Mueller Christoph, Dave Hitendu, Prêtre René
Department of Congenital Cardiovascular Surgery, University Children's Hospital Zurich, Zurich, Switzerland.
Multimed Man Cardiothorac Surg. 2012 Jan 1;2012:mms006. doi: 10.1093/mmcts/mms006.
This report presents a trans-aortic trans-infundibular double-patch repair of an aorto-left ventricular tunnel in a 17-day old male child. It reviews the literature on aorto-ventricular tunnels and debates strategic and surgical options available to correct these defects. Diagnosis of the tunnel in the case described herein was made prenatally. The child was presented with left ventricular dilatation with early and progressive signs of congestive heart failure. Decision for early surgical correction was made considering the quantum of regurgitant jet, diastolic backflow in the aorta and consequent left ventricular dilatation. After establishing cardiopulmonary bypass and arresting the heart, the aorta was transversely opened above the sinotubular junction and the tunnel identified. Aortic valve morphology and the coronary ostia not involved in the tunnel were carefully investigated. Through a transverse infundibulotomy, the thinned outer wall of the tunnel abutting the posterior wall of the infundibular septum was slit open vertically, thus clearly defining the aortic and the left ventricular orifices. The distal tunnel orifice, now presenting as a subaortic Ventricular septal defect (VSD), was closed using a xenopericardial patch and running polypropylene 7-0 stitches. The aortic end of the tunnel was closed in a similar fashion through the aortotomy, remaining clear of the right coronary artery and respecting the aortic valve geometry. The marsupialized wall of the tunnel as seen through the infundibulotomy was sutured with polypropylene stitches. The aortotomy and right ventriculotomy were closed. The postoperative course was uneventful. A follow-up echocardiography at 2 years showed a perfect outcome with no residual tunnel, no aortic stenosis and trivial aortic regurgitation.
本报告介绍了一名17日龄男童的经主动脉经漏斗部双补片修复主动脉-左心室隧道的病例。文中回顾了关于主动脉-心室隧道的文献，并探讨了纠正这些缺陷的策略和手术选择。本文所述病例的隧道在产前已确诊。该患儿出现左心室扩张，并伴有早期且进行性的充血性心力衰竭体征。考虑到反流束的大小、主动脉舒张期反流以及随之而来的左心室扩张，决定尽早进行手术矫正。建立体外循环并心脏停跳后，在窦管交界处上方横向切开主动脉，识别出隧道。仔细检查了未累及隧道的主动脉瓣形态和冠状动脉开口。通过横向漏斗部切开术，将与漏斗间隔后壁相邻的隧道变薄的外壁垂直切开，从而清晰地界定了主动脉口和左心室口。现在表现为主动脉下室间隔缺损（VSD）的隧道远端开口，用异种心包补片和7-0聚丙烯连续缝线缝合。通过主动脉切开术以类似方式封闭隧道的主动脉端，使其远离右冠状动脉并尊重主动脉瓣的几何形状。通过漏斗部切开术所见的隧道袋状化壁用聚丙烯缝线缝合。关闭主动脉切开术和右心室切开术。术后过程顺利。术后2年的超声心动图随访显示结果完美，无残余隧道、无主动脉狭窄且仅有微量主动脉反流。
