两种方法治疗肺动脉闭锁合并室间隔缺损患儿的对比研究
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摘要
目的比较改良B-T分流术和右心室-肺动脉重建术对肺动脉闭锁合并室间隔缺损患儿的治疗效果。方法回顾性分析武汉市儿童医院2012年1月至2017年6月所有接受手术治疗PA/VSD患儿的临床资料,根据手术术式的不同,将26例患儿分为改良B-T分流手术组和右心室-肺动脉重建手术组。改良B-T分流手术组9例,其中男童5例、女童4例,年龄为3个月至5岁;右心室-肺动脉重建手术组17例,其中男童11例、女童6例,年龄范围为1个月至6岁。对两组患儿术后呼吸机辅助通气时间、ICU停留时间、血氧饱和度改善情况、严重并发症发生率、手术根治率、病死率等各项指标进行分析,评价其治疗效果。结果右心室-肺动脉重建组氧合改善程度高于改良B-T分流手术组,差异有统计学意义[(33.1±6.9)%vs.(25.4±4.6)%,t=-3.357,P=0.008]。改良B-T分流手术组和右心室-肺动脉重建组术后ICU停留时间分别为(3.1±1.5)d、(4.0±2.6)d,差异有统计学意义(t=2.815,P<0.01);呼吸机辅助通气时间分别为(27.10±18.60)h、(34.30±16.15)h,差异无统计学意义(t=-1.744,P=0.417)。两组患儿术后肺部渗出分别为11.11%(1/9)和23.53%(4/17),差异有统计学意义(χ~2=0.584,P=0.445)。术后每6个月行心脏彩超或CT检查,评价心脏功能及肺血管发育情况,随访6个月至5年,右心室-肺动脉重建组Nakata指数改变明显高于B-T分流组,差异有统计学意义[(67.62±26.74)vs.(56.21±14.37),t=-3.860,P=0.008]。右心室-肺动脉重建组根治手术时间间隔为(15.10±3.22)个月,短于改良B-T分流组的(18.56±5.42)个月,差异有统计学意义(t=3.100,P=0.015)。通过随访发现右心室-肺动脉重建组手术根治率为47.06%,改良B-T分流组手术根治率为33.33%,差异无统计学意义(χ~2=0.454,P=0.500)。改良B-T分流手术组患儿术后早期院内死亡1例,右心室-肺动脉重建组患儿术后早期无死亡病例。结论姑息性右心室-肺动脉重建术相对B-T分流术可获得较好的血流动力学效果,氧合情况改善明显,但术后肺部渗出增加,重建的主肺动脉内径尚需个体化。
Objective To assessed the value of palliative right ventricular-pulmonary artery(RV-PA) shunt in staged surgical management of pulmonary atresia with ventricular septal defect. Methods We retrospectively analyzed the clinical data of 26 pulmonary atresia with ventricular septal defect(PA/VSD) patients undergoing Blalock-Taussig shunt(BTS) or RV-PA connection from January 2012 to June 2017.According to different surgical procedures,they were divided into two groups.In BTS group,there were 5 boys and 4 girls aged from 3 to 60 months.In RV-PA connection group,there were 11 boys and 6 girls aged from 1 to 72 months.Early clinical outcomes including mechanical ventilation time,length of intensive care unit(ICU) stay,improvement of oxygen saturation(SO_2),incidence of serious complications,radical curative rate and mortality were compared. Results The improvement of SO_2 was markedly higher in RV-PA connection group than that in BTS group[(33.1±6.9)% vs.(25.4±4.6)%](t=-3.357,P=0.008).The difference had statistical significance; The postoperative stay duration of ICU was in BTS and RV-PA connection groups respectively[(3.1±1.5) vs.(4.0±2.6) days](t=2.815,P<0.01).The difference had statistical significance; The mechanical ventilation time was[(27.10±18.60) vs.(34.30±16.15) hours](t=-1.744,P=0.417).The difference had no statistical significance; The postoperative pulmonary effusion was 11.11%(1/9) and 23.53%(4/17) respectively(χ~2=0.584,P=0.445).The difference had statistical significance.Cardiac color ultrasound or computed tomography(CT) was performed postoperatively for assessing the development status of cardiac functions and pulmonary vasculature every 6 months.During a follow-up period of 6-60 months,the change of Nakata index was markedly higher in RV-PA connection group than that in BTS group[(67.62±26.74) vs.(56.21±14.37)](t=-3.860,P=0.008).The difference had statistical significance; The radical surgical time interval was markedly shorter in RV-PA connection group than that in BTS group[(15.10±3.22) vs.(18.56±5.42) months](t=3.100,P=0.015).The difference had statistical significance.During follow-ups,the surgical curative rate was 47.06% in RV-PA connection group and 33.33% in BTS group(χ~2=0.454,P=0.500).The difference had no statistical significance.One case of early in-hospital mortality occurred in BTS group while RV-PA connection group had no early in-hospital mortality. Conclusion RV-PA connection is better than BTS for PA/VSD patients including greater SO_2 improvement and more stable hemodynamics,except for pulmonary effusion.And RV-PA connection in PA/VSD patients requires individualized treatment.
