中国胸心血管外科临床杂志

中国胸心血管外科临床杂志

成人左冠状动脉起源于肺动脉外科治疗

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目的 总结成人左冠状动脉起源于肺动脉的外科治疗结果及经验。 方法 1991 年 11 月至 2017 年 11 月,手术治疗 36 例年龄大于 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。

Objective To review the experience of the surgical treatment of adult patients with anomalous left coronary artery from the pulmonary artery(ALCAPA). Methods A retrospective, single institution review was conducted on thirty-six adult patients with ALCAPA surgical treatment from November 1991 to November 2017 in Fuwai Hospital. Of these patients, nine were males and twenty-seven were females. The mean age was 36.6±13.3 years. The mean weight was (60.0±9.4) kg. The preoperative echocardiography showed the mean left ventricular ejection fraction (LVEF) was 57%±6% and the mean left ventricular end-diastolic dimension (LVEDD) was 52.3±6.3 mm. Severe mitral regurgitation (MR) was seen in one patient, moderate in five patients. The operative procedures included coronary artery re-implantation in seventeen patients, Takeuchi operation in sixteen patients, ligation of left coronary artery plus coronary artery bypass graft in three patients. In addition, six patients underwent mitral valve repair. Results There was no in-hospital mortality. The mean cardiopulmonary bypass time was 152.5±72.9 min and cross clamp time was 101.9±43.6 min, respectively. The mean mechanical ventilation time and ICU time were 17.3±16.3 h and 43.1±30.7 h, respectively. The mean postoperative LVEF was 59%±6%, which did not significantly improve compared with preoperative LVEF. However, the mean postoperative LVEDD of 46.9±5.9 mm had significant reduction compared with the preoperative LVEDD. Of the six patients with mitral valve repair, one was mild and the other five were trivial. Thirty-five patients (97.2%) completed the follow up with a mean time of 5.5 years. All the patients survived with New York Heart Association class Ⅰor Ⅱ. Two patients needed interventional occlusion or re-operation due to the fistula of internal tunnel within the pulmonary artery. At the latest echocardiography, the mean LVEF of 69%±7% improved significantly compared with the preoperative LVEF. Mild MR was detected in ten patients, moderate in two patients during the follow-up period. Conclusion The surgical treatment of adult patients with ALCAPA has satisfactory short-and long-term results. The patients underwent Takeuchi procedure may need re-operation due to fistula of internal tunnel within the pulmonary artery during the long follow-up.

关键词: 左冠状动脉起源于肺动脉; Takeuchi 术; 冠状动脉再植

Key words: Anomalous left coronary artery from pulmonary artery; takeuchi procedure; coronary re-implantation

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