端-侧吻合主动脉重建技术在婴儿主动脉缩窄合并心内畸形一期矫治术中的应用

Application of End-to-side Anastomosis for Coarctation of the Aorta with Cardiac Lesions in Neonates and Infants

目的比较婴儿主动脉缩窄(CoA)合并心内畸形一期矫治手术中采用端-侧吻合技术与扩大的端-端吻合技术的临床效果。方法 2008年1月至2011年7月广州市妇女儿童医疗中心共63例婴儿CoA合并心内畸形行一期矫治手术,按主动脉重建时的技术方法不同将63例患者分为两组,端-端吻合组:24例,男17例,女7例;年龄(4.6±2.9)个月,应用扩大的端-端吻合技术行手术治疗;端-侧吻合组:39例,男24例,女15例;年龄(3.4±2.6)个月,应用端-侧吻合技术行手术治疗。比较两组患者术后早期上、下肢动脉收缩压压差和围术期相关并发症发生情况。结果端-侧吻合组新生儿比率(23.1%vs.4.2%;χ2=3.979,P=0.045)、术前24 h内酸中毒比率(15.4%vs.0%;χ2=4.080,P=0.048)均高于端-端吻合组。术后端-端吻合组无死亡,端-侧吻合组死亡1例(2.6%)。端-侧吻合组术中停循环时间明显短于端-端吻合组[(18.6±2.7)min vs.(23.4±3.7)min,F=14.617,P=0.000]。端-端吻合组入心脏监护室(CICU)时上、下肢动脉收缩压压差<5 mm Hg、5～15 mm Hg、>15 mm Hg患者分别占20.8%、45.8%和33.3%,端-侧吻合组分别占97.4%、2.6%和0%,两组间差异有统计学意义(χ2=40.380,P=0.000)。术后24 h端-端吻合组上、下肢动脉收缩压压差<5 mm Hg、5～15 mm Hg、>15 mm Hg患者分别占45.8%、41.7%和12.5%,而端-侧吻合组占100%、0%和0%,两组间差异有统计学意义(χ2=26.620,P=0.000)。随访62例,随访时间2～36个月,所有患者均无血管瘤形成,无需再次手术处理的主动脉再狭窄。结论在婴儿CoA合并心内畸形的一期矫治手术中,与扩大的端-端吻合技术相比较,应用端-侧吻合技术可以安全、有效地显著降低术后早期出现的残余梗阻。

Objective To compare the advantages of reconstructing the aorta by end-to-side anastomosis with extended end-to-end anastomosis for aortic coarctation（CoA） with cardiac lesions in neonates and infants. Methods There were 63 neonates and infants who underwent median full sternotomy for correction of CoA and cardiac lesions from January 2008 to July 2011 in Guangzhou Women and Children＇s Medical Center.These patients were divided into two groups： extended end-to-end anastomosis was performed in 24 patients（end-to-end group,17 males and 7 females with their mean age of 4.6±2.9 months）and end-to-side anastomosis in 39 patients（end-to-side group,24 males and 15 females with their mean age of 3.4±2.6 months）.We compared the two groups with regard to postoperative mortality,morbidity and difference in blood pressure between the lower and upper extremities.Results The percentage of newborn patient（23.1% vs.4.2%;χ2=3.979,P=0.045）and presence of pre-operative acidosis（15.4% vs.0%;χ2=4.080,P=0.048）were significantly higher in end-to-side group than those in end-to-end group.There was no postoperative death in end-to-end group and 1 patient died after surgery in end-to-side group（2.6%）.The average duration of circulatory arrest in end-to-side group was significantly shorter than that in end-to-end group（18.6±2.7 min vs.23.4±3.7 min,F=14.617,P=0.000）.At the time back to cardiac intensive care unit,the percentage of patients whose difference in systolic pressure between radial and femoral artery 5 mm Hg,5-15 mm Hg,and15 mm Hg was 20.8%,45.8% and 33.3% respectively in end-to-end group,and 97.4%,2.6% and 0% respectively in end-to-side group（χ2=40.380,P=0.000）.Twenty-four hours after surgery,the percentage of patients whose difference in systolic pressure between radial and femoral artery5 mm Hg,5-15 mm Hg,and15 mm Hg was 45.8%,41.7% and 12.5% respectively in end-to-end group,and 100%,0% and 0% respectively in end-to-side group（χ2=26.620,P=0.000）.All the surviving 62 patients were followed up for 2-36 months,and there was no patient with angeioma or re-stenosis needing intervention in either group during follow-up.Conclusion End-to-side anostomosis is a safe and effective method for treating CoA with cardiac lesions and eliminating residual stenosis in neonates and infants.