先天性冠状动脉瘘5例治疗体会

总结先天性冠状动脉瘘５例手术治疗体会。作者认为：冠状动脉瘘虽为罕见先天性心脏畸形,但手术安全,效果良好。非手术治疗远期可发生心肌缺血、心肌梗死、冠状动脉瘤破裂等并发症。故一经确诊,均宜手术治疗。手术方法以体外循环下切开瘘口所在心腔或冠状动脉缝闭瘘口为宜。冠状动脉造影可确定瘘口位置,具有确诊价值。     

冠状动脉瘘28例诊断及外科治疗

目的 总结冠状动脉瘘的诊断和手术治疗效果。方法 28例不同部位的冠状动脉瘘患者采用超声心动图和选择性冠状动脉造影,明确冠状动脉瘘发生位置,全部采用外科治疗,统计其疗效。结果 单纯冠状动脉瘘20例,合并其他心内畸形8例;右冠状动脉瘘18例,左冠状动脉瘘8例,双冠状动脉瘘2例。瘘入右心室13例,瘘入右心房12例,瘘入左心室1例,瘘入肺动脉2例。心腔内双瘘口及三个瘘口各有1例,余26例为单一瘘口。所有病例行手术治疗,8例合并其他心内畸形同期矫治。全组无死亡及残余瘘,效果满意。结论 心脏直视手术治疗冠状动脉瘘效果肯定,合并其他心内畸形应同期矫治。选择性冠状动脉造影对明确冠状动脉瘘发生位置和（或）瘘人心腔的位置非常必要。     

先天性心脏病冠状动脉瘘的介入治疗

收集近年来国内外先天性冠状动脉瘘100例介入文献与85例手术文献,分析冠状动脉瘘的类型,治疗方法及预后。冠状动脉瘘起源于左冠状动脉多见,出口多在右心。单一冠状动脉瘘可以考虑以经导管介入封堵治疗,这是创伤小,相对安全有效的治疗手段且预后良好,适宜推广。合并其他先天性畸形者或冠状动脉病变者以及介入治疗失败者考虑手术治疗。     

冠状动脉瘘的诊断及治疗方法探讨

目的探讨冠状动脉瘘(CAF)的诊断及治疗方法。方法16例冠状动脉瘘患者，经彩色多普勒超声检查14例，确诊12例，升主动脉及冠状动脉造影检查4例均确诊。16例患者均行手术治疗．其中非体外循环下行缝扎瘘口1例，体外循环下经心腔内闭合瘘口12例，切开冠状动脉闭合瘘口1例，分别闭合冠状动脉内瘘和心腔内瘘口2例；同期行冠状动脉旁路移植术1例，室间隔缺损修补1例。结果手术发现单一瘘口11例，两个瘘口5例。全组无死亡病例及并发症发生。术后随诊无残余瘘发生。结论选择性冠状动脉造影检查是诊断CAF的金标准；CAF自行闭合性小，一旦确诊，即使无症状也应及早手术治疗。手术宜在体外循环下进行，准确判断漏口位置和精确缝合是手术成功的关键。     

先天性冠状动脉畸形11例报告

报告经冠状动脉造影或手术证实的单纯性先天性冠状动脉畸形11例,约占同期580例冠状动脉造影的1.6％。本组冠状动脉畸形病变分两大类:①冠状动脉瘘8例,含右冠状动脉右室瘘6例;②冠状动脉起源异常3例。指出冠状动脉瘘需与其他先天性心脏病鉴别,心脏B超对诊断有一定的帮助,冠状动脉造影为确定诊断的重要手段;对大的冠状动脉瘘应及时手术治疗。     

超声心动图对小儿冠状动脉瘘诊治的价值

目的　探讨超声心动图对小儿冠状动脉瘘诊治的价值。方法　回顾性分析 2 1例小儿冠状动脉瘘患者。结果　右冠状动脉右心室瘘 7例 ,右心房瘘 2例 ,左心室瘘 2例 ,肺动脉瘘 1例 ;左冠状动脉右心室瘘 8例 ,右心房瘘 1例。经心血管造影和 /或手术结果证实 ,超声诊断准确率 10 0 %。结论　超声心动图能描述小儿冠状动脉瘘起源、走行、开口、瘘口数目 ,有无分支及血流动力学改变 ,能为选择治疗方案、术中监测和评定预后提供依据 ,具有重要的临床价值     

