張旌,王菊,施浩,李守軍,閆軍
臨床研究
先天性主動(dòng)脈弓中斷合并主動(dòng)脈肺動(dòng)脈窗一期手術(shù)治療經(jīng)驗(yàn)
張旌,王菊,施浩,李守軍,閆軍
目的:回顧總結(jié)先天性主動(dòng)脈弓中斷(IAA)合并主動(dòng)脈肺動(dòng)脈窗(APW)一期手術(shù)治療經(jīng)驗(yàn)。 方法:2009-01至2016-08,選取我院手術(shù)治療IAA合并APW患者 8例,男性4例,手術(shù)年齡 3個(gè)月~4.5歲。其中<1歲者 6例, 平均年齡( 5.2±2.7) 個(gè)月,平均體重( 5.7±1.6)kg ;>1歲者2例,平均年齡(4.1±0.6)歲,平均體重(14.6±0.9) kg。所有患者術(shù)前均有反復(fù)呼吸道感染史。IAA 分型:A型6例,B型2例;APW 分型 II 型6例,III型 2例。8例均采用胸正中切口,深低溫停循環(huán)選擇性腦灌注,一期同時(shí)糾治IAA和APW及合并畸形。 結(jié)果: 8例患者術(shù)前肺動(dòng)脈收縮壓平均值(83.1±8.3)mmHg(1mmHg=0.133 kPa);術(shù)中體外循環(huán)時(shí)間(127.0±18.5)min,主動(dòng)脈阻斷平均時(shí)間(78.0±14.1)min;術(shù)后肺動(dòng)脈收縮壓平均值( 43.6±8.5)mmHg;全組無手術(shù)死亡 。隨訪平均(19.8±13.9)個(gè)月,主動(dòng)脈弓部壓力階差平均(11.2±4.7)mmHg,均恢復(fù)良好。 結(jié)論:IAA合并APW采用一期手術(shù)可以徹底矯治,采用胸正中切口方法, 操作簡(jiǎn)便,手術(shù)效果良好。
心血管畸形;心臟外科手術(shù)
主動(dòng)脈弓中斷 (IAA)是一種罕見的先天性心臟病,發(fā)生率約占先天性心臟病的1.5%[1]?;颊甙l(fā)病早、病情嚴(yán)重合并畸形復(fù)雜,常伴有中重度肺動(dòng)脈高壓,病死率高,約75%的患者生后1周內(nèi)死亡[2]。IAA可以合并其它復(fù)雜畸形,例如動(dòng)脈導(dǎo)管未閉(PDA),室間隔缺損(VSD),主動(dòng)脈肺動(dòng)脈窗(APW),永存動(dòng)脈干,右心室雙出口,完全性大動(dòng)脈轉(zhuǎn)位等。IAA合并APW比較罕見,手術(shù)復(fù)雜,死亡率高[3]。我院小兒心臟外科自2009-01至2016-08手術(shù)治療8例IAA合并APW患者,均行一期手術(shù)矯治,效果良好。
一般資料: 選取我院小兒心臟外科中心2009-01至2016-08手術(shù)治療IAA患者107例,其中IAA合并APW共8例,均行一期手術(shù)矯治,8例(7.8%)患者中男性4例,女性4例,手術(shù)年齡 3個(gè)月~4.5歲。其中 <1 歲者 6 例,平均年齡(5.2±2.7) 個(gè)月, 平均體重(5.7±1.6)kg ;>1歲者2例,平均年齡(4.1±0.6)歲,平均體重(14.6±0.9)kg。8例患者術(shù)前均有反復(fù)呼吸道感染史,術(shù)前均由經(jīng)胸超聲心動(dòng)圖確診,且均行心臟和主動(dòng)脈計(jì)算機(jī)斷層血管造影術(shù) (CTA)明確IAA和APW分型診斷, 3例患者另行心血管造影和右心導(dǎo)管檢查。IAA分型采用Celoria分型[4],A型6例,B型2例。APW 分型采用 Mori改良分型[5-7], II 型 6 例,III型 2 例,APW 缺損直徑 10~25 mm,平均直徑(15.6±5.0)mm。合并其它心臟畸形包括PDA8例,右肺動(dòng)脈起源于升主動(dòng)脈( AORPA)5例,二尖瓣關(guān)閉不全4例,三尖瓣關(guān)閉不全1例(表1)。8例患者均合并重度肺動(dòng)脈高壓,術(shù)前肺動(dòng)脈收縮壓平均值(83.1±8.3)mmHg(1mmHg=0.133 kPa)。術(shù)前上下肢血壓壓差(26.1±8.5)mmHg。
表1 8例患者臨床資料和影像診斷結(jié)果
