Rajasinghe H A, Reddy V M, van Son J A, Black M D, McElhinney D B, Brook M M, Hanley F L
Division of Cardiothoracic Surgery, University of California, San Franscico 04143, USA.
Ann Thorac Surg. 1996 Mar;61(3):840-4. doi: 10.1016/0003-4975(95)01153-6.
Recurrent aortic coarctation after primary operative repair in the neonate and small infant is seen most commonly within the first year of life. Inadequate removal of ductal tissue, failure to address hypoplasia of the aortic arch, and suture line tension have been cited as important factors in early recurrence.
To address these issues, we have used a technique of coarctation resection and extended anastomosis of the descending aorta to the undersurface of the aortic arch. THe salient features of this approach include extensive mobilization of the aortic arch and neck vessels, careful trimming of all ductal tissue, ligation of the isthmus just beyond the left subclavian artery, and end-to-side anastomosis of the descending aorta to a separate incision in the undersurface of the aortic arch proximal to all tubular hypoplasia. Between July 1992 and January 1995, 19 consecutive neonates (median age, 13 days) and 4 consecutive infants under 3 months of age (median age, 69 days) with a mean peak systolic upper to lower extremity resting gradient of 27.9 +/- 16.9 mm Hg underwent repair of aortic coarctation and tubular hypoplasia of the arch. Other procedures performed at the time of repair included ligation of a patent ductus arteriosus (n = 19), pulmonary artery banding (n = 3), and closure of ventricular septal or atrial septal defect (n = 3).
There were no perioperative deaths. Early postoperative complication included a recurrent laryngeal nerve injury and a transient focal tonic clonic seizure. There was one late death, after a subsequent intracardiac surgical procedure, at a median follow-up of 16 months (range, 1 to 29 months). Twenty-one of 22 late survivors were free of recurrent aortic coarctation by echocardiography findings and clinical examination, with a median upper to lower extremity gradient of 0 mm Hg. Reintervention for recurrent aortic coarctation was not required in any survivor.
The technique described herein completely removes all potentially abnormal tissue from the aorta, including ductal tissue and all tubular hypoplastic tissue proximal to the coarctation site.
新生儿和小婴儿初次手术修复后复发性主动脉缩窄最常见于出生后第一年。导管组织切除不充分、未处理主动脉弓发育不全以及缝合线张力被认为是早期复发的重要因素。
为解决这些问题，我们采用了一种主动脉缩窄切除术及降主动脉与主动脉弓下表面扩大吻合术的技术。该方法的显著特点包括广泛游离主动脉弓和颈部血管、仔细修剪所有导管组织、在左锁骨下动脉远端结扎峡部、以及降主动脉与主动脉弓下表面靠近所有管状发育不全处的单独切口进行端侧吻合。1992年7月至1995年1月，19例连续的新生儿（中位年龄13天）和4例连续的3个月以下婴儿（中位年龄69天），平均静息时上肢至下肢收缩期峰值压差为27.9±16.9mmHg，接受了主动脉缩窄及主动脉弓管状发育不全的修复。修复时同时进行的其他手术包括结扎动脉导管未闭（n = 19）、肺动脉环扎术（n = 3）以及室间隔或房间隔缺损修补术（n = 3）。
围手术期无死亡病例。术后早期并发症包括1例喉返神经损伤和1例短暂性局灶性强直阵挛发作。1例晚期死亡发生在后续心脏内手术之后，中位随访时间为16个月（范围1至29个月）。22例晚期存活者中，21例经超声心动图检查和临床检查无复发性主动脉缩窄，上肢至下肢压差中位数为0mmHg。所有存活者均无需因复发性主动脉缩窄而再次干预。
本文所述技术可完全清除主动脉内所有潜在异常组织，包括导管组织及缩窄部位近端的所有管状发育不全组织。
