Department of Cardiothoracic Surgery, Our Lady's Childrens Hospital, Crumlin, Dublin, Ireland.
Ann Thorac Surg. 2010 Dec;90(6):2023-7. doi: 10.1016/j.athoracsur.2010.06.130.
Balloon angioplasty for infant coarctation is associated with a high recurrence rate, making operative repair the gold standard for low-risk infants. Debate exists as to whether high-risk infants might be better served with primary angioplasty. We compared the outcome in high-risk versus low-risk infants over 20 years, in a center that always used surgical repair as the primary intervention.
Of 192 infants from 1986 to 2005, 56 were considered "high-risk," defined as requiring prostaglandin infusion together with either epinephrine infusion for 24 hours preoperatively, or ventilation and milrinone infusion for 24 hours preoperatively. All high-risk patients had a period of ventricular dysfunction prior to surgery, ranging from mild to severe. Outcomes were compared using Bonferroni comparison of means or the Fischer exact test as appropriate.
Although the high-risk patients were smaller (3.3 ± 0.1 vs 4.2 ± 0.2 kg, p < 0.01), younger (18 ± 4 vs 57 ± 7 days, p < 0.01), and more often required a concomitant pulmonary artery band (25% vs 15%, p = 0.05), their cross-clamp times were the same as the low-risk patients (18.9 ± 0.9 vs 18.0 ± 0.4 minutes, p = 0.27) and there was no difference in postoperative morbidity (7% vs 3%, p = 0.11). However, there was a trend toward higher perioperative mortality (7% vs 2%, p = 0.07). When compared with the published studies of primary angioplasty in comparable high-risk infants, the mortality rate in our surgically treated high-risk group is much lower. Additionally, only 11% of our high-risk group required reintervention, with two-thirds treated successfully with a single angioplasty at 3.8 ± 2.2 years later, far lower than recurrence rates with primary angioplasty.
We propose that primary surgical repair of coarctation in infants who are high risk should be the primary treatment, with angioplasty reserved for recurrent coarctation.
球囊血管成形术治疗婴儿缩窄性心脏病的复发率较高，因此手术修复是低危婴儿的金标准。对于高危婴儿，是否应首选血管成形术仍存在争议。本研究比较了 20 年来，同一中心采用手术修复作为主要干预手段时，高危婴儿与低危婴儿的治疗结果。
1986 年至 2005 年间，共有 192 例婴儿接受了治疗，其中 56 例被认为是“高危”，定义为需要前列腺素输注，并在术前 24 小时内给予肾上腺素输注，或术前 24 小时给予通气和米力农输注。所有高危患者在手术前均有一段时间的心室功能障碍，从轻度到重度不等。使用均值的 Bonferroni 比较或适当的 Fisher 精确检验比较结果。
尽管高危患者的体重较小（3.3 ± 0.1 比 4.2 ± 0.2kg，p < 0.01）、年龄较小（18 ± 4 比 57 ± 7 天，p < 0.01），且更常需要同时进行肺动脉带（25%比 15%，p = 0.05），但其体外循环夹闭时间与低危患者相同（18.9 ± 0.9 比 18.0 ± 0.4 分钟，p = 0.27），术后发病率也无差异（7%比 3%，p = 0.11）。然而，围手术期死亡率有升高的趋势（7%比 2%，p = 0.07）。与类似高危婴儿的血管成形术的已发表研究相比，我们手术治疗的高危组的死亡率要低得多。此外，我们组中仅 11%的高危患者需要再次介入治疗，其中三分之二的患者在 3.8 ± 2.2 年后成功接受单次血管成形术治疗，远低于血管成形术的复发率。
我们建议高危婴儿首选手术修复缩窄性心脏病，仅对复发性缩窄性心脏病保留血管成形术治疗。
