经心包斜窦行扩大吻合口心上型全肺静脉异位引流矫治术

Surgical correction of total anomalous pulmonary venous connection with extended anastomosis via oblique pericardial sinus approach

目的探讨经心包斜窦入路行心上型全肺静脉异位引流（TAPVC）矫治术，利用垂直静脉延长共同静脉切口，从而扩大共同静脉与左心房的吻合口。方法2007年12月至2009年1月，我院共收治27例TAPVC患儿在体外循环下行畸形矫治手术，其中男17例，女10例；年龄2d至13岁；体重2．3～21kg，平均（5．16±3．49）kg；其中心上型TAPVC11例，占40．7％；心下型1例，占3．7％；心内型12例，占44．4％；混合型3例，占11．1％。在全部接受手术的11例心上型TAPVC患儿中，10例采用经心包斜窦入路行扩大吻合口的矫治技术，其中7例同时采用无内膜接触缝合技术。此10例患儿中，男7例，女3例；年龄2d至13岁；体重2．4～21kg，中位数为6．0kg。术后行心脏超声随访，随访时间为1～14个月，中位数为7个月，常规随访时间点分别设在出院前、术后3个月、术后半年及术后1年。手术选择心包斜窦入路，沿长轴横向剖开共同静脉，并将此切口上延至垂直静脉的心包返折处，使用7-0PDS缝线将左心房后壁切口与共同静脉切口或其周边的心包组织吻合。结果1例患儿因凝血功能障碍于术后第二天死亡；另1例患儿由于家庭原因于术后第五天放弃治疗死亡，其他8例患儿均存活。在8例存活患儿中，1例患儿因术前并发双侧肺实变，另1例患儿因合并重度肺动脉高压，术后机械辅助呼吸超过7d，其他患儿均无并发症发生。至目前为止，心脏超声随访提示：全部存活患儿肺静脉回流通畅，血流速度介于0．65～1．2m／s之间。结论在治疗心上型TAPVC时，选择心包斜窦入路不仅可以获得良好的术野，还可以利用垂直静脉扩大吻合口内径，同时方便采用无内膜接触缝合技术，以预防术后肺静脉梗阻的发生。但本技术路线尚有待大宗病例的远期随访进行验证。

Objective To retrospectively evaluate the clinical outcome of the surgical correction of total anomalous pulmonary venous connection （TAPVC） with extended anastomosis via the oblique pericardial sinus approach. Methods Between December 2007 and January 2009, 27 children with TAPVC underwent surgical correction. These patients, aging 2 days to 13 years old, included 17 males and 10 females with an average weight of （5.16 ± 3.49）kg （range, 2. 3-21 kg）. Of the 27 patients with TAPVC, 11 had supra-cardiac TAPVC （41 ~）, 12 had cardiac TAPVC （44%）, 1 had infra-diaphragmatic TAPVC （44%）, and 3 had mixed TAPVC （11%）. Ten out of the 11 patients with supra-cardiac TAPVC, including 7 males and 3 females aging 2 days to 13 years at surgery, underwent corrective surgery. These 10 patients have a mean weight of 6. 0 kg （range, 2. 421 kg）. The patients were followed up for 1 to 14 months （mean follow up period, 7 months）. Eehocardiogram was performed to determine patients＇ heart function when patients were discharged from the hospital and at the 3 rd, 6 th, and 12 th months after surgery. Via oblique pericardial sinus approach, the pericardium cavity was opened and the heart was rotated toward the patienvs right and positioned under the right hemi sternum after delivering cold crystal eardioplegia. A generous incision was made across the posterior wall of the left atrium and the common pulmonary vein, which extended upwards to the midpoint of the vertical vein. Then the left atrium was subsequently connected to the pulmonary venous confluence by suturing the edges of the atrium to the common pulmonary venous incision or the pericardium surrounding the common pulmonary vein and the vertical vein with 7-0 PDS. Results One patient died at the 2 nd day after surgery, another patient died at the 5 th day after surgery. The other 8 patients recovered from surgery without any complications except 2 of them have prolonged mechanic ventilation over 7 days after surgery. Improved cardiovascular function was confirmed by echocardiograrm. Conclusions To correct the TAPVC, it can provide a wide and clear operation field via the oblique pericardial sinus approach, and more importantly, the common pulmonary venous incision could he extended to the vertical vein via this approach. The extended anastomosis plus the sutureless technique can be an effective way to prevent post-repair pulmonary vein stenosis. Further studies should be carried out to evaluate the long term efficacy of this technique.