two-coronary system reconstruction

Coronary artery abnormalities originate from the pulmonary artery refers to a coronary artery or its branches (left anterior descending coronary artery or left circumflex coronary artery) or two coronary arteries originating from the proximal end of the pulmonary trunk or a few originating from the right pulmonary artery. The distribution and movement of the coronary arteries are normal. The Soloff report is divided into five categories, including the left coronary artery, the right coronary artery, two coronary arteries, the additional coronary artery, and the left circumflex coronary artery originating from the pulmonary artery (Fig. 6.17.1.1-0-1). Sometimes the left anterior descending coronary artery can also originate in the pulmonary artery. The purpose of surgery for coronary artery abnormalities originating from the pulmonary artery is to establish a two-coronary system to satisfactorily perfused the myocardium, suppressing and recovering hibernating cardiomyocytes, which contribute to the recovery and improvement of cardiac function. In recent years, aortic implantation can be used for any part of the pulmonary artery originating from the coronary artery, and the treatment effect is satisfactory, thus becoming the first choice for this deformity. Pulmonary artery tunnels have fewer clinical applications due to more postoperative complications and higher reoperation rates. Subclavian artery and coronary artery anastomosis and saphenous vein coronary artery bypass grafting have a high rate of late graft occlusion and are rarely used. Treatment of diseases: coronary heart disease Indication Two-coronary system reconstruction is available for: 1. In critically ill infants with a left coronary artery abnormality originating from the pulmonary artery, once diagnosed, a two-coronary system reconstruction should be performed urgently, without delay. The goal is to restore left ventricular function and protect more viable cells. For cases in which the right coronary artery originates from the pulmonary artery, surgery can be performed at an age of 2 to 4 years. 2. For children with a left coronary artery originating from the pulmonary artery and a child with a right coronary artery originating from the pulmonary artery, aortic implantation is the first choice. If aortic implantation is difficult to perform, intra-pulmonary tunnel (Takeuchi) surgery is used. In adults, internal mammary artery coronary artery bypass grafting is optional. Contraindications In a very small number of cases, the left ventricular function is extremely poor, and severe mitral regurgitation is not suitable for two-coronary system reconstruction. Heart transplantation should be performed. Preoperative preparation 1. Treatment of patients with recent myocardial infarction, including resting, oxygen and morphine if necessary, as well as the use of digitalis, diuretics and appropriate antiarrhythmic drugs. 2. Patients with heart failure and no recent myocardial infarction, using digitalis and diuretics. 3. When the above-mentioned treatment is used and the cardiopulmonary function is unstable, endotracheal intubation and mechanical assisted breathing are performed, and emergency aortic implantation is performed after 3 to 5 days of improvement. 4. Preoperative comprehensive analysis of echocardiography and cardiovascular angiography, etc., decided to choose direct aortic implantation or other surgical methods. 5. According to the infant's open heart surgery, preoperative routine preparation. Patients with poor left ventricular function should be prepared for left ventricular assisted circulation after surgery. Surgical procedure Aortic implantation This procedure involves implanting a branch of the left or right coronary artery or left coronary artery of abnormal origin into the aortic wall. When the abnormal coronary artery opening in the pulmonary artery is far from the aorta, the pulmonary artery wall can be used to form a tube of different length and anastomosis. This procedure is best for infants and young children in any part of the pulmonary artery from which coronary artery abnormalities originate. It can also be applied to large children and adults. The midline of the chest is incision, the thymus is removed and the happy bag is cut. The aortic perfusion tube was inserted near the innominate artery, directly inserted into the right and inferior vena cava right angle tube, and the left heart decompression tube was inserted through the right superior pulmonary vein. Completely free pulmonary trunk and its bilateral pulmonary arteries, a thick line of pulmonary arteries on both sides of the pulmonary trunk. The roots of the pulmonary artery were isolated and the epicardial branches of the left and right coronary arteries and the left coronary artery were explored. A cold blood cardioplegic perfusion tube was inserted into the proximal aorta and the proximal pulmonary artery. Immediately after extracorporeal circulation, the ligaments of both pulmonary arteries were tightened, and the patent ductus arteriosus or ligament was ligated and severed. Cool down to 28 ~ 30 ° C, block the aorta, while injecting cold blood cardioplegia from the aorta and pulmonary artery. After cardiac arrest, the following various operations are performed. (1) Direct aortic implantation of the left coronary artery: The pulmonary artery was incised above the sinus-tube junction, and the position of the origin of the left coronary artery was explored, and the pulmonary artery was transected. A U-shaped piece of the pulmonary artery wall was cut around the abnormal origin opening, and the free left coronary artery facilitated the anastomosis to the aortic wall incision without generating tension. If the abnormal opening of the coronary artery is adjacent to the branch of the pulmonary valve, the junction of the pulmonary artery wall should be free or cut off to form a U-shaped piece of the pulmonary artery wall around the opening. As with aortic transposition, the aorta is transected above the sinus junction, a longitudinal incision or U-shaped incision is made in the upper left sinus of the aorta, and a U-shaped piece containing the opening of the left coronary artery is inserted into the aortic incision or gap to prevent distortion. . A 7-gauge polypropylene line was used to anastomosed the U-shaped piece containing the opening of the left coronary artery to the aortic incision, from the lower edge to the upper edge. Do the end-to-end anastomosis of the proximal and distal aorta. The warming blood cardioplegia was perfused into the ascending aorta, and the anastomosis was observed for blood leakage. If necessary, a few needles were added to stop bleeding. Open the aorta and observe the perfusion and function of the left ventricle. The pericardium was used to