Dave Hitendu Hasmukhlal, Buechel Emanuela R Valsangiacomo, Prêtre René
Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland.
Ann Thorac Surg. 2006 Jan;81(1):243-8. doi: 10.1016/j.athoracsur.2005.06.056.
This paper describes a muscle-sparing, extrapleural approach to repair aortic coarctation, and evaluates the results with established standards.
Forty consecutive patients with aortic coarctation (median age, 8 days; weight, 3.3 kg) were approached with a less invasive technique consisting of a short posterior thoracotomy, with only minimal (24 patients) or no (16 patients) division of thoracic wall muscles and a subperiosteal-extrapleural approach. Extended resection of the coarctation with enlargement of the distal aortic arch was performed in all patients. The median cross-clamp and operative times were 22 and 90 minutes, respectively.
The repair was possible in all patients without needing conversion. There was no intraoperative or postoperative related complication. Two patients died early of low cardiac output as a result of ventricular fibroelastosis and respiratory failure. One patient died late of unrelated cause. The perioperative mean gradients across the neoarch were less than 5 mm Hg in all but 3 patients with proximal (2 patients) or mid arch (1) stenosis. The median ventilation time, intensive care unit stay, and hospital stay in isolated coarctation repairs was 2, 4.5, and 11 days, respectively. One patient had a recurrent stenosis at the site of surgical repair. Two patients underwent successful balloon dilatation, and 2 had surgical enlargement plasty of the proximal aortic arch at the time of intracardiac repair. None of the patients required chronic antihypertensive medication. At 29 months, freedom from reintervention on the isthmus and arch plus isthmus was 97.1% and 89.7%, respectively.
A muscle-sparing, extrapleural approach for the repair of aortic coarctation is possible and provides results similar to conventional techniques. The approach reduces postoperative morbidity related to division of thoracic wall muscles and handling of the lung, restores a normal intercostal space, and produces superior cosmetic results, while at the same time leading to early and permanent relief of proximal hypertension.
本文描述了一种保留肌肉的胸膜外入路修复主动脉缩窄，并根据既定标准评估结果。
连续40例主动脉缩窄患者（中位年龄8天；体重3.3kg）采用一种侵入性较小的技术，包括短后外侧开胸术，仅对胸壁肌肉进行最小程度的分离（24例患者）或不分离（16例患者），采用骨膜下-胸膜外入路。所有患者均进行了主动脉缩窄的扩大切除及远端主动脉弓的扩大。中位阻断时间和手术时间分别为22分钟和90分钟。
所有患者均成功完成修复，无需中转。无术中或术后相关并发症。2例患者因心室纤维弹性组织增生和呼吸衰竭早期死于低心排血量。1例患者后期死于无关原因。除3例近端（2例）或弓中部（1例）狭窄患者外，所有患者新主动脉弓周围的围手术期平均压差均小于5mmHg。单纯主动脉缩窄修复患者的中位通气时间、重症监护病房停留时间和住院时间分别为2天、4.5天和11天。1例患者在手术修复部位出现复发性狭窄。2例患者成功进行了球囊扩张，2例患者在心脏内修复时对近端主动脉弓进行了手术扩大成形术。所有患者均无需长期服用抗高血压药物。在29个月时，峡部和弓部加峡部无需再次干预的比例分别为97.1%和89.7%。
保留肌肉的胸膜外入路修复主动脉缩窄是可行的，其结果与传统技术相似。该入路减少了与胸壁肌肉分离和肺处理相关的术后发病率，恢复了正常的肋间间隙，并产生了更好的美容效果，同时能早期且永久性地缓解近端高血压。
