左冠状动脉起源于肺动脉术后延迟拔管原因分析

Causes of delayed extubation after left coronary artery originating from pulmonary artery

目的分析左冠状动脉起源于肺动脉(anomalous origin of the left coronary artery from pulmonary artery,ALCAPA)患儿术后早期延迟拔管的影响因素。方法收集首都医科大学附属北京安贞医院2012年1月至2020年12月期间明确诊断为ALCAPA并进行手术矫治的44例患儿临床资料,其中男19例,女25例,年龄范围为2个月至15岁,体重范围为4~97 kg,中位有创通气时间为66 h。根据有创通气时间进行分组,将有创通气时间>66 h作为延迟拔管组,共23例;将有创通气时间≤66 h作为非延迟拔管组,共21例。超声检查记录所有患儿左心室射血分数(left ventricular ejection fraction,LVEF)及二尖瓣瓣膜反流情况,收集两组患儿诊断分型、术前红细胞压积、手术方式、术后早期并发症及血管活性药指数评分(vasoactive-inotropic score,VIS)等资料。应用多因素Logistics回归分析,探究ALCAPA术后延迟拔管的影响因素。结果所有患儿中,成人型占59.1%(26/44),婴儿型占40.9%(18/44)。冠状动脉移植术43例,Takeuchi术1例。术前二尖瓣轻度反流或无反流21例,中、重度反流23例。术后早期并发症12例,其中4例为残留肺动脉瓣上狭窄。术后延迟关胸11例,应用体外膜氧合5例。与非延迟拔管组相比,延迟拔管组患儿的中位年龄较小为0.67岁,术前红细胞压积较低为(32.32±3.72)%,两组间比较差异均具有统计学意义(P<0.05)。延迟拔管组术前诊断为婴儿型占65.2%(15/23),术前二尖瓣反流为中、重度占73.9%(17/23),高于非延迟组的14.3%(3/21)和28.6%(6/21),差异均具有统计学意义(P<0.05)。延迟拔管组患儿术后24 h的LVEF为(42.77±20.60)%,低于非延迟拔管组的(57.80±10.66)%;术后24 h最大VIS为(16.94±9.92),高于非延迟拔管组的(9.87±3.99);术后并发症发生率为43.5%(10/23),高于非延迟拔管组的9.5%(2/21),两组间比较差异均具有统计学意义(P<0.05)。结论年龄是ALCAPA术后延迟拔管的影响因素,患儿年龄越大,延迟拔管的风险越小。

Objective To explore the influencing factors of early postoperative delayed extubation in children with anomalous origin of the left coronary artery from the pulmonary artery(ALCAPA).Methods From January 2012 to December 2020,clinical data were reviewed for 44 children with a definite diagnosis of ALCAPA undergoing surgical repair.There were 19 boys and 25 girls with an age range of 2 to 180 months and a weight range of 4 to 97 kg.The median invasive ventilation time was 66 h.According to the invasive ventilation time,two groups of delayed extubation(n=23,invasive ventilation time>66 h)and non-delayed extubation(n=21,invasive ventilation time≤66 h).Left ventricular ejection fraction(LVEF)and mitral regurgitation were recorded by ultrasonography.Diagnostic classification,preoperative hematocrit,surgical approaches,early postoperative complications and vasoactive index score(VIS)were recorded.Multivariate Logistic regression analysis was performed for examining the influencing factors of delayed extubation after ALCAPA.Results Among them,59.1%(26/44)were adults type and 40.9%(18/44)infants type.Coronary artery transplantation(n=43)and Takeuchi procedure(n=1)were performed.Mitral regurgitation was mild/no(n=21)and moderate/severe(n=23).There were early postoperative complications(n=12),including residual supravalvular pulmonary stenosis(n=4).There were delayed chest closure(n=11)and extracorporeal membrane oxygenation(n=5).Compared with non-delayed extubation group,median age was 0.67 year and preoperative hematocrit(32.32±3.72)%in delayed extubation group and there were significant inter-group differences(P<0.05).In delayed extubation group,65.2%(15/23)were preoperatively diagnosed as infantile type and 73.9%(17/23)had moderate/severe preoperative mitral regurgitation.It was higher 14.3%(3/21)and 28.6%(6/21)in non-delayed group and the differences were statistically significant(P<0.05).At 24h postoperatively,LVEF was(42.77±20.60)%in delayed extubation group and it was lower(57.80±10.66)%in non-delayed extubation group;maximum VIS at 24 h postoperatively was(16.94±9.92).It was higher than(9.87±3.99)in non-delayed extubation group;the incidence rate of postoperative complications was 43.5%(10/23).It was higher than 9.5%(2/21)in non-delayed extubation group and inter-group differences had statistical significance(P<0.05).Conclusions Age is a contributing factor for delayed extubation after ALCAPA surgery.And older children are associated with a lower risk of delayed extubation.