新生儿主动脉缩窄的外科治疗

目的:回顾总结新生儿主动脉缩窄(Co A)的外科治疗经验,探讨新生儿期Co A的最佳手术时机及手术方式。方法:2010年7月至2014年3月,共收治新生儿Co A 31例,男性20例,女性11例。手术年龄9~30天,平均(24.8±6.1)天,体质量2~4.1kg,平均体质量(93.2±0.7)kg。合并心内畸形者23例,合并PDA者4例,单纯Co A 4例。一期手术21例;分期手术10例,首先于非体外循环下行Co A矫治+肺动脉环缩术,随访25天~12个月后再行心内畸形矫治术。Co A矫治的方法包括:缩窄段切除行端端吻合、扩大的端端吻合或端侧吻合术、扩大的端端吻合+补片成形术、左锁骨下动脉翻转主动脉成形术。结果:1例死于出血,病死率3.2%;1例术后心肺功能较差,无法撤离呼吸机,放弃治疗;术后无肾衰竭、左上肢缺血及神经系统并发症发生。全组术毕有创动脉监测上、下肢动脉平均压差7.2mm Hg(1mm Hg=0.133k Pa)较术前39.1mm Hg明显下降(P<0.05)。结论:严重的新生儿Co A,病情危重,需早期诊断、及时治疗;对于合并心内畸形者,若导致心功能不全的主要原因为Co A、不能耐受体外循环的患儿行分期手术安全可靠;Co A合并主动脉弓发育不良者,采应扩大端端吻合或端侧吻合术可获得满意疗效。

Surgical treatment of aortic coarctation in neonates

Objective: Try to figure out the proper timing and proper procedure of choice of surgical therapy of coarctation in neonates by retrospective analysis of 31 cases in a single center. Methods: 31 cases of neonatal Co A were surgical treated from Jul. 2010 to Feb. 2013,male 20 cases,female 11 cases,mean age( 24. 8 ± 6. 1) days( 9 ~ 30d),mean body weight( 3. 2 ± 0. 7) kg( 2 ~ 4. 1kg),associated with intra-cardiac malformation in 23 cases,PDA in 4 and simple Co A in 4cases. One stage repair was perfprmed in 21 cases and staged repair performed in 10 cases. Of the 10 staged patients,Co A repair + pulmonary artery banding was done through left post-lateral thoractomy and intracardiac malformation was repaired after 25d-12 month follow up in10 patients. Surgical techniques including coarctated segment resection and end-end anastomoses,enlarged end-end or side-end anastomoses,enlarged end-end anastomoses plus aortoplasty with patch,inverted left subclavian artery aortaplasty were used in different circumstances. Results: There was one perioperative death for bleeding( the mortality was 3. 2%),one case was given up for intractable heart lung failure and unable to wean from ventilation.; no postoperative acute kidney failure and left upper extremity ischemia and Neurologic complications happened. The mean blood pressure gradient between upper and lower was reduced from 39. 1mm Hg to7. 2mm Hg postoperatively( P < 0. 05). Conclusion: Critical neonates with Co A need early diagnosis and surgical treatment. For those associated with intra-cardiac malformations,when Co A is the main factor causing heart failure and the baby is too weak to endure cardiopulmonary bypass,staged repair is the proper option. Enlarged end-end or end-side anastomosis is the proper option for Coarctation associated with hypolastic aortic arch.