右心室流出道重建术治疗复杂先天性心脏病的临床研究——单中心10年随访分析
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摘要
目的总结分析多种右心室流出道手术治疗复杂性先天性心脏病(先心病)的临床经验。方法回顾性分析2007年1月至2017年1月我院胸外科3 138例右心系统复杂性先心病患儿的临床资料,其中男1 660例、女1 478例,手术年龄9 d～84个月,体质量2.2～28.6 kg。所有患儿均完成右心室流出道重建术,手术方法包括肺动脉补片扩大术2 335例,自体组织连接右心室289例,外管道重建右心室流出道514例。结果术后早期死亡181例(5.8%),死亡原因主要为严重低心排血量综合征,肺高压危象及右心衰竭。中远期死亡15例(术后6～27个月),死亡原因主要为心功能不全和突发猝死。术后共随访2 782例患儿,中远期随访结果:右心室流出道梗阻408例,肺动脉及分支狭窄340例,中度以上肺动脉瓣反流309例。394例患儿实施二次手术,再手术率为12.6%,术后死亡39例,死亡率为9.9%。随访过程中,92.4%患儿心功能恢复良好,心功能(NYHA)分级达到Ⅱ级及以上。结论右心室流出道覆盖范围广,解剖结构复杂多变,手术方法多样,且各具优势,中远期预后均较满意。手术方案应根据病变类型、解剖特点、临床症状以及手术条件等多因素进行个体化制定。
Objective To assess the mid-and long-term outcomes of right ventricular outflow tract reconstruction for children with congenital heart disease. Methods We retrospectively analyzed the clinical data of 3 138 children with complex congenital heart disease in right heart system admitted to our hospital from January 2007 to January 2017. There were 1 660 males and 1 478 females. The age at surgery was 9 days to 84 months, and the body weight was 2.2 to 28.6 kg. Pulmonary patch enlargement was performed in 2 335 patients(1 477 patients of valve-sparing repair and 858 patients of transannular repair); autologous tissue(direct anastomosis, left auricle or pericardial conduit) was used to connect with right ventricle in 289 patients; extracardiac conduits were used for reconstruction in 514 patients.Results There were 181 in-hospital deaths with a mortality of 5.8%. The early postoperative causes of death were low cardiac output syndrome(LCOS), severe pulmonary hypertension and right heart failure. Fifteen patients died of cardiac insufficiency or sudden death during follow-up(6–27 months postoperatively). The echocardiography showed 408 patients with right ventricular outflow tract obsturction(RVOTO), 340 patients with pulmonary trunk or branches stenosis, 609 with pulmonary regurgitation(morderate or severe). 12.6%(394/3 138) of patients underwent reintervention or reoperation with 39 deaths. About 92.4% of patients exhibited an improvement of New York Heart Association(NYHA) functional class from Ⅲ or Ⅳ preoperatively to Ⅰ or Ⅱ at follow-up. Conclusion The anatomical structure of right ventricular outflow tract is complicated and various, and each operation method has different strengths and favorable outcomes. The operation should be individually designed according to pathological types, anatomical features, clinical symptoms and operation conditions.
Objective To assess the mid-and long-term outcomes of right ventricular outflow tract reconstruction for children with congenital heart disease. Methods We retrospectively analyzed the clinical data of 3 138 children with complex congenital heart disease in right heart system admitted to our hospital from January 2007 to January 2017. There were 1 660 males and 1 478 females. The age at surgery was 9 days to 84 months, and the body weight was 2.2 to 28.6 kg. Pulmonary patch enlargement was performed in 2 335 patients(1 477 patients of valve-sparing repair and 858 patients of transannular repair); autologous tissue(direct anastomosis, left auricle or pericardial conduit) was used to connect with right ventricle in 289 patients; extracardiac conduits were used for reconstruction in 514 patients.Results There were 181 in-hospital deaths with a mortality of 5.8%. The early postoperative causes of death were low cardiac output syndrome(LCOS), severe pulmonary hypertension and right heart failure. Fifteen patients died of cardiac insufficiency or sudden death during follow-up(6–27 months postoperatively). The echocardiography showed 408 patients with right ventricular outflow tract obsturction(RVOTO), 340 patients with pulmonary trunk or branches stenosis, 609 with pulmonary regurgitation(morderate or severe). 12.6%(394/3 138) of patients underwent reintervention or reoperation with 39 deaths. About 92.4% of patients exhibited an improvement of New York Heart Association(NYHA) functional class from Ⅲ or Ⅳ preoperatively to Ⅰ or Ⅱ at follow-up. Conclusion The anatomical structure of right ventricular outflow tract is complicated and various, and each operation method has different strengths and favorable outcomes. The operation should be individually designed according to pathological types, anatomical features, clinical symptoms and operation conditions.