常温非体外循环下手术治疗先天性冠状动脉瘘

目的:探讨常温非体外循环下,手术治疗先天性冠状动脉瘘(congenital coronary arterial fistula,CAF)的手术方法和远期效果。方法:2001年8月至2009年8月在阜外心血管病医院行常温非体外循环下手术治疗CAF21例。全组年龄12d～60岁,平均(20.6±20.0)岁;20例为单纯的CAF,1例合并冠心病3支病变。21例中瘘口起源于右冠状动脉5例(23.8%),左冠状动脉12例(57.1%),双冠状动脉4例(19.1%);瘘口入右心房,右心室,肺动脉及左心室分别为5例(23.8%),8例(38.1%),7例(33.3%)和1例(4.8%);结果:21例均在常温非体外循环下行冠状动脉瘘结扎或褥式带垫片缝扎,其中1例同时行常温不停跳冠状动脉搭桥术,无手术死亡。术后残余瘘1例,其余术后无心肌缺血及残余瘘等并发症。19例随访0.5～5.5年,平均(2.1±1.7)年,无远期死亡。1例残余瘘,其余无心肌缺血及残余瘘等并发症。结论:常温非体外循环下手术治疗CAF安全、有效,远期效果良好。     

彩色多普勒超声诊断先天性冠状动脉瘘的应用

目的探讨彩色多普勒在诊断先天性冠状动脉瘘(CAF)中的价值。方法应用彩色多普勒对12例超声诊断冠状动脉瘘的患者进行检查分析。结果 12例冠状动脉瘘患者全部经升主动脉及选择性冠状动脉造影检查证实,其中3例接受手术治疗。按冠状动脉来源分组,右冠状动脉来源7例,左冠状动脉来源5例;按冠状动脉瘘开口位置分,右心室瘘5例,右心房瘘2例,肺动脉瘘3例,左心室瘘2例。结论彩色多普勒对开口于心腔及肺动脉内的先天性冠状动脉瘘具有特征性的表现对诊断有应用价值。     

右后外侧小切口剖胸治疗冠状动脉右心室和/或右心房瘘

目的:总结经右外侧腋下小切口入胸体外循环辅助直视下治疗冠状动脉右心室右心房瘘的手术经验及效果。方法:选取本院2002年1月至2018年12月,行冠状动脉右心室和/或右心房瘘矫治术患儿31例,其中经胸骨正中开胸完成手术矫治的患儿16例(正中组),男性9例,女性7例,中位年龄11.8个月(6～32)个月,中位体质量12.7 kg(7.5～29 kg)。其中右冠状动脉右心室瘘9例,左冠状动脉右心室瘘5例,右冠状动脉右心房瘘2例;经右外侧小切口剖胸(右侧组)行手术矫治的患儿15例,男性9例,女性6例。中位年龄10.8个月(5～28个月),中位体质量11.6 kg(5.6～18)kg。右冠状动脉右心室瘘9例,左冠状动脉右心室瘘4例,右冠状动脉右心房瘘2例。均在全身麻醉体外循环辅助下完成冠状动脉右心室和/或右心房瘘矫治术。结果:右侧组术后无死亡。术后残余瘘2例。正中死亡1例,死于低心排出量综合征(低心排);术后残余瘘2例。右侧组手术时间、切口长度、ICU停留时间、术后引流量、术后输血量、术后呼吸机辅助时间以及住院时间都显著低于正中组;主动脉阻断时间差异无统计学意义。随访3～38个月,心脏功能恢复良好。结论:经右侧腋下小切口直视下行冠状动脉右心室右心房瘘矫治手术,手术安全可靠,术野清晰,创伤小,术后恢复良好。     

