分别于术后第6、8年行主动脉瓣置换术,2例进展为Ⅱ级主动脉瓣父闭小全.结论 主动脉窦瘤破裂外科治疗可获得满意效果.对合并主动脉瓣关闭小全及感染性心内膜炎的患者应早期手术,积极防治术后并发症并长期随访.     

成人左冠状动脉起源于肺动脉外科治疗

目的探索成人左冠状动脉起源于肺动脉的外科治疗效果。方法 1991年11月至2017年11月,手术治疗36例年龄18岁左冠状动脉起源于肺动脉患者,其中男9例、女27例,年龄(36.6±13.3)岁,体重(60.0±9.4)kg。术前超声心动图显示左心室射血分数(LVEF)为57%±6%,左心室舒张期末内径(LVEDD)为(52.3±6.3)mm;二尖瓣反流(MR)重度1例,中度5例。其中行冠状动脉再植17例,肺动脉内隧道修补术(Takeuchi术)16例,异常起源左冠状动脉结扎+冠状动脉旁路移植术3例,同期行二尖瓣成形术6例。结果体外循环时间为(152.5±72.9)min,主动脉阻断时间(101.9±43.6)min,无院内死亡,呼吸机辅助时间(17.3±16.3)h,ICU滞留时间(43.1±30.7)h,术后LVEF为59%±6%,较术前无明显改善(P=0.10),术后LVEDD为(46.9±5.9)mm较术前显著缩小(P=0.02),6例二尖瓣成形患者中,1例重度变为轻度,5例中度变为微量。所有患者顺利出院。随访35例,平均5.5年,最长26年,随访期间无死亡,2例行肺动脉内隧道修补术患者发生肺动脉内隧道瘘,分别成功行介入封堵术和外科修补术;所有患者心功能分级(NYHA)Ⅰ或Ⅱ级;最后一次随访LVEF为69%±7%,较术前显著改善,LVEDD为(48.7±5.9)mm;MR中度2例,轻度10例。结论成人左冠状动脉起源于肺动脉外科治疗近期和远期效果满意,肺动脉内隧道修补术远期可能出现内隧道瘘需要再次干预。     

The need for follow-up after surgical correction of anomalous left coronary artery arising from the pulmonary artery

Four patients are described with an anomalous origin of the left coronary artery from the pulmonary artery. Three were treated by ligation of the abnormal left coronary artery at its anomalous origin; one of them died during surgery. One patient was treated with reimplantation of the left coronary artery into the aorta. Of the survivors 2 are in normal health, but 1 developed aortic valve incompetence after reimplantation of the left coronary artery into the aorta and 1 had persistent left ventricular wall motion abnormalities and developed mitral valve prolapse. The third survivor has impaired health with diffuse left ventricular wall motion abnormality. Careful follow-up after surgery for an anomalous left coronary artery arising from the pulmonary artery is necessary for secondary prevention of problems due to incomplete recovery of myocardium or problems as a consequence of surgical therapy.     

Cleft mitral valve in association with anomalous left coronary artery arising from pulmonary artery

An anomalous origin of the left coronary artery from the pulmonary artery is commonly associated with mitral valve insufficiency. Usually this is secondary to left ventricular dysfunction or papillary muscle ischemia. We describe the association of an anomalous left coronary artery from the pulmonary artery with structural abnormalities of the mitral valve (cleft mitral leaflet) in 2 children, both of whom were being investigated for primary mitral valve disease. Both underwent successful operations for coronary transfer and mitral valve repair.     

Four cases of the anomalous origin of the left coronary artery from the pulmonary artery

We report perioperative management of 4 patients with anomalous origin of the left coronary artery from the pulmonary artery. This report involves with 3 infant cases and an adult. Two infants underwent coronary reimplantation procedure and Takeuchi's method was performed on the other infant. In all infant cases, mitral valve plasty was performed to correct mitral regurgitation secondary to papillary muscle dysfunction. The adult patient underwent CABG with ligation of LCA. General anesthesia was performed with high doses of fentanyl in all cases. We employed a relatively high PaCO2 and low FIO2 in order to maintain a high pulmonary vascular resistance. It aims to decrease the incidence of left to right shunt. We used epinephrine to wean one infant and the adult from cardiopulmonary bypass. Perioperative course was uneventful with the use of catecholamines and high doses of vasodilators for left ventricular dysfunction and coronary perfusion under mechanical ventilation.     

