Online ISSN: 2187-2988 Print ISSN: 0911-1794
特定非営利活動法人日本小児循環器学会 Japanese Society of Pediatric Cardiology and Cardiac Surgery
Pediatric Cardiology and Cardiac Surgery 39(1): 31-36 (2023)

症例報告Case Report

大動脈縮窄術後再狭窄および大動脈弁閉鎖不全症に対して側開胸を併施した正中アプローチによる再手術の1例Combined Full Median Sternotomy with Left Thoracotomy Approach for Recoarctation of the Aorta Associated with Aortic Regurgitation

1東北大学大学院医学系研究科心臓血管外科学分野Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine ◇ Miyagi, Japan

2東北大学大学院医学系研究科発生・発達医学講座小児病態学分野Department of Pediatrics, Tohoku University Graduate School of Medicine ◇ Miyagi, Japan

受付日:2022年10月12日Received: October 12, 2022
受理日:2023年2月1日Accepted: February 1, 2023
発行日:2023年2月1日Published: February 1, 2023

症例は12歳の男児で,出生後,大動脈縮窄症,心室中隔欠損症と診断され,生後1か月時に左側開胸にて拡大大動脈弓吻合法による手術が施行された.術後再狭窄を認め,バルーン血管形成術を5か月,3歳時に施行された.11歳時の精査で全長4 cmにわたる最小径5 mm, 圧較差50 mmHgに狭窄が進行した.また,大動脈弁逆流の進行も認めた.再手術に伴う大動脈周囲の高度な癒着,選択的脳分離体外循環の確立,大動脈弁閉鎖不全症と心室中隔欠損に対する外科的治療,これらの要素から胸骨正中切開と左前側方開胸を用いた下行大動脈人工血管置換,大動脈弁置換,心室中隔欠損閉鎖術を施行した.術後の上下肢圧較差は消失した.胸骨正中切開および左開胸アプローチは手術侵襲が大きいものの,安全に選択的脳分離体外循環を確立でき,解剖学的修復という観点から大動脈縮窄の根治性が高く,また心内修復も併施可能な手法である.

A 12 years-old boy was identified with coarctation of the aorta and ventricular septal defect at birth. He received extended aortic arch anastomosis for the coarctation of the aorta at the age of 1 month. He required a treatment with balloon angioplasty postoperatively for recurrent coarctation twice. On the other hand, recurrent coarctation subsequently occurred and severe aortic valve regurgitation also emerged. The recurrent coarctation developed to a minimum diameter of 5 mm and a pressure gradient of 50 mmHg across a total length of 4 cm of stenotic lesion by close examination at the age of 11 years. Moreover, severe aortic valve regurgitation was found. He had descending thoracic aortic replacement, aortic valve replacement, and ventricular septal defect closure through combined median sternotomy and left antero-lateral thoracotomy, taking considering factors such as anticipated severe adhesion around the aorta, secured establishment of selective cerebral perfusion and facilitated intracardiac repair. The postoperatively, the pressure gradient between the upper and lower limbs was diminished. Although catheter intervention and extraanatomical bypass have been variably reported for patients with recurrent coarctation, these procedures leave specific concerns in the late term. On the other hand, combined median sternotomy and left antero-lateral thoracotomy could facilitate the intracardiac repair and allow us to complete a highly curative procedure conforming anatomical repair of coarctation at the expense of seemingly excessive invasiveness.

Key words: recurrent coarctation; extended aortic arch anastomosis; graft replacement; anatomical reconstruction

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