Turley K, Bove E L, Amato J J, Iannettoni M, Yeh J, Cotroneo J V, Galdieri R J
Department of Cardiothoracic Surgery, University of California, San Francisco 94143-0118.
J Thorac Cardiovasc Surg. 1990 Apr;99(4):679-83; discussion 683-4.
Aortic stenosis in the neonate has been associated in the past with a high operative mortality. As a result, in the current era of percutaneous balloon dilatation, the optimal mode of therapy remains controversial. An approach of stabilization with cardiopulmonary bypass, followed by relief of left ventricular outflow tract obstruction, was used at three institutions, and the results are presented. During the period 1983 to 1989, 40 neonates with isolated aortic stenosis and patent ductus arteriosus or coarctation of the aorta, or both, underwent operative therapy. Ages ranged from 1 to 30 days, median of 12 days, including 17 patients in the first week of life. There were 30 boys and 10 girls; weights ranged from 2.5 to 5.5 kg with a mean of 3.6 kg. Perioperative conditions included congestive heart failure in 38 and mitral regurgitation in 16; left ventricular-aortic gradients ranged from 15 to 130 mm Hg, with a mean of 67 mm Hg. There were 30 open valvotomies and 10 transventricular dilatations. The hospital survival rate was 87.5% (35/40) with no significant difference between the methods of valvotomy (9/10 in the transventricular dilatation group, 90%; 26/30 in the open valvotomy group, 87%). Although multiple methods of perfusion and valvotomy were used, the single unifying factor of cardiopulmonary bypass stabilization was present in all 40 patients. No significant difference in survival was noted between institutions, methods of cardiopulmonary bypass, cardiopulmonary bypass times, crossclamp times, or method of valvotomy. There have been five reoperations, with one late death in a patient requiring mitral valve replacement and an apical-aortic conduit. One sudden death occurred; autopsy revealed endocardial fibroelastosis. Results demonstrate that in the three institutions using the methods described, a high operative and late survival rate is possible. The results of this technique, against which percutaneous dilatation should be compared, are standard in the current era.
过去，新生儿主动脉狭窄一直与较高的手术死亡率相关。因此，在当前经皮球囊扩张的时代，最佳治疗方式仍存在争议。本文介绍了三家机构采用的一种先通过体外循环稳定病情，然后解除左心室流出道梗阻的治疗方法及结果。在1983年至1989年期间，40例患有孤立性主动脉狭窄并伴有动脉导管未闭或主动脉缩窄，或两者皆有的新生儿接受了手术治疗。年龄范围为1至30天，中位数为12天，其中17例在出生第一周。男30例，女10例；体重范围为2.5至5.5千克，平均为3.6千克。围手术期情况包括38例充血性心力衰竭和16例二尖瓣反流；左心室 - 主动脉压差范围为15至130毫米汞柱，平均为67毫米汞柱。进行了30例直视瓣膜切开术和10例经心室扩张术。医院生存率为87.5%（35/40），瓣膜切开术方法之间无显著差异（经心室扩张组9/10，90%；直视瓣膜切开术组26/30，87%）。尽管使用了多种灌注和瓣膜切开术方法，但所有40例患者都采用了体外循环稳定这一统一因素。各机构之间、体外循环方法、体外循环时间、阻断时间或瓣膜切开术方法在生存率方面均未发现显著差异。有5例再次手术，1例晚期死亡患者需要二尖瓣置换和心尖 - 主动脉管道。发生了1例猝死；尸检显示为心内膜弹力纤维增生症。结果表明，在采用所述方法的三家机构中，较高的手术生存率和晚期生存率是可能的。在当前时代，应将经皮扩张与之比较的这项技术的结果是标准的。
