自体肺动脉补片和扩大端端/端侧术矫治婴幼儿主动脉缩窄疗效分析

Comparative study of autologous pulmonary patch and extended end-to-end/end-to-side anastomosis for treating the infants with aortic coarctation combining hypoplastic aortic arch

目的:比较分析本中心主动脉弓肺动脉补片成形术和扩大端端或端侧吻合术治疗主动脉缩窄(CoA)伴主动脉弓发育不良(HAA)的矫治效果,为临床提供更合理的手术方法。方法:回顾性分析手术方法为肺动脉补片成形和扩大端端/端侧矫治的87例CoA伴HAA患儿临床资料,其中42例患儿采用自体肺动脉补片加宽术为肺动脉补片组,45例患儿采用扩大端端/端侧吻合术为扩大端端组。比较分析2组患儿手术前后缩窄段压差及主动脉Z值变化,并进行随访。结果:术后早期扩大端端组死亡患者1例;余86例中发生严重并发症19例,其中肺动脉补片组8例,扩大端端组11例,19例患者经积极治疗后均顺利康复,全组未发现明显脑部并发症。肺动脉补片组体外循环时间、主动脉阻断时间及呼吸机辅助时间与扩大端端组相比,差异无统计学意义(P>0.05),但肺动脉补片组选择性脑灌注时间及ICU时间明显延长(P<0.05),超声所测肺动脉补片组术后早期平均缩窄段压差较术前显著降低[(9.7±3.5)mmHg∶(36.8±12.5)mmHg,P<0.05],横弓及峡部Z值较术前明显增高[(-0.50±0.21)、(-0.45±0.24)∶(-3.38±0.64)、(-2.22±0.43),P<0.05)];扩大端端组术后早期平均缩窄段压差较术前显著降低[(9.5±3.3)mmHg∶(37.2±8.9)mmHg,P<0.05],横弓及峡部Z值较术前明显增高(-0.52±0.29、-0.48±0.22∶-3.89±0.61、-2.45±0.33,P<0.05)。随访75例,随访4~106(32±12.8)个月,肺动脉补片组发生再缩窄5例,2例已行主动脉球囊扩张术,其余3例继续随访;扩大端端组发生再缩窄3例(6.98%),2例已行球囊扩张术,1例继续随访。Kaplan-Meier曲线分析表明,扩大端端补片组免于再狭窄率稍优于肺动脉补片组,但差异无统计学意义(P>0.05)。结论:自体肺动脉成形及扩大端端/端侧吻合术均为矫治CoA伴HAA较为理想手术方式,早期矫治效果无明显差异,中期随访表明扩大端端组矫治效果稍优于肺动脉补片组。

Objective：To compare and evaluate the effects of autologous pulmonary artery aortoplasty and extended end-to-end/end-to-side anastomosis for the treatment of coarctation of the aorta（CoA）and hypoplastic aortic arch,and provide a more reasonable surgical choice for clinical practice.Method：From May 2009 to May 2017,87 patients who underwent surgical correction of coarctation of the aorta with hypoplastic aortic arch through pulmonary artery aortoplasty or extended end-to-end/end-to-side anastomosis,were retrospectively analyzed.These patients were divided into 2 groups：Pulmonary patch group,n=42,and extended end-to-end group,n=45.The changes of trans-coarctation gradient and aortic Z value at post-operation and follow-up period were compared and analyzed.Result：One patient from extended end-to-end group died during early postoperative period.Severe complications occurred in 19 patients,8 among them in Pulmonary patch group,the other 11 in extended end-to-end group.All the 19 cases were cured afterward by active correspondent treatments,and no neurological complication occurred in either group.The cardiopulmonary bypass time,aortic clamping time and ventilator time were similar between 2 groups（P0.05）.Selective cerebral perfusion time and ICU stay time in extended end-to-end group was shorter than Pulmonary patch group（P0.05）.The post-operative trans-coarctation gradients in Pulmonary patch group were decreased than preoperative[（9.7±3.5 mmHg）vs（36.8±12.5 mmHg）,P0.05].The Z value of transverse arch aortic and isthmus in Pulmonary patch group were increased than preoperative[（-0.50±.50）,（-0.45±.45）vs（-3.38±0.64）,（-2.22±0.43）,P0.05）].The post-operative trans-coarctation gradients in extended end-to-end group were decreased than preoperative（9.5±3.3 mmHg vs 37.2±8.9 mmHg,P0.05）.The Z value of transverse arch aortic and isthmus in extended end-to-end group were increased than preoperative（-0.52±0.29,-0.48±0.22 vs-3.89±0.61,-2.45±0.33,P0.05）.Kaplan-Meier curves presented that Extended end-to-end group was superior to Pulmonary patch group in re-stenosis occurrence,but the difference was not statistically significant.Conclusion：Both autologous pulmonary patch aortoplasty and extended end-toend/end-to-side anastomosis were effective for these patients.The early post-operative effcacy was similar,while the mid-term follow-up result was better in extended end-to-end group.