Division of Cardiac Critical Care, Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pa.
Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Boston, Mass.
J Thorac Cardiovasc Surg. 2020 May;159(5):1957-1965.e1. doi: 10.1016/j.jtcvs.2019.09.073. Epub 2019 Oct 3.
Acute coronary artery obstruction is a rare complication of congenital heart disease surgery but imposes a high burden of morbidity and mortality. Previous case series have described episodes in specific congenital heart lesions or surgical repairs but have not examined the complication in all-comers to congenital heart surgery. We hypothesize that shorter time from a clinically recognized postoperative sentinel event suggestive of coronary ischemia to diagnosis of coronary obstruction is associated with improved clinical outcomes.
This was a single-center, retrospective review of patients diagnosed with acute coronary artery obstruction by angiography following surgical repair of congenital heart disease between January 2000 and June 2016.
In total, 34 patients were identified. The most common procedures associated with coronary artery obstruction were the Norwood procedure, arterial switch operation, and aortic valve repair/replacement. In total, 79% required mechanical circulatory support, 41% died, and 27% were listed for heart transplant. Patients who died or were listed for heart transplant had longer median sentinel-event-to-cardiac-catheterization time (28 [6-168] hours vs 10 [3-56] hours, P = .001), and longer median sentinel-event-to-intervention time (32 [11-350] hours vs 13 [5-59] hours, P = .003). Patients with hypoplastic left heart syndrome were at greater risk of death or transplant listing (odds ratio, 9.23, P = .03).
Time from clinically relevant postoperative sentinel event to diagnosis of coronary artery obstruction by angiography was associated with transplant-listing-free survival. Clinicians should maintain a high index of suspicion for coronary obstruction and consider early catheterization and coronary angiography for patients in whom post-operative coronary compromise is suspected.
急性冠状动脉阻塞是先天性心脏病手术的罕见并发症，但会导致较高的发病率和死亡率。以前的病例系列研究描述了特定先天性心脏病病变或手术修复后的发作，但并未检查所有接受先天性心脏病手术的患者的并发症。我们假设，从临床可识别的提示冠状动脉缺血的术后哨兵事件到诊断冠状动脉阻塞的时间越短，临床结局越好。
这是一项单中心、回顾性研究，对 2000 年 1 月至 2016 年 6 月期间因先天性心脏病手术后行血管造影诊断为急性冠状动脉阻塞的患者进行了研究。
共确定了 34 例患者。最常见的与冠状动脉阻塞相关的手术是 Norwood 手术、动脉转换术和主动脉瓣修复/置换术。共有 79%的患者需要机械循环支持，41%死亡，27%被列入心脏移植名单。死亡或列入心脏移植名单的患者，从哨兵事件到心导管检查的中位时间更长（28 [6-168] 小时与 10 [3-56] 小时，P=0.001），从哨兵事件到介入治疗的中位时间也更长（32 [11-350] 小时与 13 [5-59] 小时，P=0.003）。左心发育不全综合征患者死亡或列入心脏移植名单的风险更高（比值比，9.23，P=0.03）。
从临床上相关的术后哨兵事件到血管造影诊断冠状动脉阻塞的时间与移植无失败生存相关。临床医生应保持对冠状动脉阻塞的高度警惕，并考虑对疑似术后冠状动脉损伤的患者进行早期导管检查和冠状动脉造影。