Objective To assessed the value of palliative right ventricular-pulmonary artery(RV-PA) shunt in staged surgical management of pulmonary atresia with ventricular septal defect. Methods We retrospectively analyzed the clinical data of 26 pulmonary atresia with ventricular septal defect(PA/VSD) patients undergoing Blalock-Taussig shunt(BTS) or RV-PA connection from January 2012 to June 2017.According to different surgical procedures,they were divided into two groups.In BTS group,there were 5 boys and 4 girls aged from 3 to 60 months.In RV-PA connection group,there were 11 boys and 6 girls aged from 1 to 72 months.Early clinical outcomes including mechanical ventilation time,length of intensive care unit(ICU) stay,improvement of oxygen saturation(SO_2),incidence of serious complications,radical curative rate and mortality were compared. Results The improvement of SO_2 was markedly higher in RV-PA connection group than that in BTS group[(33.1±6.9)% vs.(25.4±4.6)%](t=-3.357,P=0.008).The difference had statistical significance; The postoperative stay duration of ICU was in BTS and RV-PA connection groups respectively[(3.1±1.5) vs.(4.0±2.6) days](t=2.815,P<0.01).The difference had statistical significance; The mechanical ventilation time was[(27.10±18.60) vs.(34.30±16.15) hours](t=-1.744,P=0.417).The difference had no statistical significance; The postoperative pulmonary effusion was 11.11%(1/9) and 23.53%(4/17) respectively(χ~2=0.584,P=0.445).The difference had statistical significance.Cardiac color ultrasound or computed tomography(CT) was performed postoperatively for assessing the development status of cardiac functions and pulmonary vasculature every 6 months.During a follow-up period of 6-60 months,the change of Nakata index was markedly higher in RV-PA connection group than that in BTS group[(67.62±26.74) vs.(56.21±14.37)](t=-3.860,P=0.008).The difference had statistical significance; The radical surgical time interval was markedly shorter in RV-PA connection group than that in BTS group[(15.10±3.22) vs.(18.56±5.42) months](t=3.100,P=0.015).The difference had statistical significance.During follow-ups,the surgical curative rate was 47.06% in RV-PA connection group and 33.33% in BTS group(χ~2=0.454,P=0.500).The difference had no statistical significance.One case of early in-hospital mortality occurred in BTS group while RV-PA connection group had no early in-hospital mortality. Conclusion RV-PA connection is better than BTS for PA/VSD patients including greater SO_2 improvement and more stable hemodynamics,except for pulmonary effusion.And RV-PA connection in PA/VSD patients requires individualized treatment.
引文
1 Carrillo SA,Mainwaring RD,Patrick WL,et al.Surgical repair of pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals with absent intrapericardial pulmonary arteries[J].Ann Thorac Surg,2015,100(2):606 — 614.DOI:10.1016/j.athoracsur.2015.03.110.
2 Trezzi M,Carotti A.The role of intrapericardial pulmonary arteries in patients with PA/VSD/MAPCAs[J].Ann Thorac Surg,2016,101(4):1634 — 1635.DOI:10.1016/j.athoracsur.2015.09.022.
3 Carotti A,Albanese SB,Minniti,et al.Increasing experience with integrated approach to pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries[J].Eur J Cardiothorac Surg,2003,23(5):719 — 726.DOI:10.1016/S1010 — 7940(03)00089 — 7.
