Nassar Mohamed S, Bertaud Sophie, Goreczny Sebastian, Greil Gerald, Austin Conal B, Salih Caner, Anderson David, Hussain Tarique
Department of Cardiology and Cardiac Surgery, Evelina London Children Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK Department of Cardiothoracic Surgery, Alexandria University, Alexandria, Egypt
Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.
Interact Cardiovasc Thorac Surg. 2015 May;20(5):631-5. doi: 10.1093/icvts/ivv002. Epub 2015 Feb 13.
Branch pulmonary artery (BPA) size is one of the factors that influence the efficacy of the Fontan circulation. Central pulmonary artery stenosis and small left pulmonary artery (LPA) are well-known problems following Norwood palliation for hypoplastic left heart syndrome (HLHS). We investigated anatomical and technical factors that may stand behind these problems.
A total of 47 consecutive patients were included in the study. All had complete magnetic resonance imaging (MRI) study pre-second-stage palliation. Measurements were taken using a first-pass 3D angiography technique after intravenous injection of an extravascular contrast agent. Factors investigated included the following: size and site of the pulmonary artery bifurcation stump in relation to the Damus-Kaye-Stansel (DKS) anastomosis, interaortic distance/ratio (neoaorta to descending aorta distance/antero-posterior dimension of the chest) (IAD/IAR), distance from the under surface of the arch and the size of native aorta and pulmonary artery. IAD/IAR were compared between two different arch reconstruction techniques.
Stenosis occurred either centrally, at the origin of the BPA, or more distally, in the mid-LPA (posterior to DKS). There was a significant lower incidence of central BPA stenosis when the pulmonary artery stump was placed in the mid-position compared with right/left position (26 vs 67%; P = 0.011). A more bulky pulmonary artery stump was also found in those patients with central BPA stenosis (186 vs 137 mm(2)/m(2); P = 0.047). The mid-LPA consistently showed antero-posterior compression (mean cranio-caudal diameter 3.82 mm vs mean antero-posterior diameter 3.07 mm, P < 0.001). Indexed mid-LPA area was only correlated with IAD/IAR (r = 0.49 and 0.51, P < 0.001). No correlation was shown with the distance to the under surface of the arch (r = 0.14, P = 0.37), again confirming antero-posterior compression of the LPA rather than cranio-caudal. In multivariable analysis, the only predictor of indexed mid-LPA area was the IAR (P < 0.001). There was no significant difference in the IAD or IAR between the two arch reconstruction techniques [mean IAD 15.5 vs 13.5 mm (P = 0.14)]; [mean IAR 0.17 vs 0.19 (P = 0.21)].
Of all studied factors, IAR and the size and position of the pulmonary artery bifurcation plays the main role in LPA growth and central BPA stenosis.
肺分支动脉（BPA）大小是影响Fontan循环疗效的因素之一。中央肺动脉狭窄和左肺动脉（LPA）细小是左心发育不全综合征（HLHS）诺伍德姑息手术后众所周知的问题。我们研究了这些问题背后可能存在的解剖学和技术因素。
本研究共纳入47例连续患者。所有患者在二期姑息手术前均进行了完整的磁共振成像（MRI）检查。静脉注射血管外造影剂后，采用首过三维血管造影技术进行测量。研究的因素包括：肺动脉分叉残端相对于达姆斯-凯-斯坦塞尔（DKS）吻合口的大小和位置、主动脉间距/比率（新主动脉至降主动脉距离/胸廓前后径）（IAD/IAR）、距主动脉弓下表面的距离以及天然主动脉和肺动脉的大小。比较了两种不同的主动脉弓重建技术之间的IAD/IAR。
狭窄发生在中央，即BPA起源处，或更远处，在LPA中部（DKS后方）。与右/左位置相比，当肺动脉残端置于中间位置时，中央BPA狭窄的发生率显著降低（26%对67%；P = 0.011）。在中央BPA狭窄的患者中也发现肺动脉残端更粗大（186对137 mm²/m²；P = 0.047）。LPA中部始终显示前后径受压（平均头尾径3.82 mm对平均前后径3.07 mm，P < 0.001）。LPA中部索引面积仅与IAD/IAR相关（r = 0.49和0.51，P < 0.001）。与距主动脉弓下表面的距离无相关性（r = 0.14，P = 0.37），再次证实LPA存在前后径受压而非头尾径受压。在多变量分析中，LPA中部索引面积的唯一预测因素是IAR（P < 0.001）。两种主动脉弓重建技术之间的IAD或IAR无显著差异[平均IAD 15.5对13.5 mm（P = 0.14）]；[平均IAR 0.17对0.19（P = 0.21）]。
在所有研究因素中，IAR以及肺动脉分叉的大小和位置在LPA生长和中央BPA狭窄中起主要作用。
Zotero 插件