Anomalous coronary artery origin from the pulmonary artery: correlation between surgical timing and left ventricular function recovery

BACKGROUND: This study investigates the correlation between surgical timing and 15-year longitudinal left ventricular and mitral valve function, after repair of anomalous coronary artery origin from the pulmonary artery. METHODS: Between 1987 and 2002, 31 patients (median age, 7.1 months) underwent repair for anomalous origin of the left (n = 28), right (n = 2), or both (n = 1) coronary arteries from the pulmonary artery. Repair was accomplished by subclavian interposition in 5 patients, intrapulmonary tunnel in 12, and direct aortic reimplantation in 14. Primary mitral valve repair was never associated with coronary revascularization. Total follow-up was 186.4 patient-years (mean, 77.2 months). RESULTS: Fifteen-year actuarial survival was 92.9% +/- 4.9% for coronary transfer, 40.0% +/- 21.9% for subclavian interposition, and 89.9% +/- 7.5% for intrapulmonary tunnel (p = 0.019). Five patients required further intervention for supravalvular pulmonary stenosis (n = 3), baffle leak (n = 1), and mitral valve replacement (n = 1). Coronary transfer allowed best freedom from long-term reoperation (92.3% +/- 7.4%). Left ventricular shortening fraction increased from 17.3% +/- 6.3% before operation to 34.1% +/- 4.6% at last follow-up (p < 0.01). Regression analysis demonstrated a linear relationship between age at repair and shortening fraction recovery (r(2) = 0.573, p < 0.01). Patients younger than 6 months of age showed worse preoperative shortening fraction (15.9% +/- 5.2%) and best longitudinal shortening fraction recovery (36.4% +/- 5.1%; p < 0.001). Major improvement in mitral valve function was observed within 1 year from surgery in 90.4% of survivors. CONCLUSIONS: Repair of anomalous coronary artery origin from the pulmonary artery in younger symptomatic infants offers the best potential for recovery of left ventricular function, despite a worse initial presentation. Coronary transfer is associated with superior long-term survival and freedom from reoperation. Most patients with patent two-coronary repair will recover normal mitral valve function; therefore, simultaneous mitral valve surgery seems unwarranted.     

Combined coronary artery bypass, mitral valve plasty, and abdominal aneurysmectomy in an 80-year-old patient: Report of a case

An 80-year-old man suffering from angina on exertion due to stenosis of the left main coronary artery, heart failure due to mitral valve regurgitation, and an abdominal aortic aneurysm (AAA) was successfully operated on with simultaneous surgical procedures. A coronary cineangiography revealed 90% stenosis of the left main coronary artery in segment 5, and 99% and 90% stenosis in segments 2 and 4AV, respectively, of the right coronary artery. Left ventriculography and aortography showed moderate mitral valve regurgitation and the presence of a fusiform-shaped AAA with a maximum diameter of 6 cm. It was thought that insertion of an intraaortic balloon pump (IABP) would prove difficult due to AAA; therefore, simultaneous surgery combining triple coronary artery bypass grafting (CABG), mitral valve plasty, and prosthetic replacement of the AAA was undertaken. The patient's postoperative course was uneventful, and subsequent angiography showed good patency of all coronary bypass grafts and the abdominal prosthesis, along with the disappearance of mitral regurgitation. This patient's clinical course suggests that an extended surgical procedure is effective for the treatment of complicated cardiovascular disease, even in very elderly patients.     

Anomalous origin of the left coronary artery from the pulmonary artery: new electrocardiographic, echocardiographic and surgical observations

The case of a two year old girl with anomalous origin of the left coronary artery from the pulmonary artery is described. She was never in heart failure but had cardiomegaly and anginal pain. The ECG showed a typical infarct pattern with left ventricular hypertrophy. An unusual finding was a prolonged QTc of 0.52. During cardiac catheterization and twice 24 hours later she developed ventricular fibrillation treated with electroshock and prevented later with propranolol. The QTc returned to normal after surgery. Echocardiography showed diastolic flutter and early systolic closure of the pulmonary valve. This disappeared after surgical correction. Transverse 2D echo of the aortic root showed a large right coronary artery which decreased in size after surgery. The left coronary artery was not seen on echocardiography. At cardiac catheterization the diagnosis of an anomalous origin of the left coronary artery from the pulmonary artery was established, with a large shunt to the pulmonary artery through the anomalous artery. Mild pulmonary hypertension and mild mitral regurgitation were present. At surgery, since direct implantation was technically impossible, the left coronary artery was successfully connected to the aorta via a 6 mm expanded Poly-Tetra-Fluoro-Ethylene (P.T.F.E.) graft.     