先天性冠状动脉瘘早中期手术疗效分析

目的:探讨先天性冠状动脉瘘手术治疗的最佳时机、方法及疗效,努力提高手术成功率。方法:我院2013年10月-2019年10月共收治19例冠状动脉瘘患者,其中男11例,女8例,年龄4.5(1～61)岁,体重16.25(7～69) kg。右冠状动脉右房瘘3例,右冠状动脉右室瘘7例,右冠状动脉左室瘘1例,左冠状动脉右房瘘2例,左冠状动脉左房瘘2例,左冠状动脉右室瘘2例,左冠状动脉肺动脉瘘2例;合并先天性二尖瓣发育不良2例,房间隔缺损、室间隔缺损、卵圆孔未闭、三尖瓣关闭不全各1例。所有患者均胸正中切口体外循环下行动脉瘘矫治术,同期矫治其他心脏畸形,围术期常规监护治疗,术后1、6个月及每年随访复查。对所有患者临床资料进行统计、分析及总结。结果:升主动脉阻断时间(61.330±11.479) min,体外循环时间(99.940±15.206) min,手术时间(140.610±19.150) min,呼吸机使用时间(33.000±19.275) h,ICU时间(2.220±1.215) d,住院时间(20.940±8.795) d。患者术前左室射血分数(63.167±8.031)%,术后当日左室射血分数(69.390±8.389)%,术后左室功能明显改善(P0.05)。患者术前心胸比0.506±0.0769,术后当日心胸比0.479±0.060 3,手术前后心胸比差异显著(P0.05)。19例患者围手术期无严重并发症及死亡,均痊愈出院。术后随访6个月～5年,未见残余瘘及严重心血管症状。结论:冠状动脉瘘发病率低,出现心悸、呼吸困难等症状应尽早手术治疗,外科手术治疗疗效较好,并发症少。     

少见冠状动脉畸形18例

目的 :探讨 18例少见冠状动脉 (冠脉 )畸形特征及评价选择性冠脉造影在其诊断中的作用。方法 :对17例患者进行冠脉造影 ,13例患者进行手术纠正治疗。另 1例二维超声心动图误诊为动脉导管未闭 ,术中证实为右冠脉 -右室瘘。结果 :18例患者中共发现有 9种冠脉畸形 ,包括冠脉起源异常 2例 ;左冠脉回旋支缺如 1例 ;左、右冠脉 -肺动脉瘘 3例 ;左冠脉 -肺动脉瘘 3例 ;右冠脉 -右心房瘘 3例 ;右冠脉 -右室瘘 2例 ;右冠脉 -静脉瘘 1例 ;左冠脉 -右室瘘 1例 ;左冠脉 -左心室瘘 2例。其中 13例患者经手术治疗得到再证实。结论 :冠脉畸形是少见的先天性血管畸形 ,选择性冠脉造影是确诊的重要手段 ,需与先天性心脏病和冠心病心绞痛鉴别 ,术后效果良好。     

Acquired coronary artery fistula after open heart surgery for congenital heart disease

BACKGROUND: Most coronary artery fistulas were reported as congenital. Acquired coronary artery fistula occurring after cardiac surgery has rarely been reported. METHODS: From 1998 to 2003, 10 patients with coronary artery fistula detected by echocardiography after open heart surgery for congenital heart disease were included. Their ages ranged from 2 months to 41 years (median 4.2 years). The underlying heart disease was tetralogy of Fallot in five patients, ventricular septal defect in three, double chamber right ventricle in one, and transposition of the great arteries with ventricular septal defect in the remaining one. RESULTS: Of these 10 patients, the coronary artery fistula originated from the left coronary artery in four, right coronary artery in two, and unknown origin in the remaining four. The coronary artery fistula drained into the right ventricle in nine and into the left ventricle in the remaining one. The incidence of acquired coronary artery fistula after open heart surgery for congenital heart disease was 0.44% (8/1832). The identified risk factors for acquired coronary artery fistula were reoperation and right ventricular muscle resection in ventricular septal defect. After follow-up for 0.5-12 years (mean 4.1+/-3.3 years), the coronary artery fistula persisted, but neither symptoms nor significant left-to-right shunt was noted. CONCLUSIONS: Acquired coronary artery fistula is a rare complication after cardiac surgery. Reoperation and resection of right ventricular hypertrophic muscle increase the risk of this complication. Although shunt flow did not increase during follow-up, the significance of acquired coronary artery fistula needs further investigation.     