手術(shù)方法:本組8例患者全部在體外循環(huán)下行一期矯治手術(shù),體外循環(huán)采用深低溫停循環(huán)(DHCA)加上選擇性腦灌注(ASCP)。患者在麻醉誘導(dǎo)后,建立上、下肢動(dòng)脈血壓和中心溫度監(jiān)測(cè)。均采用胸骨正中切口一期矯治IAA、APW及心內(nèi)畸形。切除雙側(cè)胸腺,解剖游離升主動(dòng)脈、無名動(dòng)脈、左頸總動(dòng)脈和左鎖骨下動(dòng)脈,同時(shí)游離左、右肺動(dòng)脈,并套帶以備阻斷。體外循環(huán)選擇單泵雙管,一根經(jīng)升主動(dòng)脈插入主動(dòng)脈灌注管(靠近無名動(dòng)脈處插管),另一根經(jīng)肺動(dòng)脈連接的動(dòng)脈導(dǎo)管插入主動(dòng)脈灌注管行降主動(dòng)脈灌注(如果患者PDA太細(xì),可以只行升主動(dòng)脈插管)。經(jīng)上腔靜脈和下腔靜脈置入上、下腔靜脈插管。開始體外循環(huán)轉(zhuǎn)流,升主動(dòng)脈插管灌注上半身血流,而肺動(dòng)脈干插管的血流經(jīng)動(dòng)脈導(dǎo)管灌注下半身血流。將左、右肺動(dòng)脈阻斷以防止發(fā)生灌注肺,并可以防止主動(dòng)脈根部灌注心肌保護(hù)液流入左右肺動(dòng)脈造成無效灌注。阻斷升主動(dòng)脈,主動(dòng)脈根部注入組氨酸-色氨酸-酮戊二酸(HTK)心肌保護(hù)液(康斯特HTK溶液,德國(guó)克勒化學(xué)制藥公司),心臟停跳。至肛溫26℃時(shí),將升主動(dòng)脈插管導(dǎo)入無名動(dòng)脈行正向選擇性腦灌注,從動(dòng)脈導(dǎo)管中拔出降主動(dòng)脈插管,下半身停循環(huán)。切除動(dòng)脈導(dǎo)管,肺動(dòng)脈端縫合關(guān)閉,降主動(dòng)脈與升主動(dòng)脈弓行端側(cè)吻合,如果降主動(dòng)脈與主動(dòng)脈弓距離太遠(yuǎn)或者主動(dòng)脈發(fā)育不良,可以采用補(bǔ)片(采用部分自體肺動(dòng)脈前壁或者自體心包片)行主動(dòng)脈弓成形。主動(dòng)脈弓重建后,將主動(dòng)脈插管從無名動(dòng)脈退回到重建升主動(dòng)脈,恢復(fù)全身灌注。切開主動(dòng)脈或者主肺動(dòng)脈顯露APW,用自體心包片或者Dacron滌綸片修補(bǔ)APW,同時(shí)矯治其它心內(nèi)畸形。如果合并AORPA,AORPA的矯治方法基本分二類:第一種方法,主動(dòng)脈內(nèi)補(bǔ)片修補(bǔ)APW的同時(shí)將右肺動(dòng)脈和主肺動(dòng)脈連接;第二種方法,將右肺動(dòng)脈連同一部分主動(dòng)脈壁一并切下,與主肺動(dòng)脈吻合,升主動(dòng)脈行補(bǔ)片修補(bǔ)或者端端吻合。
8例患者術(shù)中一般情況:全部行一期矯治手術(shù),其中升主動(dòng)脈+PDA插管3例,單純升主動(dòng)脈插管5例。術(shù)中矯正IAA的方法: 4例采用降主動(dòng)脈與主動(dòng)脈弓直接端側(cè)吻合,4例采用自體肺動(dòng)脈前壁或者自體心包片行升主動(dòng)脈和弓部擴(kuò)大成形術(shù)(3例采用自體肺動(dòng)脈前壁,1例采用自體心包片)。術(shù)中矯正APW的方法:4例經(jīng)主動(dòng)脈切口修補(bǔ)APW,4例經(jīng)主肺動(dòng)脈切口修補(bǔ)APW。本組5例同時(shí)合并AORPA(62.5%,5/8例),其中有4例采用第一種方法矯治,1例采用第二種方法矯治。本組8例患者體外循環(huán)時(shí)間102~157 min,平均(127.0±18.5)min,主動(dòng)脈阻斷時(shí)間 60~101min,平均(78.0±14.1)min,下半身停循環(huán)時(shí)間19~46 min,平均(36.2±10.2)min。
8例患者術(shù)后一般情況:無手術(shù)死亡,無肺動(dòng)脈高壓危象及心功能衰竭等并發(fā)癥。術(shù)后肺動(dòng)脈壓明顯下降,肺動(dòng)脈收縮壓平均值(43.6±8.5)mmHg。術(shù)后上下肢血壓壓差均明顯改善,上下肢血壓壓差平均(6.8±5.0)mmHg。氣管內(nèi)插管 10~69 h,平均(39.4±22.8)h, 重癥監(jiān)護(hù)病房(ICU)停留時(shí)間3~15 d,平均 (8.7±4.5)d。住院時(shí)間 8~25 d,平均(15.4±5.9 )d。術(shù)后心臟超聲顯示降主動(dòng)脈血流速度0~2.8 m/s,壓力階差0~31mmHg,平均(13.6±10.8)mmHg。
8例患者隨訪結(jié)果:8例患者隨訪2~50個(gè)月,平均隨訪(19.8± 13.9)個(gè)月。1例患者出院后術(shù)后1個(gè)月因大量心包積液再次入院行心包開窗術(shù),術(shù)后恢復(fù)良好。8例患者術(shù)后主動(dòng)脈弓部壓力階差0~29 mmHg,平均(11.2±4.7)mmHg。隨訪期間患者左心室功能正常,左心室射血分?jǐn)?shù)64.4%~70.6%,平均(65.8±2.5)% ,無殘余心內(nèi)畸形。
