冠状动脉异常起源于对侧冠状动脉窦的临床治疗经验

Clinical Strategies of Anomalous Aortic Origin of the Coronary Artery Arising from the Opposite Sinus

目的总结冠状动脉异常起源于对侧冠状动脉窦(AAOCA)的临床治疗经验。方法回顾性分析阜外医院2005年l0月至2017年9月收治的64例AAOCA患者的临床资料,根据患者年龄及临床症状将其分为青少年组及中老年组。青少年组8例,其中男5例,女3例;年龄11~29岁,年龄平均(15.9±11.2)岁;中老年组56例,其中男39例,女17例,年龄30~75岁,年龄平均(54.2±10.3)岁。回顾性分析两组患者临床表现,治疗方法及效果,死亡率和并发症发生率。结果青少年组8例患者均为左冠状动脉异常起源于右冠窦(AAOLCA),并走行于主动脉与肺动脉之间,其中5例为壁内走行;患者均有运动后晕厥、急性心肌梗死、猝死等临床表现。其中5例施行去顶术,1例施行冠状动脉再植术,另2例行CABG术。中老年组56例患者中右冠状动脉异常起源于左冠窦者(AAORCA)为49例,AAOLCA7例,其中29例患者冠脉走行于主动脉与肺动脉之间。治疗方案包括:CABG 3例,PCI 10例,射频消融7例,起搏器植入3例,ASD修补术同时行冠状动脉去顶术1例,保守对症治疗32例。两组患者术后均无严重并发症及住院死亡。术后随访时间为6个月至12年,随访期间青少年组患者无死亡,心功能恢复正常。1例患者CABG术后1年行冠脉CTA检查,发现LIMA血管桥未见显影。中老年组随访过程中失访5例,死亡2例,其中1例死于急性心肌梗死,另1例非心源性死亡。接受保守治疗的患者中6例症状反复发作。结论青少年时期发病的AAOCA患者多为AAOLCA,异常起源的冠脉走行于主动脉与肺动脉之间,心源性猝死发生率高,一经确诊需尽早手术治疗。手术方法推荐冠脉去顶术及冠脉再植术,不推荐CABG。中老年发病的AAOCA患者多为AAORCA,猝死发生率较低,合并症多,建议采用保守对症治疗。

Objective To summarize the experience of the clinical treatment and strategies of anomalous aortic origin of the coronary artery arising from the opposite sinus（AAOCA）. Methods We retrospectively analyzed the clinical data of 64 patients with AAOCA in our hospital between October 2005 and Setember 2017. They were divided into 2 groups： group 1 included 8 young people and adolescents（11-29 years）; and group 2 included 56 middle aged and elderly patients（30-75 years）. Definitive diagnosis was achieved with coronary angiography and computed tomography scan. Results All the 8 patients of group 1 presented with myocardial infarction, heart failure, syncope and sudden death, the anomalous origin of the LCA from the right sinus（AAOLCA） had an intramural course except 3 cases with interarterial（but not intramural） course. All the 8 patients underwent surgical procedures, included 5 cases of unroofing of an intramural segment, 2 cases of CABG and 1 case of direct re-implantation of the coronary artery into the appropriate sinus of Valsalva. There was no death in-hospital. During the follow-up period, no patient died due to cardiac reason. One patient underwent CABG was reported early graft failure 1 year after surgery due to competitive flow from patent native vessels. In group 2, 49 cases of 56 patients（87.5%） were AAORCA and 7 cases（12.5%） were AAOLCA. The symptoms included palpitation, angina pectoris, arrhythmias, but without sudden death. The clinical treatments involved 3 cases of CABG, 1 case unroofing procedure, 10 cases of PCI, 7 cases of radiofrequency ablation, 3 cases of pacemaker implantation and 32 cases of conservative managements. During the follow-up period, 1 patient died due to myocardial infarction who received conservative managements and 1 patient died due to noncardiac reason. Six patients who received conservative managements had recurrent symptoms of angina pectoris. Conclusion Surgical interventions performed on younger AAOCA（with interarterial course） patients are considered to be the standard treatment, especially in symptomatic AAOLCA patients. Conservative managements are recommended in middle aged and elderly patients of AAOCA.