冠状动脉变异对动脉调转手术的影响

Influence of coronary artery variation on the outcome of arterial switch operation

目的 观察冠状动脉变异对动脉调转手术结果的影响.方法 2001年1月至2008年12月中国医学科学院北京协和医学院阜外心血管病医院共有280例患者行动脉调转手术,73例（26.1%）合并冠状动脉变异（变异组）,其中男54例,女19例,年龄7 d～6岁,平均（0.6±1.1）岁,体重3.0～18.0（5.8±2.6）kg.合并室间隔缺损的完全性大动脉转位21例,室间隔缺损完整的完全性大动脉转位30例,Taussig-Bing畸形22例.其余207例冠状动脉正常（正常组）.手术方法包括动脉调转和冠状动脉移植以及其他心内畸形的矫治.结果 全组早期死亡29例,总病死率10.4%,其中变异组死亡12例,病死率为16.4%,而正常组死亡17例,病死率为8.2%,两组患者病死率差异有统计学意义（P＜0.05）,2001至2005年间冠状动脉异常的患者手术病死率是冠状动脉正常的患者手术病死率的2倍.冠状动脉变异组平均体外循环时间（229±84）min,主动脉阻断时间（146±48）min,均长于冠状动脉正常组（206±59）min和（137±40）min,两组患者体外循环时间的差异有统计学意义（P＜0.05）.冠状动脉变异组6例患者术中证实有冠状动脉受压或梗阻,早期死亡的12例患者中包括单冠畸形5例,冠状动脉走行异常4例,其他少见畸形3例.结论 冠状动脉变异增加手术难度并影响手术结果,手术技术的成熟可以减少病死率.

Objective To investigate the influence of coronary artery variation on the outcome of arterial switch operation for transposition of great arteries. Methods Among 280 patients undergoing arterial switch operations at our hospital from 2001 to 2008, 73 （26. 1% ） had concurrent coronary arteries variation （54 males and 19 females; median age： 0. 6 ± 1.1 years old; mean body weight： 5. 8 ±2. 6 kg）. Of these 73 patients （variant group）, 21 cases had transposition of great arteries with a ventricular septal defect and 30 cases with an intact ventricular septum. The other 22 cases were of Taussig-Bing anomalies. Another 207 cases had usual coronary arteries （usual group）. Coronary artery transfer was achieved by implantation of buttons to the previously anastomosed neo-aorta. Results There were 29 early death （ 10. 4% ） including 12 cases （16.4%） in variant group and 17 cases （8.21%） in usual group （P 〈0.05）. Mean cardiopulmonary bypass and cross-clamp durations were 229 ± 84 and 146 ± 48 min in variant group while 206 ± 59 and 137 ± 40 min in usual group （ P 〈 0. 05 ）. Six cases were confirmed intra-operatively as coronary compression or obstruction. Complications included infection （n = 11 ）, low output syndrome （ n =7 ）, diaphragm paralysis （ n = 3 ）, pericardial effusion （ n = 2 ） and atrioventricular block （ n = 2 ）.Conclusion Coronary artery variation increases the operative difficulty and influences the outcome. The operative proficiency may decrease the mortality.