repair the U-shaped gap of the pulmonary artery, and the end-to-end anastomosis of the proximal and distal segments of the pulmonary artery was performed. Place the left atrium and right atrial pressure tube and cardiac pacing lead. Rewarming to 37 ° C, stop extracorporeal circulation. Postoperative cardiac function is poor, and dopamine and/or dobutamine are used to enhance myocardial contractility. If it is not possible to bypass the extracorporeal circulation, the left ventricular assisted circulation should be used in time. If the left coronary artery trunk is located on the left side of the pulmonary artery root or on the left side of the right sinus of the pulmonary artery or on the left side of the middle part of the pulmonary artery, where it is far from the aorta, the upper and lower ends of the pulmonary artery are cut into a rectangular shape, and the 7-0 polypropylene is used. The sutures of different lengths were sutured and sutured to the left incision of the aorta. (2) Direct aortic implantation of the right coronary artery: The abnormal origin of the right coronary artery is often located in front of the superior pulmonary artery. After cardiac arrest, the proximal segment of the right coronary artery was separated by approximately 3 cm to facilitate anastomosis to the aorta without tension. The wall of the pulmonary artery was cut around the opening of the right coronary artery and buttoned with the appropriate part of the ascending aorta. The aorta was opened by suturing the incision of the pulmonary artery and exhausting the gas inside the heart. 2. Improved transpulmonary tunnel surgery or modified Takeuchi surgery In the original Takeuchi operation, the pulmonary artery was tunneled through the anterior wall of the pulmonary artery, and the modified Takeuchi was an intra-pulmonary tunnel using expanded polytetrafluoroethylene tablets. This surgical procedure and starting surgical procedure are the same as aortic implantation. At the beginning of extracorporeal circulation, the bilateral pulmonary artery slings must also be tightened, as well as adequate left ventricular decompression. After aortic occlusion and cardiac arrest, a longitudinal incision of the pulmonary artery is explored and an abnormal origin of the left coronary artery is sought. A 5 to 6 mm diameter hole is made above the ascending aortic sinus-tube junction; if there is a doubt, a longitudinal aortic incision is made, through which the hole is made under direct vision to avoid aortic valve injury. Close to the aortic hole, the same size hole was made on the side of the pulmonary artery, and the main-pulmonary window was anastomosed using a 7-0 polypropylene thread. A 4 mm diameter expanded polytetrafluoroethylene tube was longitudinally split and flattened, and an internal tunnel was formed to separate the aortic blood flow through the main-pulmonary window to the left coronary artery opening. Suture was performed from the left side of the coronary artery opening, and the upper edge of the lower edge was first sutured until the main-pulmonary window was covered. After completion of the tunnel in the pulmonary artery, the pericardium is used to enlarge the pulmonary artery incision to prevent stenosis of the superior pulmonary artery. 3. Subclavian artery and left coronary artery anastomosis This procedure can be performed by extracorporeal circulation through the median incision of the chest, or by extracorporeal circulation through the posterolateral thoracic incision. Application of extracorporeal circulation is beneficial to stabilize the condition of critically ill infants and prevent ventricular fibrillation during surgery. Through the median incision in the chest, the left subclavian artery is completely dissociated and as far as possible is ligated and cut at its distal end. After extracorporeal circulation, the temperature was controlled at 35-37 °C without aortic occlusion. The button-shaped pulmonary artery wall was cut around the origin of the left coronary artery abnormality, and the pulmonary artery incision was directly sutured. The left subclavian artery was pulled downward and the button-shaped piece around the opening of the left coronary artery was end-to-end anastomosis. The left chest posterior lateral incision can also be used to make an end-to-side anastomosis of the subclavian artery and the abnormal left coronary artery, and the origin of the left coronary artery is abnormally ligated. 4. Coronary artery bypass grafting Coronary artery bypass grafting is rarely used in cases where the abnormal coronary artery originates from the pulmonary artery. For the treatment of abnormal left coronary artery ligation only after the use of two-coronary system reconstruction or in the internal mammary artery coronary artery bypass grafting. Long-term effects are poor due to the risk of obstruction by coronary artery bypass grafting with saphenous vein. If there is no other graft, the saphenous vein can be applied. complication 1. Low cardiac output syndrome This syndrome is the most common complication of left coronary artery abnormality originating from pulmonary artery surgery. Most patients need drugs such as dopamine and nitroglycerin to support myocardial contractility and improve coronary circulation and peripheral circulation. However, there are also a few critically ill infants who need 2 to 70 hours of left ventricular assisted circulation to recover. Left ventricular mechanical support is often used for cases that cannot be separated from extracorporeal circulation and that require large doses of myocardial contraction drugs to damage the internal organs after surgery. 2. Severe mitral regurgitation before mitral regurgitation, mostly due to papillary muscle fibrosis and prolongation or endocardial calcification extending to the papillary muscles and valves, often can not be reduced after surgery, need to be half a year after surgery One year of elective mitral valve repair and replacement surgery. 3. There are often different degrees of supra-valvular stenosis after Takeuchi surgery, which is significantly reduced after modified Takeuchi surgery. However, in a small number of cases with severe pulmonary stenosis, pulmonary artery dry patch enlargement should be performed again. Both Takeuchi surgery and its improved methods can be combined with partial tearing of the tunnel patch to produce left-right shunt or tunnel obstruction. Echocardiography and cardiovascular angiography should be performed at appropriate time, and the repair of the intra-pulmonary tunnel patch or the internal mammary artery should be performed at an elective stage. Coronary artery bypass grafting. 4. The incidence of late obstruction after high saphenous vein coronary artery bypass grafting was high, and elective internal carotid artery bypass grafting was performed.