扩大的端侧吻合一期修复主动脉弓中断诊治分析

End-to-side anastomosis for interrupted aortic arch in neonates and infants

目的总结扩大的端侧吻合法在婴幼儿主动脉弓中断合并心内畸形一期修复弓部重建中的应用经验。方法回顾性分析2010年1月至2016年12月在广州市妇女儿童医疗中心心脏中心接受手术治疗的46例主动脉弓中断患者的临床资料。男性34例，女性12例，26例为新生儿，接受手术时年龄为2 d至8岁，中位年龄为23 d。按解剖分型，A型36例，B型10例，42例合并心内畸形，均经胸骨正中切口采用扩大的端侧吻合法完成主动脉弓部重建，同期矫治心内合并畸形。4例未合并心内畸形患者经左胸廓后外侧切口采用扩大的端侧吻合法重建主动脉弓。术后随访重点关注主动脉弓复发梗阻、左心室流出道梗阻和气管狭窄等并发症。结果手术死亡3例，病死率6.5%。余43例患者手术获得成功。39例患者采用胸骨正中切口在深低温停循环下完成手术，停循环时间（16±3）min。8例患者延迟关胸，余均一期闭合胸骨。术后机械通气时间（3.4±1.6）d（范围：2～12 d）；ICU停留时间（6.4±2.7）d（范围：3～16 d）。术前16例患者存在不同程度的气管狭窄，存活患者术后均顺利脱离气管插管，无新发气管受压狭窄病例。出院时上下肢血压无明显残余压差，复查超声心动图提示主动脉弓降部血流通畅。随访（36.2±18.9）个月（范围：6个月至7年）。失访2例，远期死亡1例。复发主动脉弓部梗阻者4例，其中2例重度狭窄，2例患者轻度狭窄，术前左心室流出道梗阻2例，随访无明显加重，新发左心室流出道梗阻2例，均为轻-中度，暂未手术。术前气管狭窄患者术后均缓解，无复发气管狭窄病例。结论扩大的端侧吻合重建主动脉弓并一期矫治合并心内畸形治疗主动脉弓中断疗效满意。充分游离，确保无张力吻合是预防术后并发症和远期梗阻复发的关键。

ObjectiveTo review the early and mid-term results of end-to-side anastomosis technique for interrupted aortic arch in neonates and infants.MethodsClinic data of 46 patients were diagnosed as interrupted aortic arch in Department of Cardiac Surgery, Guangzhou Women and Children′s Medical Center between January 2010 and December 2016 were analyzed retrospectively. Twenty-six cases were neonates. The median age underwent surgery was 23 days （range： 2 days to 8 years）. Anatomical subtypes included 36 cases of type A and 10 cases of type B. There was no type C case. The reconstruction of the aortic arch was completed by an extended end-to-side anastomosis technique between the descending aorta and the undersurface of the proximal aortic arch. In 42 patients, all with intracardiac anomalies, had concomitant complete repair of intracardiac anomalies through a median sternotomy. The remaining 4 patients, all without intracardiac anomalies, an end-to-side anastomosis was constructed through a left thoracotomy. During follow-up, aortic arch recurrent obstruction, left ventricular outflow tract obstruction （LVOTO） and tracheal stenosis were focused.ResultsThere were 3 surgical deaths, with amortality rate of 6.5%. The remaining 43 patients survived after surgery. In 39 of these patients, deep hypothermic cardiac arrest （DHCA） strategy was used for brain protection, and the mean time of DHCA was （16±3） minutes. Eight patients underwent delayed sternal closure. The mean mechanical ventilation time and ICU stay time were （3.4±1.6） days （range： 2 to 12 days） and （6.4±2.7） days （range： 3 to 16 days） respectively. In 16 patients, all with tracheal or bronchial stenosis before surgery, mechanical ventilation was successfully evacuated, and no new airway stenosis occurred. There was no residual pressure difference between upper and lower extremity arterial blood pressure at discharge. Echocardiography showed normal arterial blood flow velocity in aortic arch. At a mean follow-up of （36.2±18.9） months （range： 6 months to 7 years）, there were two patients lost and one late date. Four patients developed a recurrent stenosis at the aortic arch, of which two were severe, and the other two were mild. In 2 patients, both with mild LVOTO before surgery, no significant increase in the degree of obstruction was found during the follow-up. Two patients developed new mild to moderate LVOTO without clinical symptoms, and continued to follow up. In all patients, the tracheal or bronchial stenosis were extenuated, and there was no new progressive airway stenosis by regular bronchoscopy.ConclusionsThe end-to-side anastomosis technique for the reconstruction of the aortic arch achieved excellent early and mid-term results in neonates and infants suffered from interrupted aortic arch. Reducing the anastomotic tension by extensive mobilization is the key to prevent postoperative early complications and late recurrent arch obstruction.