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): 3-8 (2023)


先天性心疾患に対する冠動脈移植術に伴う冠動脈閉塞性合併症手術法の検討と提言Coronary Obstructive Complication Following Coronary Transfer Procedures for Congenital Heart Disease: Evaluation of Surgical Managements and Proposal for Guidelines

1公益財団法人 循環器病研究振興財団Japan Cardiovascular Research Foundation ◇ Osaka, Japan

2国立循環器病研究センターNational Cerebral and Cardiovascular Center ◇ Osaka, Japan

受付日:2022年9月9日Received: September 9, 2022
受理日:2022年12月21日Accepted: December 21, 2022
発行日:2023年2月1日Published: February 1, 2023

冠動脈移植手術(coronary transfer)を要する小児期手術後の冠動脈狭窄や閉塞は稀であるが,重篤な合併症で手術死・遠隔死の重要な原因となる.この早期発見と早急な対処は手術成績,遠隔期成績の改善に通じる.この合併症は新生児期に行う大血管転位症に対する動脈スイッチ手術(arterial switch operation: ASO)において特に重要である.低体重で,かつ冠動脈の異常が少なくないからである.この合併症に対して2つの手術法が存在するが,その適応基準は定められていない.1つは外科的冠動脈口パッチ形成術(surgical ostial angioplasty: SOAP),他は内胸動脈グラフトを用いた小児冠動脈バイパス法である(pediatric coronary artery bypass surgery with an internal thoracic artery graft: PCABS-ITA).両法にはそれぞれ利点と欠点があるが,早期成績には両者の差は明らかでない.現状では病変の重症度と範囲に鑑みながら,急性期の緊急救命手術にはSOAPがI(C),PCABS-ITAがIIa(C),ASO術後遠隔期の冠閉塞には,新大動脈の拡張や弁閉鎖不全,右室流出路狭窄等がなければPCABS-ITAがI(C),SOAPがIIa(C)と考えている.今後,遠隔成績の追跡が重要となる.幸い稀な合併症であるため,databaseによる遠隔成績の解析が必須である.

Coronary artery obstructive complications after coronary transfer procedures needed for congenital heart surgery are rare but serious, and it frequently results in death or severe heart failure that requires extracorporeal membrane oxygenation (ECMO) use in the early and late phases of surgery. This complication is particularly crucial in an arterial switch operation for transposition of the great arteries (TGA), which is conducted at the newborn to infant stage when there is a low body-weight. In addition, TGA is commonly associated with various anatomic coronary abnormalities. The following two surgeries are employed to manage this complication: redo of coronary anastomosis, often with autologous patch enlargement (surgical ostial angioplasty: SOAP), and pediatric coronary artery bypass utilizing the internal thoracic artery (PCABS-ITA). Both procedures have advantages and disadvantages compared with the other, but early surgical survival results are equivalent. Based on several database analyses, I currently suggest SOAP as I(C) and PCABS-ITA as IIa(C) for a rescue operation where coronary obstruction is due to mechanical compression, kinking, and/or stretching. For late coronary complications where fibroproliferative obstruction is the main cause, PCABS-ITA as I(C)and SOAP as IIa(C). Furthermore, tight stenosis (>90%) or total obstruction extending into the bifurcation area of the left main trunk favors for PCABS-ITA, and localized left main stenosis of mild degree favors SOAP. Careful follow-up and late results are crucial. Because this is a severe but rare complication, a long-term database analysis is essential.

Key words: coronary transfer; arterial switch operation; coronary obstruction; surgical angioplasty; pediatric coronary bypass surgery

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