左心辅助在左冠状动脉起源于肺动脉患者围手术期的应用  

The left ventricular assistance device was used for anomalous origin of the left coronary artery from the pulmonary artery in perioperative period

作　　者：仇黎生 郁夏风 刘锦纷[1] 张蔚[1] 

机构地区：[1]上海交通大学医学院附属上海儿童医学中心心胸外科,200127

出　　处：《中华外科杂志》2015年第6期430-435,共6页Chinese Journal of Surgery

摘　　要：目的 探讨和总结左心辅助（LVAD）在左冠状动脉起源于肺动脉（ALCAPA）患者围手术期治疗中的应用方法和经验.方法 回顾性分析2006年5月至2013年5月上海交通大学医学院附属上海儿童医学中心心胸外科29例接受手术治疗的具有婴儿型冠状循环的ALCAPA患者.年龄3.3～12.1个月,体重4.1 ～9.5 kg.术前射血分数23％ ～ 45％,临床表现为严重心功能不全症状.合并二尖瓣中重度关闭不全8例,中度以下关闭不全21例.重建左冠状动脉的方法包括带蒂左冠状动脉直接与升主动脉左侧吻合6例,部分肺动脉壁和主动脉壁或心包片作左冠状动脉延伸与升主动脉左侧吻合19例,建立肺动脉内通道与升主动脉开窗吻合（Takeuchi方法）4例.对合并二尖瓣重度关闭不全者作二尖瓣瓣环环缩整形（5例）.术后单独用药物治疗22例,2010年1月后,3例患者于术毕、4例于术后24 h内,因低血压、心律失常应用LVAD治疗.结果 术毕经食管超声检查,左冠状动脉血流通畅,左心室明显增大.单独用药物治疗组22例中,18例循环稳定,3例在术后24 h内死于严重低心排血量和心室颤动,1例在术后72 h死于弥漫性血管内凝血.LVAD治疗组7例中,6例应用LVAD时间72 ～ 108 h,循环稳定后拆除LVAD,1例死于多器官功能衰竭.患者住院病死率5/29（17.2％）.19例术后随访1～7年,超声心动图提示左冠状动脉血流通畅,二尖瓣中度关闭不全2例,轻-中度关闭不全9例,轻度关闭不全8例,射血分数43％ ～ 55％.心电图提示未见显著心律失常.结论 婴儿型ALCAPA远期预后良好,但术后早期病死率较高.即使有术中良好的心肌保护措施,术后仍易发生严重心律失常、心功能衰竭.术后全面评估心功能状况并及时安置LVAD以度过急性左心衰竭期,是降低病死率的有效方法.Objective To review the experience of left ventricular assistance device （LVAD） using for anomalous origin of the left coronary artery from the pulmonary artery （ALCAPA） in perioperative period.Methods There were 29 patients with ALCAPA underwent surgical repair from May 2006 to May 2013.The mean age was 6.5 months （ranging from 3.3 to 12.1 months）.The mean weight was 6.2 kg （ranging from 4.1 to 9.5 kg）.Diagnosis was established by echocardiography in all patients.There were clinical symptomatic of the severe heart dysfunction and ejection fraction were 23% to 45%.Mitral insufficiency was moderate to severe in 8 patients and less than moderate in others.Surgical methods included the intrapulmonary tunnel （Takeuchi procedure） of 4 cases,direct reimplantation of the left coronary artery onto the aorta of 6 cases and reimplantation by pericardiac patch enlarge of 19 cases.Valvuloplasty were performed in 5 patients with mitral severe insufficiency.Twenty-two patients were treated only by medicine therapy.LVAD was used in 7 patients：there were 3 patients with low blood pressure at the end of surgical repair and 4 patients with low cardio output within 24 hours postoperatively.Results Postoperatively,transesophageal echocardiography demonstrated that blood flow of the left coronary artery is fluently but left ventricular is also largement.The hemodynamic of 18 patients was stable in medicine group but 3 patients were sudden died of low cardiao output and ventricular fibrillation respectively.One patient was died of diffuse intravascular coagulation at the time of 72 hours after operation.The hemodynamic was stable in 6 patients in LVAD group and the devices after using time from 72 to 108 hours was taken down except one patient died of multi-organ dysfunction.The hospital mortality was 5/29 （17.2%）.Nineteen survival （19/24） was followed up of 3.5 years （ranging from 1 to 7 years）.Reoperations was performed for one patient with the supravalvar pulmonary stenosis due to the Takeuchi proc

关 键 词：心脏缺损 先天性 冠状血管畸形 心脏辅助装置 婴儿 

分 类 号：R726.5[医药卫生—儿科]