4 邓喜成,李守军.肺动脉闭锁合并室间隔缺损的外科治疗策略[J].中国胸心血管外科临床杂志,2010,17(1):50 — 54.Deng XC,Li SJ.Surgical strategy for pulmonary atresia with ventricluar septal defect[J].Chin J Clin Thorac Cardiovasc Surg,2010,17(1):50 — 54.
5 Ishibashi N,Shin'oka T,Ishiyama M,et al.Clinical results of staged repair with complete unifocalization for pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries[J].Eur J Cardiothorac Surg,2007,32(2):202 — 208.DOI:10.1016/j.ejcts.2007.04.022.
6 Mcmahon CJ,Franklin O,Walsh KP.Stenting of central aortopulmonary shunt in a child with pulmonary atresia,ventricular septal defect,and severely hypoplastic pulmonary arteries[J].J Invasive Cardiol,2013,25(12):216 — 218.
7 Sadiq A,Rajanbabu B.Tetralogy with pulmonary atresia and leaking left pulmonary artery aneurysm[J].Ann Thorac Surg,2014,97(3):87.DOI:10.1016/j.athoracsur.2013.12.054.
8 Ong K,Boone R,Gao M,et al.Right ventricle to pulmonary artery conduit reoperations in patients with tetralogy of Fallot or pulmonary atresia associated with ventricular septal defect[J].Am J Cardiol,2013,111(11):1638 — 1643.DOI:10.1016/j.amjcard.2013.01.337.
9 Bradley SM,Erdem CC,Hsia TY,et a1.Right ventricle-to-pulmonary artery shunt:alternative palliation in infants with inadequate pulmonary blood flow prior to two-ventricle repair[J].Ann Thorac Surg,2008,86(1):183 — 188.DOI:10.1016/j.athoracsur.2008.03.047.
10 Grosse-Wortmann L,Yoo SJ,van Arsdell G,et al.Preoperative total pulmonary blood flow predicts right ventricular pressure inpatients early after complete repair of tetralogy of Fallot and pulmonary atresia with major aortopulmonary collateral arteries[J].Thorac Cardiovasc Surg,2013,146(5):1185 — 1190.DOI:10.1016/j.jtcvs.2013.01.032.
11 Fouilloux V,Bonello B,Kammache I,et al.Management of patients with pulmonary atresia,ventricular septal defect,hypoplastic pulmonary arteries and major aorto-pulmonary collaterals:Focus on the strategy of rehabilitation of the native pulmonary arteries[J].Arch Cardiovasc Dis,2012,105(12):666 — 675.DOI:10.1016/j.acvd.2012.08.003.
12 Gomez O,Soveral I,Bennasar M,et al.Accuracy of fetal echocardiography in the differential diagnosis between truncus arteriosus and pulmonary atresia with ventricular septal defect[J].Fetal Diagn Ther,2016,39(2):90 — 99.DOI:10.1159/000433430.
13 Zheng S,Yang K,Li K,et al.Establishment of right ventricle pulmonary artery continuity as the first-stage palliation in older infants with pulmonary atresia with ventricular septal defect maybe preferable to use of an arterial shunt[J].Interact Cardiovasc Thorac Surg,2014,19(1):88 — 94.DOI:10.1093/icvts/ivu052.
14 Zhang Y,Hua Z,Yang K,et al.Outcomes of the rehabilitative procedure for patients with pulmonary atresia,ventricular septal defect and hypoplastic pulmonary arteries beyond the infant period[J].Eur J Cardiothorac Surg,2014,46(2):297 — 303.DOI:10.1093/ejcts/ezt622.
15 Gerelli S,van Steenberghe M,Murtuza B,et al.Neonatal right ventricle to pulmonary connection as a palliative procedure for pulmonary atresia with ventricular septal defect or severe tetralogy of Fallot[J].Eur J Cardiothorac Surg,2014,45(2):278 — 288.DOI:10.1093/ejcts/ezt401.
2 Trezzi M,Carotti A.The role of intrapericardial pulmonary arteries in patients with PA/VSD/MAPCAs[J].Ann Thorac Surg,2016,101(4):1634 — 1635.DOI:10.1016/j.athoracsur.2015.09.022.
