儿童先天性冠状动脉瘘并巨大冠状动脉瘤的治疗及随访  

Treatment and follow-up of congenital coronary artery fistula with giant coronary artery aneurysm in children

作　　者：王燕飞 黄萍[1] 张丽[1] 汪周平[1] 李伟[1] 谢小斐[1] 杨盛春[2] 邹明晖[2] 陈欣欣[2] Wang Yanfei;Huang Ping;Zhang Li;Wang Zhouping;Li Wei;Xie Xiaofei;Yang Shengchun;Zou Minghui;Chen Xinxin(Department of Pediatric Cardiology,Guangzhoa Women and Children's Medical Center,Guangzhou Medical University,Guangzhou 510623,China;Department of Cardiac Surgery,Guangzhou Women and Children's Medical Center,Guangzhou Medical University,Guangzhou 510623,China)

机构地区：[1]广州医科大学附属广州市妇女儿童医疗中心心脏内科,510623 [2]广州医科大学附属广州市妇女儿童医疗中心心脏外科,510623

出　　处：《中华实用儿科临床杂志》2019年第1期43-46,共4页Chinese Journal of Applied Clinical Pediatrics

基　　金：国家自然科学基金(81100233);广州市科技计划项目(201510010287).

摘　　要：目的总结儿童先天性冠状动脉瘘并巨大冠状动脉瘤的疗效及随访结果。方法对2009年7月至2016年12月在广州医科大学附属广州市妇女儿童医疗中心诊断为先天性冠状动脉瘘并巨大冠状动脉瘤的13例病历资料进行回顾性分析,其中男8例,女5例;年龄40 d^12岁(中位年龄18个月);体质量3.8~29.0 kg(中位体质量8.8 kg)。瘘口发生于右冠状动脉8例,左冠状动脉5例。瘘入右心房3例,右心室8例,左心室2例,多发瘘口1例,冠状动脉瘤的直径8~16 mm(平均9.2 mm)。结果本组病例中,1例表现为气促、生长发育落后、听诊无明显杂音,其余12例无明显临床症状,均在常规体检时发现心脏杂音而就诊。1例在非体外循环下行瘘管结扎术,12例在体外循环下行冠状动脉瘘矫治术(10例直接缝闭瘘口,2例心包补片连续缝合瘘口),术中对巨大冠状动脉瘤未予特殊处理。其中2例并房间隔缺损,术中同时行房间隔缺损修补术。住院时间(11.0±2.5) d。其中2例术后3 d内出现射血分数下降最低至38%,术后1个月复查时升至50%以上,7例术后出现一过性T波改变,2例术后出现1~2 mm残余瘘。无死亡病例。术后所有患儿均服用抗血小板药物(12例服用阿司匹林,1例服用双嘧达莫),剂量为3~5 mg/(kg·d),服用时间3 d^13个月,服用抗血小板药物中位时间为1个月。随访8个月~8年,患儿均无明显症状,心电图未提示心肌缺血,复查超声心动图提示心功能正常,冠状动脉直径较术前无明显变化,冠状动脉内无血栓形成。结论儿童先天性冠状动脉瘘可并巨大冠状动脉瘤,应尽早手术,对儿童患者冠状动脉瘤的处理和术后抗凝药及抗血小板药物的使用目前尚缺乏循证依据,仍需长期随访。Objective To analyze the treatment and follow-up of congenital coronary artery fistula (CAF) with giant coronary artery aneurysm (GCAA) in children. Methods The clinical data were analyzed retrospectively in 13 patients who were diagnosed as congenital CAF with GCAA between July 2009 and December 2016 in Guangzhou Women and Children′s Medical Center.There were 8 boys and 5 girls.The median age was 18 months, ranging from 40 days to 12 years old.The body weight ranged from 3.8 kg to 29.0 kg with a median of 8.8 kg.Fistulas originated from right coronary artery accounted in 8 patients, with 5 from left coronary artery.Fistulas drained into right atrium in 3 patients, right ventricular in 8 patients and left ventricular in 2 patients.Single fistula occurred in 12 patients and multiple fistulas in 1 patient.The diameter of coronary artery aneurysm ranged from 8 mm to 16 mm with a median of 9.2 mm. Results One patient had tachypnea and growth retardation without heart murmur.The other 12 patients were asymptomatic with heart murmurs occasionally found in routine physical examination.One patient underwent fistula ligation without cardiopulmonary bypass (CPB). The remaining 12 cases received fistula correction with beating heart CPB.Direct suture was used in 10 patients and autologous pericardial patch in other 2 patients.Two patients were associated with atrial septal defect (ASD) and underwent repair of ASD concurrently.The coronary artery aneurysm remained ori-ginal shape without any intervention during the operation.The mean hospital delay was (11.0±2.5) days.Two patients had decreased ejection fraction as low as 38% within 3 days after the operation, but went up to over 50% in follow-up 1 month later.Transient T wave change occurred in 7 patients, and another 2 patients showed a residual shunt with size of 1 to 2 millimeters through the fistula without further intervention after the surgical closure.All 13 patients had antiplatelet therapy with 12 taking Aspirin and one taking Dipyridamole.The dosage was 3-5 mg/

关 键 词：冠状动脉瘘 儿童 巨大冠状动脉瘤 抗血小板 随访 

分 类 号：R725.4[医药卫生—儿科]