动脉调转术治疗新生儿室间隔完整型大动脉转位及危险因素

Arterial switch operation on transposition of great arteries with intact ventricular septmn in neonates and its risk factors

目的分析动脉调转术治疗新生儿室间隔完整型大动脉转位（D-TGA／IVS）临床结果及危险因素。方法回顾分析上海儿童医学中心2000年1月至2006年12月共62例行动脉调转术治疗的D-TGA／IVS新生儿围术期临床结果。手术年龄15h～28d，平均（8．91±8．04）d，体重2．30～4．40k，平均（3．34±0．44）k。手术均在深低温低流量体外循环下和深低温停循环下进行。结果全组死亡6例，住院病死率9．7％。其中急诊手术组和非急诊手术组病死率分别为15．6％（5／32）和3．3％（1／30），小年龄组（年龄≤14d）和大年龄组（年龄15～28d）病死率分别为8．0％（4／50）和16．7％（2／12），冷晶体停搏液组和冷含血晶体停搏液组病死率分别为4．0％（1／25）和13．5％（5／37）。典型冠状动脉组和非典型冠状动脉组病死率分别为8．3％（4／48）和14．3％（2／14）。对应各组间病死率差异均无统计学意义。急诊手术组（148．52±193．98）与非急诊手术组（66．38±34．58）的术后插管时间差异有统计学意义（P=0．039），重症监护时间（P=0．088）、术后住院时间（P=0．100）差异无统计学意义；小年龄组与大年龄组、晶体停搏液组与含血停搏液组、典型冠状动脉组与非典型冠状动脉组的术后插管时间、重症监护时间、术后住院时间差异均无统计学意义。结论新生儿DTGA／IVS行动脉调转术治疗，效果满意。术前明确诊断、纠正酸中毒、维持动脉导管开放，积极改善术前一般情况，术中精心的手术设计和操作，术后应用综合治疗措施，积极防治各种并发症，是降低围术期病死率的关键。早期诊断，早期手术，尽量减少急诊手术，可减少术后呼吸机辅助时间，有利患儿术后顺利康复。

Objective To assess the outcome and the risk factors of arterial switch operation （ASO） on transposition of the great arteries with intact ventricular septum （TGA/IVS） in infants younger than 4 weeks of age. Methods Sixty-two neonates with TGA/IVS who underwent primary ASK） from Jan. 2000 to Dec. 2006 were investigated retrospectively. The age at operation ranged from 15 hours to 28 days（mean 8. 91 ± 8. 04 d） ,and the weight ranged from 2.30 kg to 4. 40 kg（mean 3.34 kg ± 0. 44 kg）. According to the clinical presentation, the patients were divided into emergent group （n = 32） and selective group （n = 30）. Acted on the age at operation, they were divided into younger age group （age 414 day, n = 50）and elder age group （age 15-28 day, n = 12）. Surgical correction was performed under cardiopulmonary bypass with deep hypothermia and low-flow （DHLF） perfusion or circulatory arrest （DHCA）. Results There were 56 cases survived and 6 patients died postoperatively（ mortality 9. 7%）. The mortality rate based on different groups was calculated respectively. The mortality rate were 15.6% （5/32） and 3.33% （1/30） in emergent group and selective group, 8. 0% （4/ 50） and 16. 7% （2/12） in younger age group and elder age group;4. 0%（1/25） and 13. 5% （5/37） in cold crystalloid cardioplegia group and cold blood cardioplegia group, and 8. 3% （4/48） and 14. 3% （2/14） in typical coronary artery group and non typical coronary artery group. There was no statistics difference in the mortality between each paired group and in the length of ICU stay as well（10. 89 d± 9. 61 d versus 7. 62 d ± 3.07 d, P = 0. 088）and the hospitalization （ 16. 89 d ± 11.21 d vs. 13.07 d ± 4. 83 d, P = 0. 100）between the emergent group and selective group. The duration of postoperative ventilation was significantly prolonged for the emergent group （148. 52 h ± 193. 98 h vs. 66. 38 h ± 34. 58 h, P = 0.039）. Conclusions The efficacy of arterial switch operation on D-TGA/IVS in neonates is satisfactory. A confirmed diagnosis, adequate rectified acidosis, pharmacologic administered to open the PDA and improved status of the newborns, specific designed procedure of repair and optimal postoperative care are key points to decrease the perioperative mortality. An adequate preoperative preparation instead of performance of emergency repair on the patients in unstable condition can reduce postoperative ventilation time and contribute to uneventful recovery.