McElhinney D B, Yang S G, Hogarty A N, Rychik J, Gleason M M, Zachary C H, Rome J J, Karl T R, Decampli W M, Spray T L, Gaynor J W
Division of Pediatric Cardiothoracic Surgery, The Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, USA.
J Thorac Cardiovasc Surg. 2001 Nov;122(5):883-90. doi: 10.1067/mtc.2001.116316.
Repair of aortic coarctation is often delayed in small infants because of the belief that such patients are at risk of recurrent arch obstruction and that growth will decrease this risk. To determine whether low weight was a risk factor for recurrent arch obstruction, we reviewed our experience with coarctation repair via left thoracotomy in infants less than 3 months of age.
From 1990 to 1999, 103 patients less than 3 months of age underwent repair of aortic coarctation through a left thoracotomy. Median age was 18 days (1-90 days), with 45 patients less than 2 weeks. Median weight was 3.3 kg (1.0-6.4 kg) and 14 patients were less than 2 kg. The method of repair was resection and end-to-end anastomosis in 64 patients, subclavian flap angioplasty in 34, and patch augmentation of the arch in 5. Demographic, echocardiographic, and operative variables were analyzed for correlation with recurrent arch obstruction.
One early and 1 late death occurred, both in patients who had complications but no evidence of recoarctation. At median follow-up of 24 months, reinterventions for recurrent arch obstruction were performed in 15 patients. The median time to reintervention was 5 months and was less than 1 year in 12 patients. Kaplan-Meier freedom from arch reintervention was 88% at 1 year (95% confidence intervals: 82%-94%) and 82% at 5 years (95% confidence intervals: 72%-92%). Factors associated with shorter duration to arch reintervention by univariable Cox regression included younger age (continuous, P =.01; <2 weeks, P =.005), smaller transverse arch (absolute diameter, P <.001; indexed to weight, P =.03; indexed to ascending aortic diameter, P =.02), and smaller ascending aorta (absolute diameter, P =.02). Smaller absolute transverse arch diameter and younger age were the only independent predictors of shorter time to arch reintervention by multivariable Cox regression analysis. Weight and type of repair did not correlate with risk of recoarctation.
Low weight is not a risk factor for recurrent obstruction after repair of coarctation of the aorta in infants less than 3 months of age. Rather, risk of recoarctation is more a function of the anatomy of the arch. Thus, it is not indicated to delay repair in low weight infants with the goal of achieving growth.
由于认为小婴儿行主动脉缩窄修复术后有复发主动脉弓梗阻的风险，且生长可降低此风险，故主动脉缩窄修复术常在小婴儿中延迟进行。为确定低体重是否为复发主动脉弓梗阻的危险因素，我们回顾了小于3个月婴儿经左胸切口行缩窄修复术的经验。
1990年至1999年，103例小于3个月的婴儿经左胸切口行主动脉缩窄修复术。中位年龄为18天（1 - 90天），45例小于2周。中位体重为3.3 kg（1.0 - 6.4 kg），14例小于2 kg。64例行切除端端吻合修复，34例行锁骨下动脉瓣血管成形术，5例行主动脉弓补片扩大术。分析人口统计学、超声心动图及手术变量与复发主动脉弓梗阻的相关性。
发生1例早期死亡和1例晚期死亡，均为有并发症但无再缩窄证据的患者。中位随访24个月时，15例患者因复发主动脉弓梗阻接受再次干预。再次干预的中位时间为5个月，12例患者在1年内。1年时无主动脉弓再次干预的Kaplan - Meier生存率为88%（95%可信区间：82% - 94%），5年时为82%（95%可信区间：72% - 92%）。单变量Cox回归分析显示，与主动脉弓再次干预时间较短相关的因素包括年龄较小（连续变量，P = 0.01；<2周，P = 0.005）、主动脉弓横径较小（绝对直径，P < 0.001；与体重指数化，P = 0.03；与升主动脉直径指数化，P = 0.02）及升主动脉较小（绝对直径，P = 0.02）。多变量Cox回归分析显示，较小的主动脉弓横径绝对直径和较小年龄是主动脉弓再次干预时间较短的唯一独立预测因素。体重和修复方式与再缩窄风险无关。
小于3个月婴儿主动脉缩窄修复术后，低体重不是复发梗阻的危险因素。相反，再缩窄风险更多取决于主动脉弓的解剖结构。因此，以生长为目的延迟低体重婴儿的修复术并无必要。