引文
1 He GW. Current strategy of repair of tetralogy of Fallot in children and adults:emphasis on a new technique to create a monocusppatch for reconstruction of the right ventricular outflow tract. J Card Surg, 2008, 23(6):592-599.
2 Sasikumar N, Ramanan S, Rema KM, et al. Prosthetic reconstruction of bicuspid pulmonary valve in tetralogy of Fallot.Asian Cardiovasc Thorac Ann, 2014, 22(4):436-441.
3 Lee C, Lee CH, Kwak JG, et al. Bicuspid pulmonary valve implantation using polytetrafluoroethylene membrane:early results and assessment of the valve function by magnetic resonance imaging. Eur J Cardiothorac Surg, 2013,43(3):468-472.
4 Sasson L, Houri S, Raucher SA, et al. Right ventricular outflow tract strategies for repair of tetralogy of Fallot:effect of monocusp valve reconstruction. Eur J Cardiothorac Surg, 2013, 43(4):743-751.
5 Pande S, Sharma JK, Siddartha CR, et al. Fresh autologous pericardium to reconstruct the pulmonary valve at the annulus when tetralogy of Fallot requires a transannular patch at midterm.Tex Heart Inst J, 2016,43(3):207-213.
6 Isomatsu Y, Shin'Oka T, Aoki M, et al. Establishing right ventriclepulmonary artery continuity by autologous tissue:an alternative approach for prosthetic conduit repair. Ann Thorac Surg, 2004,78(1):173-180.
7 Gerelli S, Van SM, 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.Eur J Cardiothorac Surg, 2014, 45(2):278-288.
8 Luo K, Zheng J, Zhu Z, et al. Outcomes of right ventricular outflow tract reconstruction for children with persistent truncus arteriosus:a 10-year single-center experience. Pediatr Cardiol, 2017, 39(12):1-10.
9 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. Am J Cardiol, 2013, 111(11):1638-1643.
10胡小松,杨克明,李守军,等.同种带瓣管道用于右心室流出道重建的中期效果.中国循环杂志,2016, 31(4):385-388.
11 Schiller O, Sinha P, Zurakowski D, et al. Reconstruction of right ventricular outflow tract in neonates and infants using valved cryopreserved femoral vein homografts. J Thorac Cardiovasc Surg,2014,147(3):874-879.
12 Kumar TK, Bricenomedina M, Sathanandam S, et al. Femoral vein homograft as right ventricle to pulmonary artery conduit in stage 1Norwood operation. Ann Thorac Surg, 2017, 103(6):1969-1974.
13 Fiore AC, Ruzmetov M, Huynh D, et al. Comparison of bovine jugular vein with pulmonary homograft conduits in children less than 2 years of age. Eur J Cardiothorac Surg, 2010, 38(3):318-325.
14 Prior N, Alphonso N, Arnold P, et al. Bovine jugular vein valved conduit:up to 10 years follow-up. J Thorac Cardiovasc Surg,2011,141(4):983-987.
15 Sandica E, Boethig D, Blanz U, et al. Bovine jugular veins versus homografts in the pulmonary position:an analysis across two centers and 711 patients-conventional comparisons and time status graphs as a new approach. Thorac Cardiovasc Surg, 2015, 64(1):25-35.
16 Ugaki S, Rutledge J, Al AM, et al. An increased incidence of conduit endocarditis in patients receiving bovine jugular vein grafts compared tocryopreserved homograft for right ventricular outflow reconstruction. Ann Thorac Surg, 2015, 99(1):140-146.
17 Takahashi Y, Tsutsumi Y,Monta O, et al. Expanded polytetrafluoroethylene-valved conduit with bulging sinuses for right ventricular outflow tract reconstruction in adults. Gen ThoracCardiovasc Surg, 2010, 58(1):14-18.
18 Shinkawa T,Tang X,Gossett JM, et al. Valved polytetrafluoroethylene conduits for right ventricular outflow tract reconstruction. Ann Thorac Surg, 2015,100(1):129-137.
19 Shinkawa T, Chipman C, Bozzay T, et al. Outcome of right ventricle to pulmonary artery conduit for biventricular repair. Ann Thorac Surg, 2015, 99(4):1357-1366.