IAA是指升主動(dòng)脈與降主動(dòng)脈的連續(xù)性中斷,由胚胎期左背主動(dòng)脈近側(cè)端或第4弓的退化或萎縮形成,是一種罕見的先天性心臟病,本組患者IAA分型采用Celoria分型[4]。APW是另一種罕見的先天性心臟病,由于胚胎期動(dòng)脈水平分隔為主動(dòng)脈和肺動(dòng)脈的過程不完全,在升主動(dòng)脈和主肺動(dòng)脈之間形成的缺損,發(fā)生率約占心天性心臟病的0.1%~0.2%[5]。 Mori在Richardson經(jīng)典分型的基礎(chǔ)上進(jìn)行改良,本組患者APW分型采用Mori改良分型[6,7]。IAA通常合并VSD和PDA,IAA合并APW非常罕見,國(guó)外報(bào)道IAA患者中合并APW約占3.5%~4.2%[3],發(fā)病率僅占先天心臟病發(fā)病率的0.046%[8],IAA合并APW病例約占所有IAA病例的4%[9]。我院IAA合并APW患者約占所有IAA患者7.5%(8/107例)。
術(shù)前經(jīng)胸心臟超聲檢查簡(jiǎn)單無創(chuàng),但容易漏診APW,或者將IAA誤診為主動(dòng)脈縮窄。心管造影檢查可以明確診斷,但由于就診患兒年齡較小、發(fā)育不良、肺動(dòng)脈高壓等因素,心血管造影檢查存在一定風(fēng)險(xiǎn)[10]。心臟和主動(dòng)脈CTA具有無創(chuàng)、安全、直觀的優(yōu)點(diǎn),圖像空間分辨率高,是目前首選影像學(xué)檢查。本組8例術(shù)前經(jīng)胸心臟超聲均正確診斷IAA合并APW,但為進(jìn)一步明確IAA與APW分型全部輔以心臟和主動(dòng)脈CTA檢查。對(duì)于大齡患兒有嚴(yán)重肺動(dòng)脈高壓建議行右心導(dǎo)管檢查[5],本組有3例術(shù)前行心血管造影和右心導(dǎo)管檢查顯示為可逆性肺動(dòng)脈高壓。
由于IAA的存在以及患者往往年齡小、癥狀重、身體狀況差等因素,選擇一期或分期矯治手術(shù)尚存爭(zhēng)議,主要考慮嬰兒是否能承受長(zhǎng)時(shí)間體外循環(huán)的打擊。早期多選擇分期手術(shù) ,即一期非體外循環(huán)下經(jīng)側(cè)開胸重建主動(dòng)脈弓與降主動(dòng)脈的連續(xù)性并進(jìn)行肺動(dòng)脈環(huán)縮術(shù),二期體外循環(huán)下正中切口糾治合并心內(nèi)畸形及肺動(dòng)脈環(huán)縮拆除術(shù)。但隨著外科技術(shù)的進(jìn)步,以及圍術(shù)期監(jiān)護(hù)及體外、麻醉技術(shù)的進(jìn)步,目前多數(shù)采取一期矯治手術(shù),取得滿意療效[11-13]。本組8例全部選擇一期矯治手術(shù)。
深低溫停循環(huán)對(duì)神經(jīng)系統(tǒng)有一定程度損傷[14],本組8例全部采用均采用深低溫停循環(huán)加選擇性腦灌注的方法,術(shù)后未無腎功能不全及神經(jīng)系統(tǒng)并發(fā)癥。心肌保護(hù)液我們采用HTK冷晶體停跳液,主動(dòng)脈阻斷3 h之內(nèi)可以單次灌注,減少因反復(fù)灌注而延長(zhǎng)手術(shù)時(shí)間和影響手術(shù)操作。
IAA合并APW施行一期矯治術(shù)包括將降主動(dòng)脈與主動(dòng)脈弓連接,并完成主肺動(dòng)脈窗的修補(bǔ)和其它心內(nèi)畸形的矯治。嬰幼兒主動(dòng)脈弓連續(xù)性重建有多種方法,目前大多采用降主動(dòng)脈與主動(dòng)脈弓直接端側(cè)吻合術(shù),吻合口張力較大或主動(dòng)脈升弓部發(fā)育不良者需要同時(shí)作補(bǔ)片加寬,必要時(shí)用自體心包或自體肺動(dòng)脈補(bǔ)片擴(kuò)大升主動(dòng)脈及弓部,可以減少吻合口狹窄或氣管壓迫的發(fā)生率。國(guó)外也有報(bào)道用單片法同時(shí)矯正IAA和APW[15]。APW的手術(shù)方法目前的首選方法是在體外循環(huán)下心臟停跳下經(jīng)主動(dòng)脈切口或者肺動(dòng)脈切口補(bǔ)片修補(bǔ)[16]。