Alexi-Meskishvili V, Hetzer R, Weng Y, Lange P E, Jin Z, Berger F, Loebe M
Department of Thoracic and Cardiovascular Surgery, German Heart Institute, Berlin.
J Thorac Cardiovasc Surg. 1994 Aug;108(2):354-62.
Between January 1991 and June 1993, eleven children with anomalous origin of the left coronary artery from the pulmonary artery underwent direct aortic reimplantation of the left coronary artery at the German Heart Institute Berlin. The patients' ages ranged from 2.5 months to 10.5 years; six were infants. Three infants were intubated and their lungs ventilated before the operation, and one was resuscitated 2 days before the operation. The electrocardiograms of eight patients indicated deep Q waves. All but three of these patients had insufficient collaterals between the right and left coronary arteries. The entire group exhibited reduced left ventricular ejection fraction (minimum 15%) including mitral valve incompetence, which was moderate in six patients and severe in three. All six infants underwent emergency operations, and the remaining children, who were older, underwent elective operations involving moderate hypothermic perfusion and cold crystalloid cardioplegia. Aortic cross-clamping time ranged from 22 to 79 minutes (mean 54 minutes). A two-coronary artery system was established in all patients by direct reimplantation of the anomalous left coronary artery into the ascending aorta. Three patients who also exhibited severe mitral valve incompetence underwent modified Kay mitral valve annuloplasty. A delayed sternal closure procedure (closure performed 1 to 10 days after the operation) was used on eight patients. A 10-month-old patient was successfully treated after the operation with a centrifugal left heart assist device and a 9-year-old patient received extracorporeal membrane oxygenation because of severe heart failure. No postoperative deaths occurred. Left ventricular end-diastolic volume decreased dramatically after the operation and returned to near normal values 1 to 9 months postoperatively. At the same time, the preoperatively depressed left ventricular ejection fraction returned to normal and mitral valve incompetence decreased or vanished in eight patients. Color Doppler echocardiograms (eleven patients) and coronary angiograms (three patients) indicated that the reimplanted left coronary artery was patent in all eleven patients during the follow-up period. Reimplantation of the left coronary artery into the ascending aorta is an effective method of establishing a two-coronary artery system in children with anomalous origin of the left coronary artery from the pulmonary artery. Mitral valve annuloplasty is recommended for patients who also have severe mitral valve incompetence. Prolonged assisted circulation must be used in cases of severe postoperative heart failure.
1991年1月至1993年6月期间，11例左冠状动脉起源于肺动脉的患儿在柏林德国心脏研究所接受了左冠状动脉直接主动脉再植入术。患者年龄从2.5个月至10.5岁不等；其中6例为婴儿。3例婴儿在手术前插管并进行肺通气，1例在手术前2天进行了复苏。8例患者的心电图显示有深Q波。除3例患者外，其余患者左右冠状动脉之间的侧支循环均不足。整个组的左心室射血分数均降低（最低为15%），包括二尖瓣关闭不全，其中6例为中度，3例为重度。所有6例婴儿均接受了急诊手术，其余年龄较大的儿童接受了涉及中度低温灌注和冷晶体心脏停搏的择期手术。主动脉阻断时间为22至79分钟（平均54分钟）。通过将异常的左冠状动脉直接再植入升主动脉，在所有患者中建立了双冠状动脉系统。3例同时伴有严重二尖瓣关闭不全的患者接受了改良的Kay二尖瓣环成形术。8例患者采用了延迟胸骨闭合术（术后1至10天进行闭合）。1例10个月大的患者术后使用离心式左心辅助装置成功治疗，1例9岁患者因严重心力衰竭接受了体外膜肺氧合治疗。术后无死亡病例。术后左心室舒张末期容积显著下降，并在术后1至9个月恢复到接近正常水平。与此同时，术前降低的左心室射血分数恢复正常，8例患者的二尖瓣关闭不全减轻或消失。彩色多普勒超声心动图（11例患者）和冠状动脉造影（3例患者）显示，在随访期间，所有11例患者再植入的左冠状动脉均通畅。将左冠状动脉再植入升主动脉是在左冠状动脉起源于肺动脉的儿童中建立双冠状动脉系统的有效方法。对于同时伴有严重二尖瓣关闭不全的患者，建议进行二尖瓣环成形术。对于术后严重心力衰竭的病例，必须使用延长的辅助循环。
