镶嵌技术与传统Ⅰ期根治手术治疗3个月龄内主动脉缩窄合并室间隔缺损

The comparison of Hybrid technique to the traditional complete surgical way for CoA/VSD under the age of three months

目的探讨3个月龄内小婴儿主动脉缩窄合并室间隔缺损的手术方法，分析比较镶嵌手术技术（Hybrid）的纠治效果。方法回顾性研究2004年1月至2011年8月于复旦大学附属儿科医院Ⅰ期纠治主动脉缩窄合并室间隔缺损的3个月龄内的小婴儿，排除严重主动脉弓发育不良，排除合并右心室双出口，完全性房室间隔缺损，完全性大动脉转位等复杂心内畸形的病例；共有75例患儿纳入了本研究中，其中男57例，女18例，年龄9～91d，平均（47．1±23．5）d，体重1．9～6．5kg，平均（3．9±1．1）kg；体外循环时间31～161min，平均（74．7±33．4）min，主动脉阻断时间10～61min，平均（34．0±12．1）min。按照不同的手术方式分为三组，A组应用正中切口完成心内纠治术，共45例，B组采用正中切口修补室间隔缺损联合左侧侧胸切口纠治主动脉缩窄，共16例，C组应用心导管球囊扩张纠治主动脉缩窄结合心脏直视手术修补室间隔缺损的Hybrid技术，共14例。结果A组早期死亡2例，因喉返神经损伤引起声音嘶哑7例，其中伴呛奶症状3例，随访1个月至7年，因主动脉再缩窄而干预的有4例，1例于侧胸切口进行狭窄段切除，端端吻合，余3例在心导管下球囊扩张，术后随访主动脉弓均无压差。B组无早期死亡，出现声音嘶哑1例，再缩窄2例，均在心导管下球囊扩张成功。C组无早期死亡，无声音嘶哑，Hybrid手术在主动脉阻断时间、体外循环时间、机械通气时间、ICU滞留时间上较手术组明显减少（P〈0．05），随访1个月至2．5g，1例在半年后因主动脉再缩窄于左侧侧胸切口行缩窄段切除，端端吻合，1例压差在30mmHg，余随访心超测得压差在20mmHg以内，未发现假性动脉瘤。结论Hybrid手术在3个月龄以内的主动脉弓缩窄伴有室间隔缺损的纠治中取得了良好的效果，可减少术后恢复时间，特别在重症患儿中可降低手术病死率，早中期再缩窄率可以接受，但仍需长期随访。

Objective The Hybrid technique is a new way to repair the CoA/VSD,which is the combination of balloon dilation on CoA and surgically repairing VSD. The purpose of this study is to assess the advantage of the Hybrid technique when compared to the traditional surgical way in the treatment of CoA/VSD in patients under the age of three months. Methods 75 patients with CoA/ VSD underwent one stage complete repair from Jan 2004 to Aug 2011. The age ranged from 9 days to 91days with a mean of 47. 1 ± 23. 5 days. Body weights ranged from 1.9 kg to 6. 5 kg（mean 3. 9 ± 1.1 kg）. Cardiopulmormry bypass duration was 31min＋ 161min, with a mean of 74. 7 ± 33. 4 mira Aortic clamp duration was 10 min-61 min,with a mean of 34. 0 ± 12. 1 mira All cases were divided into three groups （A, B and C） according to different operative ways. Group A was operated inthe traditonal way through the mid-sternal approach, Group B was repaired by the combination of the mid-sterna incision and thoracic lateral incision, Group C was by the Hybrid technique through mid-sternal approach. Re- sults Group C （Hybrid） had no death, no hoarseness due to recurrent laryngeal nerve palsy. Com- pared to the other two groups, Group C patients had less timeon the aortic clamp, cardiopulmonary by- pass,mechanical support and ICU stay （P〈0. 05）. During follow-up for one month to two and a half years, only one case was re-operated due to aortic arch restenosis. No pseudoaneurysmwas found. Con-clusions The Hybrid technique had better results in the treatment of CoA/VSD in patients under the age of three months.. The incidence of aortic restenosiswas acceptable during the early and mid-term followup.