經(jīng)主動(dòng)脈切口的優(yōu)點(diǎn)是切開主動(dòng)脈后可以直視探查,可明確瓣膜,冠狀動(dòng)脈開口,左右肺動(dòng)脈開口等解剖關(guān)系,但是IAA合并APW常合并升主動(dòng)脈發(fā)育不良,尤其是低齡患兒升主動(dòng)脈偏細(xì),切開主動(dòng)脈后直接縫合升主動(dòng)脈容易造成升主動(dòng)脈狹窄,還需要補(bǔ)片加寬升主動(dòng)脈。IAA合并APW患兒均伴有重度肺動(dòng)脈高壓并且主肺動(dòng)脈明顯增寬,可以經(jīng)肺動(dòng)脈切口顯露APW,補(bǔ)片需要經(jīng)APW仔細(xì)探查瓣膜、冠狀動(dòng)脈等解剖結(jié)構(gòu)。本組手術(shù)效果良好,未見主動(dòng)脈或肺動(dòng)脈扭曲變形及術(shù)后狹窄。
本組患者中有5例同時(shí)合并AORPA,矯治AORPA的方法有兩種(見手術(shù)方法),有文獻(xiàn)報(bào)道第二種矯治方法可能會(huì)降低右肺動(dòng)脈狹窄的發(fā)生率[17,18]。本組患者術(shù)中矯治AORPA的兩種方法均取得良好效果,術(shù)后食道超聲和術(shù)后隨訪超聲均未發(fā)現(xiàn)右肺動(dòng)脈狹窄或升主動(dòng)脈狹窄。因此,這兩種方法都可以保留大部分可生長(zhǎng)的動(dòng)脈壁,又可避免主動(dòng)脈壓迫,從而降低右肺動(dòng)脈狹窄的發(fā)生率。
IAA合并APW手術(shù)死亡率可高達(dá)15%,明顯高于單純IAA(或單純APW)或者合并簡(jiǎn)單畸形患兒[19]。IAA合并APW術(shù)后5年手術(shù)再干預(yù)比例約50%,主要原因是主動(dòng)脈狹窄和主動(dòng)脈壓迫氣管[19]。本組8例IAA合并APW的患者采用一期矯治手術(shù),術(shù)后及隨訪期間未發(fā)生主動(dòng)脈狹窄及氣管壓迫等并發(fā)癥,均取得滿意的效果。相對(duì)于國(guó)外報(bào)道,本組患者就診年齡偏大,有6例患者年齡在1歲以內(nèi),還有2例患者年齡超過3歲,均合并嚴(yán)重肺動(dòng)脈高壓。有報(bào)道稱對(duì)于>3歲的高年齡患者術(shù)后肺動(dòng)脈高壓難以逆轉(zhuǎn),近遠(yuǎn)期效果不佳[20]。由于這類患者術(shù)前常有中度至重度肺動(dòng)脈高壓,對(duì)于年齡>3歲的大齡患者,術(shù)前應(yīng)常規(guī)性右心導(dǎo)管檢查,評(píng)估肺動(dòng)脈壓力和肺動(dòng)脈阻力,評(píng)估肺動(dòng)脈壓力是否能夠逆轉(zhuǎn)。本組2例年齡>3歲的患者術(shù)前均行右心導(dǎo)管檢查評(píng)估,均為重度肺動(dòng)脈高壓,肺動(dòng)脈阻力均大于10個(gè)Wood單位,吸氧下條件下外周血氧飽和度>95%,右心導(dǎo)管資料顯示為可逆性肺動(dòng)脈高壓,有手術(shù)指證。術(shù)后早期要充分鎮(zhèn)靜,延長(zhǎng)機(jī)械輔助呼吸時(shí)間。Barnes等[5]報(bào)道建議IAA合并APW術(shù)后監(jiān)測(cè)肺動(dòng)脈壓并鎮(zhèn)靜12~24 h。本組患者氣管內(nèi)插管 10~69 h,平均(39.4±22.8) h,術(shù)后聯(lián)合靜脈應(yīng)用前列腺素E,米力農(nóng)或吸入一氧化氮(NO),本組8例患者均順利渡過術(shù)后肺高壓危象期,痊愈出院。因此盡早明確診斷、積極外科手術(shù)治療以及術(shù)后嚴(yán)格監(jiān)控和管理是成功關(guān)鍵。隨著我國(guó)新生兒重癥監(jiān)護(hù)及先心外科的發(fā)展,對(duì)IAA合并APW的早期診斷和治療未來會(huì)有更大的進(jìn)步。
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One-stage Repair and Surgical Management in Patients With Interrupted Aortic Arch Combining Aortopulmonary Window
ZHANG Jing, WANG Ju, SHI Hao, LI Shou-jun, YAN Jun.
Center of Pediatric Cardiac Surgery, National Center for Cardiovascular Disease and Fuwai Hospital, CAMS and PUMC, Beijing(100037), China
