169例动脉调转手术治疗大动脉转位的早、中期结果

Early and mid-term outcome of the arterial switch operation for transposition of great arteries： predictors and functional evaluation

目的 探讨大动脉调转手术（ASO）治疗完全性大动脉转位（TGA）的早、中期结果,分析其随访死亡、术后主动脉瓣反流及肺动脉狭窄的危险因素.方法 2004年1月至2007年12月,169例行动脉调转术病儿入选,其中男129例,女40例,平均年龄（11.7±26.3）个月.病儿分两组：Ⅰ组为室间隔完整组（56例）,Ⅱ组为室间隔缺损组（113例）.所有术后生存病儿均进行超声随访,平均随访时间（27.7±14.6）个月.危险因素采用Logistic回归模型分析.结果 全组住院死亡19例（11.24%）,两组间差异无统计学意义.随着整体治疗水平的提高,住院病死率由2004年的16.67%下降到2007年的3.92%.1、3及5年生存率分别为94.00%、91.33%及91.33%,两组间差异无统计学意义.Logistic回归分析发现,ASO术后随访死亡的危险因素为手术年龄大于6个月;术后主动脉瓣反流的危险因素为合并室间隔缺损、年龄大于6个月、术后新主动脉瓣Z值〉1;术后肺动脉狭窄的危险因素为手术年龄小于1个月和肺动脉采用补片成形.结论 ASO手术具有良好的早、中期结果,是治疗完全性大动脉转位的理想术式.TGA病儿应该尽早手术治疗,手术年龄大于6个月是随访死亡及主动脉瓣反流的重要危险因素;新主动脉根部与主动脉远端不匹配是术后主动脉瓣反流的危险因素;病儿的生长发育与肺动脉成形材料无生长特性的矛盾是导致术后肺动脉狭窄的危险因素.

Objective The aim of this report was to study the early and mid-term outcome in hospital and follow-up mortality, predictors for late pulmonary stenosis （PAS） and insufficiency of neo-aortic valve （neo-AVI） in patients with transposition of great arteries （TGA） and Taussig-Bing malformation undergoing arterial switch operation （ ASO ）. Methods Between January 2004 and December 2007, 169 patients （129 male, 40 female; mean age of [（11.71 ± 26.3 ） months] with TGA or Taussig-Bing malformation underwent ASO. The patients were divided into Group Ⅰ （n = 56 ）： TGA with intact ventricular septum and Group Ⅱ （ n = 113 ）： TGA with ventricular septal defect （VSD）. All patients were followed up in out-patient department by ultrasonic cardiogram. The mean follow-up periods was （27.66 ± 14.6 ） months. Multiple logistic regression analysis was performed to find out the risk factors. Results The overall hospital mortality was 11.24% （19/169）and there was no significant difference between the two Groups. With the improving of perioperative management, the hospital mortality decreased from 16.67% in 2004 to 3.92% in 2007. The overall actuarial survival at 1-, 3- and 5-year follow-up was 94.00%,91.33%, and 91.33%, respectively. The multivariate analysis revealed that age above 6 months was a strong predictor for poor postoperative survival. Predictors for neo-AVI were： combined with VSD, age 〉 6 months and postoperative neo-AVI Z-score 〉 1. Predictors for moderate to severe PAS were age 〈 1 months and pulmonary artery plasty with an unstretchable patch. Conclusion ASO remains the optimal choice for treating various forms of TGA with an acceptable early and mid-term outcome regarding overall survival rate. Patients with TGA should be treated as early as possible. Age 〉6 months is a predictor for poor postoperative survival and neo-AVI. Mismatch between the neo-aortic root and distal aorta may induce neo-AVI. Unstretchable patch in pulmonary artery plasty may induce PAS.