Bautista-Hernandez Victor, Marx Gerald R, Gauvreau Kimberlee, Pigula Frank A, Bacha Emile A, Mayer John E, del Nido Pedro J
Department of Cardiac Surgery, Children's Hospital Boston, Harvard Medical School, Boston, Mass 02115, USA.
J Thorac Cardiovasc Surg. 2007 Jun;133(6):1540-6. doi: 10.1016/j.jtcvs.2006.12.067. Epub 2007 Apr 27.
Neoaortic arch obstruction after stage I palliation is an important risk factor affecting interstage mortality in patients with hypoplastic left heart syndrome, with no accepted standard surgical approach. We sought to determine the efficacy of different techniques for aortic arch reconstruction to reduce the incidence of postoperative neoaortic arch obstruction.
From January 2000 through June 2005, 210 patients underwent stage I palliation. To enlarge the aortic arch, 12 (6%) patients had a direct connection, 115 (55%) patients had an aortic homograft, 53 (25%) patients had a pulmonary homograft patch, and 30 (14%) patients had autologous pericardium. Independent of the technique for aortic enlargement, 55 (26%) children had coarctectomy.
Eighty patients had a significant arch gradient, as determined by means of echocardiography, and of these, 50 required balloon angioplasty, surgical arch augmentation, or both. Preoperative aortic coarctation was consistently linked to neoaortic arch obstruction (P = .032). Patients having aortic arch enlargement by means of direct connection or with autologous pericardium were less likely to have neoaortic arch obstruction (P = .049). Coarctectomy resulted in a lower incidence of neoaortic arch obstruction, as determined by means of echocardiography (P = .015), or need for reintervention (P = .01).
Patients with hypoplastic left heart syndrome undergoing aortic arch enlargement with autologous tissue are less likely to require intervention for neoaortic arch obstruction compared with those having homograft patch reconstruction. Excision of all ductal tissue by means of coarctectomy reduces the risk of recurrent aortic arch obstruction. An aggressive approach to reconstruction of the arch and the use of autologous tissue at the time of stage I palliation is advocated.
一期姑息治疗后新主动脉弓梗阻是影响左心发育不全综合征患者过渡期死亡率的重要危险因素,目前尚无公认的标准手术方法。我们试图确定不同主动脉弓重建技术减少术后新主动脉弓梗阻发生率的疗效。
2000年1月至2005年6月,210例患者接受了一期姑息治疗。为扩大主动脉弓,12例(6%)患者采用直接连接,115例(55%)患者采用主动脉同种异体移植物,53例(25%)患者采用肺动脉同种异体移植物补片,30例(14%)患者采用自体心包。无论主动脉扩大技术如何,55例(26%)儿童接受了缩窄切除术。
通过超声心动图确定,80例患者有明显的弓部压差,其中50例需要球囊血管成形术、手术性弓部扩大或两者兼用。术前主动脉缩窄与新主动脉弓梗阻始终相关(P = 0.032)。采用直接连接或自体心包进行主动脉弓扩大的患者发生新主动脉弓梗阻的可能性较小(P = 0.049)。通过超声心动图(P = 0.015)或再次干预需求(P = 0.01)确定,缩窄切除术导致新主动脉弓梗阻的发生率较低。
与同种异体移植物补片重建的患者相比,接受自体组织主动脉弓扩大的左心发育不全综合征患者因新主动脉弓梗阻而需要干预的可能性较小。通过缩窄切除术切除所有导管组织可降低复发性主动脉弓梗阻的风险。提倡在一期姑息治疗时积极进行弓部重建并使用自体组织。