Coles J G, Yemets I, Najm H K, Lukanich J M, Perron J, Wilson G J, Rabinovitch M, Nykanen D G, Benson L N, Rebeyka I M
Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.
J Thorac Cardiovasc Surg. 1995 Nov;110(5):1513-9; discussion 1519-20. doi: 10.1016/S0022-5223(95)70075-7.
The use of endovascular devices as an adjunct to repair of congenital heart anomalies represents a novel but unproven therapeutic approach. Intraoperative implantation of pulmonary arterial stents (5 to 15 mm diameter) was done in 11 patients with pulmonary atresia with ventricular septal defect (n = 4), classic tetralogy of Fallot (n = 2), truncus arteriosus (n = 1), hypoplastic left heart syndrome (stage II [n = 1] and stage III [n = 1] Norwood procedure), and miscellaneous pulmonary arterial stenoses (n = 3), as well as in patients with congenital (n = 1) and postoperative (n = 3) pulmonary venous obstruction and in 1 patient with combined pulmonary arterial and venous obstruction. The stents were effective at achieving immediate patency in all patients. There were two early deaths, one related to acute thrombosis of a small-diameter left pulmonary artery stent. Reintervention because of stent-related pulmonary arterial stenosis was frequently necessary. In five of seven patients who survived more than 1 month after implantation of stent size 8 mm or smaller severe stent-related pulmonary arterial obstruction developed. In four of the five patients with pulmonary vein stent implantation intractable obstruction developed, resulting in death in all three patients who had bilateral pulmonary vein stent implantation. Intraoperative occlusion of apical muscular ventricular septal defect with use of a clamshell device inserted from the right atrial approach was accomplished in four patients. One patient who underwent associated aortic arch reconstruction died as a result of left ventricular hypoplasia. The results in the remaining three patients were favorable on the basis of absence of significant late residual intraventricular shunting, left ventricular dysfunction, or arrhythmia. We conclude that recurrent intraluminal obstruction as a result of neointimal hyperplasia appears to be an eventual certainty in currently designed small-diameter endovascular stents. For this reason, we would recommend standard surgical techniques for repair of obstructive lesions of the pulmonary arterial confluence to maximize growth potential. Device occlusion of muscular ventricular septal defects is feasible but probably only indicated for complex cases of ventricular septal deficiency that otherwise necessitate a left ventriculotomy.
使用血管内装置辅助修复先天性心脏畸形是一种新颖但未经证实的治疗方法。对11例患有室间隔缺损的肺动脉闭锁患者（n = 4）、典型法洛四联症患者（n = 2）、永存动脉干患者（n = 1）、左心发育不全综合征患者（诺伍德手术II期[n = 1]和III期[n = 1]）、各种肺动脉狭窄患者（n = 3），以及先天性（n = 1）和术后（n = 3）肺静脉梗阻患者和1例合并肺动脉和静脉梗阻患者术中植入了肺动脉支架（直径5至15毫米）。支架在所有患者中均能立即实现血管通畅。有2例早期死亡，1例与小直径左肺动脉支架急性血栓形成有关。因支架相关肺动脉狭窄而进行再次干预常常是必要的。在植入8毫米或更小尺寸支架后存活超过1个月的7例患者中，有5例出现了严重的支架相关肺动脉梗阻。在植入肺静脉支架的5例患者中，有4例出现了难治性梗阻，导致所有3例双侧肺静脉支架植入患者死亡。4例患者通过经右心房途径插入的蛤壳装置术中封堵了心尖肌部室间隔缺损。1例接受相关主动脉弓重建的患者因左心室发育不全死亡。其余3例患者的结果良好，未出现明显的晚期残余心室内分流、左心室功能障碍或心律失常。我们得出结论，对于目前设计的小直径血管内支架，内膜增生导致的复发性管腔内梗阻似乎最终是不可避免的。因此，我们建议采用标准手术技术修复肺动脉汇合处的梗阻性病变，以最大限度地提高生长潜力。装置封堵肌部室间隔缺损是可行的，但可能仅适用于室间隔缺损复杂的病例，否则需要进行左心室切开术。