E-Flow血流显像技术对胎儿冠状动脉瘘的诊断价值

目的探讨E-Flow血流显像技术对胎儿冠状动脉瘘的诊断价值。方法在胎儿超声心动图检查中除使用常规彩色多普勒外加用了E-Flow血流显像技术,产前诊断冠状动脉瘘5例。使用Alokaα10彩色超声诊断仪,探头频率为3.5～5.0 MHz。对二维超声(2D)发现胎儿一侧心房、心室异常增大或冠状动脉增粗的患者,进一步探查冠状动脉。先以彩色多普勒超声(CDFI)获取心腔内异常血流,再以连续多普勒(CW)获取舒张期为主的高速血流频谱,初步证实该异常血流来自于冠状动脉。此时启动E-Flow显像模式追溯该异常血流。结果 5例胎儿冠状动脉瘘均出生后经超声证实。其中2例为左冠状动脉右心室瘘、1例为左冠状动脉右心房瘘,1例为右冠状动脉右心房瘘,1例为右冠状动脉右心室瘘。E-Flow显像技术能够敏感地捕捉冠状动脉瘘血流,清晰显示冠状动脉瘘的起源、瘘管的走行以及瘘口的位置、大小,其血流显像优于传统的彩色多普勒。结论应用E-Flow显像技术可以在产前更加准确、快速地诊断胎儿冠状动脉瘘。推荐E-Flow血流显像技术成为胎儿冠状动脉瘘的诊断工具之一。     

经导管介入治疗冠状动脉瘘

目的：探讨经导管介入治疗冠状动脉瘘的方法及临床疗效。方法：经导管堵塞冠状动脉瘘14例，平均年龄7．1岁。结果：13例应用弹簧圈堵塞，平均瘘口大小为3．65mm，除3例失败外均获成功；1例（瘘口6．6mm）应用Amplatzer动脉导管未闭堵塞器堵塞成功。所有病例随访1个月－4年，均无残余分流及任何并发症。结论：经导管介入治疗冠状动脉瘘具有良好的临床疗效及安全性。可控弹簧圈一般用于堵塞瘘口较小的冠状动脉瘘，而瘘口较大的冠状动脉瘘可选用Amplatzer动脉导管未闭堵塞器。     

Noninvasive diagnosis of coronary artery fistula by Doppler color flow mapping

Sixteen patients with coronary artery fistula proved by coronary angiography or surgery were studied using two-dimensional echocardiography and Doppler color flow mapping. The coronary artery fistula drained into the right atrium in 4 patients, the right ventricle in 2 and the pulmonary artery in 10. The dilated coronary artery was visualized in 7 of the 16 patients with a fistula, as compared with none of the 40 control subjects. These 7 patients included 5 of 6 patients with a fistula draining into the right atrium or right ventricle and only 2 of 10 patients with a fistula draining into the pulmonary artery. Abnormal flow signals in the dilated coronary artery were visualized with Doppler color flow mapping in five of these seven patients. Color flow imaging visualized abnormal flow signals with mosaic appearance in the pulmonary artery in eight patients, the right atrium in four and the right ventricle in two. The chamber in which abnormal signals were detected corresponded with the entry site of the fistula by angiography. Intraoperative imaging during surgical repair was needed in two cases to confirm ligation of all arteries feeding into the fistula network. In conclusion, Doppler color flow imaging is diagnostically useful to visualize shunt flows originating from the opening or exit of a coronary artery fistula. Furthermore, intraoperative use of this technique may provide confirmation of successful surgical ligation of the fistula.     

Recognition of abnormal connections of coronary arteries with the use of Doppler color flow mapping

Anomalous connection of a coronary artery to a ventricle or pulmonary artery causes shunting of blood from the coronary circuit and may produce myocardial ischemia. Such a coronary anomaly may occur in isolation or with other defects. Doppler color flow mapping and two-dimensional echocardiography were used to diagnose anomalous coronary connections in 13 patients, 1 day to 7 years of age, over a 1 year period. The diagnoses were anomalous origin of the left coronary artery from the pulmonary trunk in five patients, a coronary artery to left ventricle fistula or coronary artery to pulmonary artery fistula in four patients with other complex defects, right ventricular sinusoids in two patients with pulmonary atresia and intact ventricular septum and an isolated coronary artery fistula in two patients. In all cases, the abnormal coronary connection was recognized on the basis of an abnormal, continuous or to and fro flow pattern in the fistula and its connections as demonstrated by scanning in multiple views with Doppler color flow mapping. The low spatial resolution of Doppler color flow mapping limits the anatomic detail available; nonetheless, it is a significant advance in the noninvasive diagnosis of abnormal coronary connections.     

