Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA.
J Thorac Cardiovasc Surg. 2013 Feb;145(2):455-60. doi: 10.1016/j.jtcvs.2012.11.028. Epub 2012 Dec 4.
We reviewed our experience with repair of congenital coronary artery fistulas.
From June 1983 to December 2009, 46 patients (median age, 59 years; range, 1-84 years) underwent surgical repair. The presenting symptoms included angina in 16 patients (35%), congestive heart failure in 11 (24%), and bacterial endocarditis in 5 (11%). Preoperatively, 9 patients (20%) had at least moderate tricuspid regurgitation. Coronary artery dominance was right in 38 patients (83%). Coronary artery aneurysms were found in 8 patients (17%). The most common pattern was right coronary artery-to-coronary sinus fistula (18 patients, 39%); 11 patients had (23%) more than 1 fistula. One patient had undergone previous coil embolization.
Cardiopulmonary bypass was used in 39 patients (85%), with extracardiac and intracardiac repair performed in 30 (65%) and 16 (35%), respectively. The most common associated procedures were coronary artery bypass in 13 patients (28%). Early mortality occurred in 1 patient (2%). Postoperative myocardial infarction occurred in 5 patients (11%); 4 of these patients underwent simple ligation or division of their fistulas. The mean follow-up was 6 ± 5.8 years (maximum, 22 years). Late mortality occurred in 11 patients (24%). Two patients underwent reoperation for severe tricuspid regurgitation. Survival was significantly reduced compared with the age- and gender-matched population (P = .03). Residual fistulas were detected in 3 patients (6%), with no reintervention needed.
Perioperative myocardial infarction is an important complication of ligation of coronary artery fistulas and can contribute to reduced late survival. The tricuspid valve should be evaluated carefully at repair because of the relatively high rate of residual regurgitation in survivors.
我们回顾了先天性冠状动脉瘘的修复经验。
1983 年 6 月至 2009 年 12 月，共有 46 例患者（中位年龄 59 岁；范围 1-84 岁）接受了手术修复。临床表现包括心绞痛 16 例（35%）、充血性心力衰竭 11 例（24%）和细菌性心内膜炎 5 例（11%）。术前，9 例（20%）至少有中度三尖瓣反流。冠状动脉优势为右优势型 38 例（83%）。8 例（17%）患者发现冠状动脉瘤。最常见的类型是右冠状动脉-冠状窦瘘（18 例，39%）；11 例（23%）患者有 1 个以上瘘管。1 例患者曾行线圈栓塞术。
39 例（85%）患者采用体外循环，其中 30 例（65%）行心外修复，16 例（35%）行心内修复。最常见的合并手术是 13 例（28%）患者行冠状动脉旁路移植术。1 例（2%）患者术后早期死亡。5 例（11%）患者发生术后心肌梗死；其中 4 例患者单纯结扎或切断瘘管。平均随访时间为 6±5.8 年（最长 22 年）。晚期死亡 11 例（24%）。2 例患者因严重三尖瓣反流行再次手术。与年龄和性别匹配的人群相比，生存率显著降低（P=.03）。3 例（6%）患者检测到残余瘘管，无需再次干预。
冠状动脉瘘结扎术后心肌梗死是一个重要的并发症，可导致晚期存活率降低。由于幸存者中残留反流的发生率相对较高，因此在修复时应仔细评估三尖瓣。