3 Carotti A,Albanese SB,Minniti,et al.Increasing experience with integrated approach to pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries[J].Eur J Cardiothorac Surg,2003,23(5):719 — 726.DOI:10.1016/S1010 — 7940(03)00089 — 7.
4 邓喜成,李守军.肺动脉闭锁合并室间隔缺损的外科治疗策略[J].中国胸心血管外科临床杂志,2010,17(1):50 — 54.Deng XC,Li SJ.Surgical strategy for pulmonary atresia with ventricluar septal defect[J].Chin J Clin Thorac Cardiovasc Surg,2010,17(1):50 — 54.
5 Ishibashi N,Shin'oka T,Ishiyama M,et al.Clinical results of staged repair with complete unifocalization for pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries[J].Eur J Cardiothorac Surg,2007,32(2):202 — 208.DOI:10.1016/j.ejcts.2007.04.022.
6 Mcmahon CJ,Franklin O,Walsh KP.Stenting of central aortopulmonary shunt in a child with pulmonary atresia,ventricular septal defect,and severely hypoplastic pulmonary arteries[J].J Invasive Cardiol,2013,25(12):216 — 218.
7 Sadiq A,Rajanbabu B.Tetralogy with pulmonary atresia and leaking left pulmonary artery aneurysm[J].Ann Thorac Surg,2014,97(3):87.DOI:10.1016/j.athoracsur.2013.12.054.
8 Ong K,Boone R,Gao M,et al.Right ventricle to pulmonary artery conduit reoperations in patients with tetralogy of Fallot or pulmonary atresia associated with ventricular septal defect[J].Am J Cardiol,2013,111(11):1638 — 1643.DOI:10.1016/j.amjcard.2013.01.337.
9 Bradley SM,Erdem CC,Hsia TY,et a1.Right ventricle-to-pulmonary artery shunt:alternative palliation in infants with inadequate pulmonary blood flow prior to two-ventricle repair[J].Ann Thorac Surg,2008,86(1):183 — 188.DOI:10.1016/j.athoracsur.2008.03.047.
10 Grosse-Wortmann L,Yoo SJ,van Arsdell G,et al.Preoperative total pulmonary blood flow predicts right ventricular pressure inpatients early after complete repair of tetralogy of Fallot and pulmonary atresia with major aortopulmonary collateral arteries[J].Thorac Cardiovasc Surg,2013,146(5):1185 — 1190.DOI:10.1016/j.jtcvs.2013.01.032.
11 Fouilloux V,Bonello B,Kammache I,et al.Management of patients with pulmonary atresia,ventricular septal defect,hypoplastic pulmonary arteries and major aorto-pulmonary collaterals:Focus on the strategy of rehabilitation of the native pulmonary arteries[J].Arch Cardiovasc Dis,2012,105(12):666 — 675.DOI:10.1016/j.acvd.2012.08.003.
12 Gomez O,Soveral I,Bennasar M,et al.Accuracy of fetal echocardiography in the differential diagnosis between truncus arteriosus and pulmonary atresia with ventricular septal defect[J].Fetal Diagn Ther,2016,39(2):90 — 99.DOI:10.1159/000433430.
13 Zheng S,Yang K,Li K,et al.Establishment of right ventricle pulmonary artery continuity as the first-stage palliation in older infants with pulmonary atresia with ventricular septal defect maybe preferable to use of an arterial shunt[J].Interact Cardiovasc Thorac Surg,2014,19(1):88 — 94.DOI:10.1093/icvts/ivu052.
14 Zhang Y,Hua Z,Yang K,et al.Outcomes of the rehabilitative procedure for patients with pulmonary atresia,ventricular septal defect and hypoplastic pulmonary arteries beyond the infant period[J].Eur J Cardiothorac Surg,2014,46(2):297 — 303.DOI:10.1093/ejcts/ezt622.
15 Gerelli S,van Steenberghe M,Murtuza B,et al.Neonatal right ventricle to pulmonary connection as a palliative procedure for pulmonary atresia with ventricular septal defect or severe tetralogy of Fallot[J].Eur J Cardiothorac Surg,2014,45(2):278 — 288.DOI:10.1093/ejcts/ezt401.