Anomalous origin of the left coronary artery from the pulmonary artery: late results with special attention to the mitral valve
Anomalous origin of the left coronary artery from the pulmonary artery: late results with special attention to the mitral valve
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DOI：
10.1016/j.ejcts.2009.03.014
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发表时间：
2009-08-01
影响因子：
3.4
通讯作者：
Vouhe, Pascal R.
中科院分区：
文献类型：
--
作者：
Ben Ali, Walid;Metton, Olivier;Vouhe, Pascal R.
目的：评价统一入路治疗左冠状动脉起源异常(ALCAPA)的远期疗效。方法：1986-2007年间，62例ALCAPA患儿接受了手术治疗。中位年龄16个月(10天~11岁)。采用统一的方法，包括(1)确诊后立即手术，(2)在技术可行的情况下直接行主动脉再植入术(61/62，98%)，(3)无论二尖瓣返流的严重程度如何，不同时行二尖瓣手术(59/62，95%)。平均随访9.7年(3个月~21年)，完成率为98%。结果：住院死亡6例(9.7%)。四名患者接受了左心室辅助治疗，两名患者死于相关并发症。较差的左心室射血分数是早期死亡率的递增风险因素(p=0.043)；二尖瓣返流的严重程度不是。有两例晚期死亡，15年后的精算存活率为86%。5例再次手术(3例二尖瓣修补术，2例冠状动脉手术)；15年后再手术的精算率为89%。所有幸存者的左心功能均已恢复。50例初次手术未行二尖瓣手术的晚期存活者，二尖瓣返流严重程度减轻者占58%，无变化者占40%(其中3例再次手术行二尖瓣修补术)，恶化者占2%，末次随访二尖瓣返流消失或轻微者占42%，轻度者占50%，中度者占8%，重度者占0%。结论：(1)早期死亡率与术前左心功能不全的严重程度有关，术后慎用心脏支持技术可降低死亡率。(2)远期疗效满意，左心功能总能恢复。(3)二尖瓣返流随着左心功能的改善而改善，但恢复可能不完全，需要再次手术。这些数据表明，二尖瓣手术可能不是最初手术的适应症，除非是在有两种恢复潜力的特定病例中(严重反流，左心功能相对保存良好)。(C)2009年欧洲胸心外科协会。爱思唯尔出版，保留Alt版权所有。
Objective: Evaluate the late results of a uniform approach to the surgical management of children with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). Methods: Between 1986 and 2007, 62 children with ALCAPA underwent surgery. The median age at operation was 16 months (range 10 days to 11 years). A uniform approach was applied, including (1) immediate surgery as soon as the diagnosis was established, (2) direct aortic reimplantation of the anomalous artery, when technically feasible (61/62, 98%), and (3) no concomitant mitral valve surgery, regardless of the severity of mitral regurgitation (59/62, 95%). The mean follow-up was 9.7 years (range 3 months to 21 years) and was 98% complete. Results: There were six hospital deaths (9.7%). Left ventricular assistance was used in four patients; two died of related complications. The poor left ventricular ejection fraction was an incremental risk factor for early mortality (p = 0.043); severity of mitral regurgitation was not. There were two late deaths, yielding an actuarial survival rate of 86% at 15 years. Five patients underwent reoperation (mitral valve repair in three, coronary procedure in two); the actuarial freedom from reoperation was 89% at 15 years. Left ventricular function recovered in all survivors. In the 50 late survivors who did not undergo mitral surgery at initial operation, the severity of mitral regurgitation decreased in 58%, remained unchanged in 40% (of which 3 patients underwent reoperation for mitral valve repair) and worsened in 2%; at last follow-up, mitral regurgitation was absent or trivial in 42%, mild in 50%, moderate in 8% and severe in 0%. Conclusions: (1) Early mortality is related to the severity of preoperative left ventricular dysfunction; it may be reduced by a careful use of postoperative cardiac support techniques. (2) Late results are satisfactory and left ventricular function always recovers. (3) Mitral regurgitation improves along with left ventricular function, but recovery may be incomplete and need reoperation. The data suggest that mitral valve surgery is probably not indicated at initial surgery, except in selected cases with a tow potential of recovery (severe regurgitation with relatively well-preserved left ventricular function). (C) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. Alt rights reserved.