YAN Jun, Email: yanjun.1112@aliyun.com
Objective: To retrospectively summarize the clinical experience of one-stage repair and surgical management in patients with interrupted aortic arch (IAA) combining aortopulmonary window (APW).
Methods: A total of 8 patients with IAA combining APW received surgical repair in our hospital from 2009-01 to 2016-08 were enrolled including 4 male, the age at operation was between 3 months to 4.5 years. There were 6 patients<1 year at the mean age of (5.2±2.7) months with the mean body weight at (5.7±1.6) kg; 2 patients>1 year at the mean age of (4.1±0.6)years with the mean body weight at (14.6±0.9) kg. All patients had the history of repeated respiratory infection before the operation. The IAA morphology included type A in 6 patients and type B in 2; APW morphology included type II in 6 patients and type III in 2. All patients received median sternotomy with deep hypothermic circulatory arrest and antegrade selective cerebral perfusion. The malformation of IAA combining APW was corrected by one-stage operation.
Results: The mean pre-operative pulmonary artery systolic pressure (PASP) was (83.1±8.3) mmHg, mean cardiopulmonary bypass time was (127.0±18.5) min, aortic cross-clamp time was (78.0±14.1) min; the mean post-operative PASP was (43.6±8.5) mmHg, no operative death occurred. The patients were followed-up for (19.8±13.9) months and the mean aortic arch pressure gradient was (11.2±4.7) mmHg, all patients were well recovered.
Conclusion: Primary anatomical IAA combining APW can be thoroughly corrected by one-stage operation; median sternotomy was simple method with good effect.
Cardiovascular abnormalities; Cardiac surgery
十三五國(guó)家重點(diǎn)研發(fā)計(jì)劃項(xiàng)目(2017YFC1308100)
100037 北京市,中國(guó)醫(yī)學(xué)科學(xué)院 北京協(xié)和醫(yī)學(xué)院 國(guó)家心血管病中心 阜外醫(yī)院 小兒心臟外科中心
張旌 副主任醫(yī)師 博士 主要從事心血管外科方面研究 Email:zhangjingfw@163.com 通訊作者:閆軍 Email:yanjun.1112@aliyun.com
R541
A
1000-3614(2017)12-1213-04
10.3969/j.issn.1000-3614.2017. 12.017
(Chinese Circulation Journal, 2017,32:1213.)
2017-01-19)
(編輯:曹洪紅)