Anomalous left coronary artery from pulmonary artery with mitral stenosis

The usual presentation of anomalous left coronary artery from pulmonary artery is severe left-sided heart failure and mitral valve insufficiency presenting during the first months of life. The manifestations of left heart failure may be masked if pulmonary artery pressure remains high. We believe this is a rarest of rare case of anomalous left coronary artery from pulmonary artery with severe mitral stenosis and pulmonary hypertension in which pulmonary hypertension, along with good collateral circulation helped to preserve left ventricular function.     

Elective operations for post-infarction left ventricular aneurysms.

During a two-year period (February 1973 to February 1975) 20 consecutive patients with post-infarction left ventricular aneurysm, seen at the Wessex Cardiac and Thoracic Centre, underwent aneurysmectomy with or without aorta-to-coronary artery saphenous vein bypass grafts, ventricular septal defect closure, or valve replacement. The diagnoses were established by clinical means, plain chest radiographs, left ventriculography, and selective coronary arteriography. The indications for surgery were uncontrollable congestive heart failure and angina, ventricular arrhythmias, or a rapidly growing aneurysm. Low cardiac indices or high left ventricular end-diastolic pressure were not considered to be contraindications to operation. Resection of the left ventricular aneurysm was performed with the use of normothermic cardiopulmonary bypass with haemodilution. In addition to the aneurysmectomy, four of these patients had concomitant closure of post-infarction ventricular septal defects; four had valve replacements; two had grafts to coronary arteries; and one had both replacement of the mitral valve and a right coronary vein graft. There were two hospital deaths (10%) and two late deaths (10%), making an overall mortality of 20%. All but one of the deaths were related to coronary artery disease. The survivors are active, and their rehabilitation was satisfactory. The longest survivor is doing well two years after left ventricular aneurysmectomy, ventricular defect closure, and tricuspid valve replacement. It is evident from our experience and from the reports of others that surgery has an established place in the management of post-infarction left ventricular aneurysm.     

Surgical treatment of ischaemic valve disease

Mitral valve regurgitation secondary to ischaemic heart disease carries a significant mortality even after open-heart surgery. In this study, 21 patients with mitral regurgitation associated with ischaemic heart disease were evaluated with respect to valvular pathology. Pathological examination of the mitral valve revealed chorda elongation or rupture in seven patients (group 1), papillary muscle dysfunction in 10 (group 2), and papillary muscle rupture in four (group 3). Significant preoperative characteristics in each group were subacute haemodynamic deterioration in group 1, chronic severe left ventricular failure in group 2, and a high incidence of acute renal failure associated with haemodynamic shock in group 3. Mitral valve plasty was performed in six patients and mitral valve replacement, using the St Jude Medical valve, in 15. Fourteen patients underwent mitral valve surgery combined with coronary artery bypass grafting. Mitral plasty was applied to the patients with low left ventricular function with mean(s.d.) fraction shortening of 19.2(6.2)% compared with 30.2(8.4)% in patients with mitral valve replacement. There were no operative deaths. Of four late deaths, two in group 1 resulted from infection and myocardial infarction, respectively, and one in group 2 resulted from arrhythmia. One patient in group 3 died from renal failure. It is suggested that incorporation of these therapeutic concepts may lead to satisfactory results in the surgical treatment of ischaemic mitral regurgitation.     

Clinical outcomes of surgery of mitral valve regurgitation and coronary artery bypass grafting

The impact of etiology of associated mitral valve regurgitation and a valve procedure on operative and long-term outcomes after coronary bypass grafting surgery is yet to be clearly defined. Results of combined coronary artery bypass grafting and valve procedures for mitral valve regurgitation were retrospectively analyzed in 468 patients. The regurgitation was of ischemic in 45%, degenerative in 55% and 78% valve repairs, 22% valve replacements were performed. Severe coronary artery disease, acute myocardial infarction, low ejection fraction, ischemic mitral regurgitation, advanced heart failure symptoms, failure to use internal mammary artery, valve replacement surgery, and emergency operations are predictors of operative mortality. The 5-year survivals for propensity-matched patients of ischemic and degenerative disease were similar (66%), but 67% vs. 83%, respectively, for unmatched patients. Low ejection fraction (<35%), advanced age (>67 years), valve replacement surgery, residual mitral regurgitation, and severe coronary artery disease were predictors of poor long-term survival. Left ventricular remodeling processes, optimal valve procedure without residual mitral regurgitation and left ventricular function are important determinants of long-term outcome than the etiology of valve regurgitation.