成人左冠状动脉起源于肺动脉的外科治疗

摘要

目的 总结成人左冠状动脉起源于肺动脉的外科治疗结果及经验.方法 2006年2月至2014年10月,共收治19例年龄大于18岁左冠状动脉起源于肺动脉患者,其中男5例,女14例,年龄(35.3±11.7)岁,体质量(61.2±9.4) kg.术前心电图正常1例,完全性右束支传导阻滞1例,异常Q波形成4例,ST-T改变13例.12例冠状动脉造影、4例CT提示左右冠状动脉间大量侧支循环形成,3例术前未行冠状动脉造影或CT检查.术前超声心动图显示左心室射血分数(LVEF)0.60±0.07,左心室舒张末内径(LVEDD)(52.4±4.4) mm;二尖瓣反流(MR)重度2例,中度3例,轻度4例.行Takeuchi术7例,左冠状动脉结扎+冠状动脉旁路移植术2例,冠状动脉再植10例,其中二尖瓣成形2例.结果 术中探查发现左冠状动脉起源于肺动脉位置:左前2例,左后7例,右侧4例,右后6例.所有患者无住院死亡.体外循环(144.5 ±66.9) min,主动脉阻断(96.4±38.8)min,呼吸机辅助(12.9±3.7)h,ICU滞留(39.2±12.5)h.术后LVEF 0.62±0.04,LVEDD (45.8±5.5) mm.术后MR轻度1例,微量4例.随访16(84.2％)例,平均19.2个月,随访期间无死亡和再次手术及入院,所有患者心功能分级NY-HA Ⅰ或Ⅱ级;最后一次随访LVEF 0.63±0.05,LVEDD(49.2 ±4.6)mm;MR轻度6例,微量3例.结论 成人左冠状动脉起源于肺动脉发病隐匿,一经诊断即需手术治疗,治疗方法首选冠状动脉再植,对于合并二尖瓣反流患者,应遵循成人二尖瓣反流治疗原则.%Objective To review the experience of the surgical treatment of adult patients with anomalous left coronary artery from the pulmonary artery(ALCAPA).Methods A retrospective,single institution review was conducted on nineteen adult patients with ALCAPA surgical treatment from February 2006 to October 2012.Of these patients,five were males and fourteen were females.The age was(35.3 ± 11.7) years.The weight was (61.2 ± 9.4) kg.Most patients showed some evidence of myocardial infarction or ischemia with either abnormal Q waves (4) or ST-T abnormality (13).Twelve patients with coronary angiography and four patients with coronary CT scan showed good coronary collateralization.The preoperative UCG showed the mean left ventricular ejection fraction(LVEF) was 0.60 ± 0.07,and the mean left ventricular end-diastolic dimension(LVEDD) was(52.4 ± 4.4) mm.Severe mitral regurgitation(MR) was seen in two patients,moderate in three patients and mild in four patients.The operative procedures included Takeuchi operation in seven patients,ligation of left coronary artery concomitant with coronary artery bypass graft in two patients,coronary artery re-implantation in ten patients.Of the ten patients with coronary artery re-implantation,two patients underwent mitral valve repair.Results There was no operative mortality.The mean cardiopulmonary bypass time was (144.5 ± 66.9) min and cross-clamp time was (96.4 ± 38.8) min,respectively.The mean mechanical ventilation time was(12.9 ± 3.7) h and intensive care unit time was(39.2 ± 12.5) h,respectively.The mean postoperative LVEF was 0.62 ± 0.04.No significant reduction in LVEDD (45.8 ± 5.5) mm,P ＞ 0.05.Mild and trivial MR were observed in one and four patients,respectively.Sixteen patients(84.2％) completed the follow up with a mean time of 19.2 months.All the patients survived with New York Heart Association class Ⅰ or Ⅱ.During the follow up period,no patient required reoperation or readmission.At the latest echocardiography,the mean LVEF of 0.63 ± 0.05 and mean LVEDD of(49.2 ± 4.6) mm did not significantly improved compared with the data preoperatively or postoperatively.Mild MR was detected in six patients,trivial in three patients during the follow-up period.Conclusion The adult patients with ALCAPA have a dormant disease process.Surgical treatment has been recommended at the time of diagnosis and the coronary re-implantation could be the first choice.As for the concomitant MR,the guideline for the adult MR should be followed.