完全性房室间隔缺损的外科治疗

Surgical repair of complete atrioventricular septal defect

目的回顾性总结手术治疗完全性房室间隔缺损的经验。方法112例病儿，≤6个月43例（38%，X组），〉6个月69例（62%，Y组）。85例行心导管检查。Rastelli A型89例，Rastelli B型10例，Rastelli C型13例。手术技术分单片法，双片法和简化单片法。术中经食管超声检查发现异常而即刻再次手术者7例（二尖瓣反流4例，二尖瓣狭窄2例，左室流出道梗阻1例）。术后入重症监护室，左房压8～21 mm Hg，中心静脉压7～12mm Hg。呼吸机平均应用47h，监护室平均滞留6.3d。结果室间隔缺损残余分流（直径〉2mm）13例，二尖瓣中度反流12例，完全性房室传导阻滞4例。院内死亡6例（X组1例，Y组5例）。术后随访91例（81%），随访1～5年，平均2.3年。1例术后1年因肺炎心衰死亡，1例术后2年因二尖瓣中-重度反流而换瓣。结论院内死亡率提示，小于6月龄完全性房室间隔缺损病婴手术是安全的。随着年龄增大，瓣膜成形效果、肺动脉高压的预后可能会更差。双片法修补室间隔缺损较易发生残余漏（9例，18%），简化单片法出院时二尖瓣关闭不全发生率明显高于另外两种方法（6例，16%）。

Objective To review the experience of surgical treatment for complete atrioventricular septal defect（CAVSD）.Methods From 2000 to 2005,112 patients with CAVSD,43 patients（38%）were younger than 6 months（group X）and 69 patients（62%） were older than 6 months（group Y）,underwent surgery.All patients were explored by 2D-echo cardiography and 85 patients underwent cardia catheterization.89 patients had Rastelli＇s type A defects,10 had type B defects and 13 had type C defects,The repair of CAVSD had been described using single-patch, two-patch arid modified single-patch techniques. Postoperatively,the transesophageal echocardio-diograhy was used to evaluate for residual VSD, subaortic stenosis,mitral and tricuspid valve insufficiency or stenosis. 7 patients suffeted an immediate re-repair of the noted abnormality. In cardiac intensive care unit （CICU）, left atrial pressure was 8-21 mmHg and central venus pressme was 7 - 12 mmHg. The mean time of ventilation was 47 hours and the time of staying at CICU was 6.3 days, respectively. Results 13 patients had residual VSD（ Ф〉 2mm）, 12 patients had residual mitrial valve reguitation （moderate）. 4 patients had complete heart block （3 patients require perment pace maker）. Hospital deaths were 6,1 in group X and 5 in group Y. 91（81%） petients were followed-up and mean follow-up was 2.3 yeats （from 1 to 5 years）. One petient died of low cardiac output one year after surgery arid one patient received mitral valve replacement because d persistent mitrial valve insufficiency two years later. Conclusion The results suggest that the early surgical repair （less than 6 months d life） for CAVSD is safe arid beneficial. The progress of the pulmonary hypertention and the mitral valve insufficiency may be worse along with the years. Data indicates that the residual VSD（9, 18% ） are often developed in two-patch technique group and the moderate mitral valve regurgitation （6, 25% ） significantly occurred in one- patch technique group.