20 Yamashita E, Yamagishi M, Miyazaki T, et al. Smaller-sized expanded polytetrafluoroethylene conduits with a fan-shaped valve and bulging sinuses for right ventricular outflow tract reconstruction. Ann Thorac Surg, 2016,102(4):1336-1344.
2 Sasikumar N, Ramanan S, Rema KM, et al. Prosthetic reconstruction of bicuspid pulmonary valve in tetralogy of Fallot.Asian Cardiovasc Thorac Ann, 2014, 22(4):436-441.
3 Lee C, Lee CH, Kwak JG, et al. Bicuspid pulmonary valve implantation using polytetrafluoroethylene membrane:early results and assessment of the valve function by magnetic resonance imaging. Eur J Cardiothorac Surg, 2013,43(3):468-472.
4 Sasson L, Houri S, Raucher SA, et al. Right ventricular outflow tract strategies for repair of tetralogy of Fallot:effect of monocusp valve reconstruction. Eur J Cardiothorac Surg, 2013, 43(4):743-751.
5 Pande S, Sharma JK, Siddartha CR, et al. Fresh autologous pericardium to reconstruct the pulmonary valve at the annulus when tetralogy of Fallot requires a transannular patch at midterm.Tex Heart Inst J, 2016,43(3):207-213.
6 Isomatsu Y, Shin'Oka T, Aoki M, et al. Establishing right ventriclepulmonary artery continuity by autologous tissue:an alternative approach for prosthetic conduit repair. Ann Thorac Surg, 2004,78(1):173-180.
7 Gerelli S, Van SM, 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.Eur J Cardiothorac Surg, 2014, 45(2):278-288.
8 Luo K, Zheng J, Zhu Z, et al. Outcomes of right ventricular outflow tract reconstruction for children with persistent truncus arteriosus:a 10-year single-center experience. Pediatr Cardiol, 2017, 39(12):1-10.
9 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. Am J Cardiol, 2013, 111(11):1638-1643.
10胡小松,杨克明,李守军,等.同种带瓣管道用于右心室流出道重建的中期效果.中国循环杂志,2016, 31(4):385-388.
11 Schiller O, Sinha P, Zurakowski D, et al. Reconstruction of right ventricular outflow tract in neonates and infants using valved cryopreserved femoral vein homografts. J Thorac Cardiovasc Surg,2014,147(3):874-879.
12 Kumar TK, Bricenomedina M, Sathanandam S, et al. Femoral vein homograft as right ventricle to pulmonary artery conduit in stage 1Norwood operation. Ann Thorac Surg, 2017, 103(6):1969-1974.
13 Fiore AC, Ruzmetov M, Huynh D, et al. Comparison of bovine jugular vein with pulmonary homograft conduits in children less than 2 years of age. Eur J Cardiothorac Surg, 2010, 38(3):318-325.
14 Prior N, Alphonso N, Arnold P, et al. Bovine jugular vein valved conduit:up to 10 years follow-up. J Thorac Cardiovasc Surg,2011,141(4):983-987.
15 Sandica E, Boethig D, Blanz U, et al. Bovine jugular veins versus homografts in the pulmonary position:an analysis across two centers and 711 patients-conventional comparisons and time status graphs as a new approach. Thorac Cardiovasc Surg, 2015, 64(1):25-35.
16 Ugaki S, Rutledge J, Al AM, et al. An increased incidence of conduit endocarditis in patients receiving bovine jugular vein grafts compared tocryopreserved homograft for right ventricular outflow reconstruction. Ann Thorac Surg, 2015, 99(1):140-146.
17 Takahashi Y, Tsutsumi Y,Monta O, et al. Expanded polytetrafluoroethylene-valved conduit with bulging sinuses for right ventricular outflow tract reconstruction in adults. Gen ThoracCardiovasc Surg, 2010, 58(1):14-18.
18 Shinkawa T,Tang X,Gossett JM, et al. Valved polytetrafluoroethylene conduits for right ventricular outflow tract reconstruction. Ann Thorac Surg, 2015,100(1):129-137.
19 Shinkawa T, Chipman C, Bozzay T, et al. Outcome of right ventricle to pulmonary artery conduit for biventricular repair. Ann Thorac Surg, 2015, 99(4):1357-1366.
20 Yamashita E, Yamagishi M, Miyazaki T, et al. Smaller-sized expanded polytetrafluoroethylene conduits with a fan-shaped valve and bulging sinuses for right ventricular outflow tract reconstruction. Ann Thorac Surg, 2016,102(4):1336-1344.