Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
Ann Thorac Surg. 2024 Sep;118(3):527-544. doi: 10.1016/j.athoracsur.2024.04.012. Epub 2024 Jun 20.
Although coarctation of the aorta without concomitant intracardiac pathology is relatively common, there is lack of guidance regarding aspects of its management in neonates and infants.
A panel of experienced congenital cardiac surgeons, cardiologists, and intensivists was created, and key questions related to the management of isolated coarctation in neonates and infants were formed using the PICO (Patients/Population, Intervention, Comparison/Control, Outcome) Framework. A literature search was then performed for each question. Practice guidelines were developed with classification of recommendation and level of evidence using a modified Delphi method.
For neonates and infants with isolated coarctation, surgery is indicated in the absence of obvious surgical contraindications. For patients with risk factors for surgery, medical management before intervention is reasonable. For those stable off prostaglandin E, the threshold for intervention remains unclear. Thoracotomy is indicated when arch hypoplasia is not present. Sternotomy is preferable when arch hypoplasia is present that cannot be adequately addressed through a thoracotomy. Sternotomy may also be considered in the presence of a bovine aortic arch. Antegrade cerebral perfusion may be reasonable when the repair is performed through a sternotomy. Extended end-to-end, arch advancement, and patch augmentation are all reasonable techniques.
Surgery remains the standard of care for the management of isolated coarctation in neonates and infants. Depending on degree and location, arch hypoplasia may require a sternotomy approach as opposed to a thoracotomy approach. Significant opportunities remain to better delineate management in these patients.
虽然主动脉缩窄伴发心脏内病变相对少见，但对于新生儿和婴儿的主动脉缩窄的治疗方面仍缺乏相关指导。
创建了一个由经验丰富的先天性心脏外科医生、心脏病专家和重症监护医生组成的专家组，使用 PICO（患者/人群、干预、比较/对照、结果）框架形成了与新生儿和婴儿单纯性主动脉缩窄管理相关的关键问题。然后针对每个问题进行文献检索。使用改良 Delphi 法，根据推荐分类和证据水平制定实践指南。
对于患有孤立性主动脉缩窄的新生儿和婴儿，如果没有明显的手术禁忌证，建议进行手术。对于有手术风险因素的患者，在干预前进行药物治疗是合理的。对于那些在停止前列腺素 E 治疗后仍稳定的患者，干预的阈值仍不明确。当不存在弓降部发育不良时，建议行开胸手术。当存在无法通过开胸手术充分解决的弓降部发育不良时，建议行胸骨切开术。当存在牛型主动脉弓时，也可以考虑行胸骨切开术。当通过胸骨切开术进行修复时，顺行性脑灌注可能是合理的。延长端对端吻合、弓部延伸和补片增强都是合理的技术。
手术仍然是新生儿和婴儿单纯性主动脉缩窄治疗的标准方法。根据程度和位置的不同，弓降部发育不良可能需要胸骨切开术而不是开胸术。在这些患者中，仍有很大的机会更好地明确管理方法。
