Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif.
Department of Cardiovascular Medicine, Stanford University, Stanford, Calif.
J Thorac Cardiovasc Surg. 2018 Oct;156(4):1618-1626. doi: 10.1016/j.jtcvs.2018.01.081. Epub 2018 Jun 9.
Although myocardial bridges (MBs) are traditionally regarded as incidental findings, it has been reported that adult patients with symptomatic MBs refractory to medical therapy benefit from unroofing. However, there is limited literature in the pediatric population. The aim of our study was to evaluate the indications and outcomes for unroofing in pediatric patients.
We retrospectively reviewed all pediatric patients with MB in our institution who underwent surgical relief. Clinical characteristics, relevant diagnostic data, intraoperative findings, and postoperative outcomes were evaluated.
Between 2012 and 2016, 14 pediatric patients underwent surgical unroofing of left anterior descending artery MBs. Thirteen patients had anginal symptoms refractory to medical therapy, and 1 patient was asymptomatic until experiencing aborted sudden cardiac arrest during exercise. Thirteen patients underwent exercise stress echocardiography, all of which showed mid-septal dys-synergy. Coronary computed tomography imaging confirmed the presence of MBs in all patients. Intravascular ultrasound imaging confirmed the length of MBs: 28.2 ± 16.3 mm, halo thickness: 0.59 ± 0.24 mm, and compression of left anterior descending artery at resting heart rate: 33.0 ± 11.6%. Invasive hemodynamic assessment with dobutamine confirmed the physiologic significance of the MBs with diastolic fractional flow reserve: 0.59 ± 0.13. Unroofing was performed with the patient under cardiopulmonary bypass (CPB) in the initial 9 cases and without CPB in the subsequent 5 cases. All patients were discharged without complications. The 13 symptomatic patients reported resolution of symptoms on follow-up, and improvement in symptoms and quality of life was documented using the Seattle Angina Questionnaire version 7.
Unroofing of MBs can be safely performed in pediatric patients, with or without use of CPB. In symptomatic patients, unroofing can provide relief of symptoms refractory to medical therapy.
尽管心肌桥（MB）传统上被认为是偶发发现，但已有报道称，对药物治疗有反应的成年症状性 MB 患者受益于去顶。然而，儿科人群中的文献有限。我们研究的目的是评估小儿 MB 去顶的适应证和结果。
我们回顾性分析了我院所有接受手术减压的 MB 患儿。评估了临床特征、相关诊断数据、术中发现和术后结果。
2012 年至 2016 年期间，14 例小儿左前降支 MB 患者接受了手术去顶。13 例患者有药物治疗无效的心绞痛症状，1 例患者无症状，直至运动时发生心脏骤停。13 例患者行运动负荷超声心动图检查，均显示中隔中段收缩期运动不协调。冠状动脉 CT 成像证实所有患者均存在 MB。血管内超声成像证实 MB 长度：28.2±16.3mm，晕厚度：0.59±0.24mm，静息心率时左前降支受压：33.0±11.6%。多巴酚丁胺的有创血流动力学评估证实 MB 的生理意义为舒张期血流储备分数：0.59±0.13。最初 9 例患者在体外循环（CPB）下行去顶，随后 5 例患者在无 CPB 下行去顶。所有患者均无并发症出院。13 例有症状的患者报告随访时症状缓解，西雅图心绞痛问卷版本 7 记录了症状和生活质量的改善。
小儿 MB 去顶术可安全进行，无论是否使用 CPB。在有症状的患者中，去顶术可缓解药物治疗无效的症状。