Clinical evaluation of coronary artery fistula and coronary artery-cardiac chamber shunt

Coronary artery fistula and coronary artery-cardiac chamber shunts were observed in 16 cases out of 462 consecutive cases in which coronary angiography was performed. 9 of these cases had coronary artery fistula, 5 of the cases had coronary artery-cardiac chamber shunts. 2 cases had both of these conditions. Coronary artery fistula has a draining vein originating from the coronary artery and an entering vein terminating in the cardiac chamber or the pulmonary artery. Coronary artery-cardiac chamber shunts have no such veins, and contrast material used in the injection phase of coronary angiography escapes directly into the cardiac chamber. 2 cases of coronary artery fistula, 2 cases of coronary artery-cardiac chamber shunts, and 1 case involving the both of these conditions showed positive results in submaximal exercise tolerance tests, and no significant arteriosclerotic changes in the coronary artery. These factors lead us to suggest that coronary artery-cardiac chamber shunts cause cardiac ischemia for the same reason that coronary artery fistula does.     

经导管弹簧圈栓堵法治疗先天性冠状动脉瘘

目的　探讨经导管弹簧圈栓堵冠状动脉瘘的安全性和有效性。方法　总结我院 1999年 5月至 2 0 0 2年 12月 6例 38～ 70岁 (平均年龄 5 0 7岁 )的先天性冠状动脉瘘进行栓堵治疗的患者 ,其中冠状动脉瘘由左冠状动脉至肺动脉 2例、右冠状动脉至肺动脉 2例、右冠状动脉至右下肺静脉及双侧冠状动脉至肺动脉各 1例。结果　 5例 (83 3% )栓堵后完全闭合 ;1例因瘘管迂曲 ,导管到位困难而放弃介入治疗。无手术死亡及并发症。 5例患者经体检和超声心动图随访 3～ 4 6个月 ,无残余瘘 ,无复发。结论　经导管弹簧圈栓堵先天性冠状动脉瘘不用开胸 ,病人易接受 ,安全、有效、方便 ,可作为治疗冠状动脉瘘的一种方法。     

Right coronary artery fistula to left ventricle complicated with huge coronary artery aneurysm

Congenital coronary artery fistula (CAF) with huge coronary artery aneurysm is a very rare condition. In this paper, we describe a 26-year-old asymptomatic male patient with right coronary artery (RCA) to the left ventricle fistula with a huge coronary artery aneurysm which was diagnosed by multidetector computed tomography and coronary angiography. The patient received surgical treatment for coronary artery after diagnosis. Both RCA and a giant aneurysm were excised; surgical closure of CAF and coronary artery bypass grafting were performed on this patient. Two months after surgery, the enlarged left ventricle returned to normal as evaluated by echocardiography.     

Coronary artery fistula in children and adults: a review of 25 cases with long-term observations

We studied 25 patients with coronary artery fistula between 1976 and 1994. Age ranged from 1 to 58 years. Twelve patients were symptomatic; seven had dyspnoea, four had angina, one had palpitation and one had syncope. Coronary artery fistula involved right coronary artery in 10, left coronary artery in 11 and both right and left coronary arteries in four. Coronary artery fistula drained into right ventricle in 11, right atrium in nine, pulmonary artery in four and left ventricle in two. The Qp/Qs ranged from 1.0 to 2.6 with a mean of 1.39±0.38. Five patients had associated cardiac anomalies. Two had atrial septal defects, one had patent ductus arteriosus, one had atresia of proximal right coronary artery and in one patient, the right coronary artery was arising from left coronary artery. Five patients underwent surgery without any operative mortality. Thirteen patients were followed-up medically for a mean period of 6.1±5.1 years. There were no complications related to coronary artery fistula during follow-up. In one patient coronary artery fistula closed spontaneously.