快速二期动脉转位术后患者左心室功能和主动脉瓣反流的远期随访

Long-term Follow-up of Left Ventricular Function and Aortic Valve Regurgitation after Rapid Two-stage Arterial Switch Operation

目的通过对快速二期动脉转位术（ASO）的长期随访,探讨其远期并发症和预防措施。方法随访研究2002年9月至2007年9月期间上海儿童医学中心21例行快速二期动脉转位术患者的临床资料,其中男13例,女8例;手术年龄75 d（29-250 d）,体重5 kg（3.5-7.0 kg）。对患者的左心功能锻炼期资料和二期动脉转位术术中和术后数据进行统计分析,并采用logistic逐步回归分析方法筛选对术后远期主动脉瓣反流加重的危险因素。结果术后远期肺动脉和主动脉吻合口直径较术后早期有所增加（0.96±0.30 cm vs.0.81±0.28 cm,t=-1.183,P=0.262;1.06±0.25 cm vs.0.09±0.21 cm,t=-1.833,P=0.094）,但差异无统计学意义。术后远期肺动脉和主动脉吻合口血流速度无明显增快,说明吻合口无梗阻。术后远期心功能较术后早期有所改善,但左心室射血分数（LVEF）值的变化差异无统计学意义（62.88%±7.28%vs.67.92%±7.83%,t=1.362,P=0.202）;术后早期与术后远期比较左心室舒张期末直径（LVDd）差异有统计学意义（2.16±0.30 cm vs.2.92±0.60 cm,t=-5.281,P=0.003）,术后远期左心室舒张期末后壁厚度（LVPWT）较术后早期略有增长（0.39±0.12 cm vs.0.36±0.10 cm,t=0.700,P=0.500）,但差异无统计学意义。术后远期随访中发现,主动脉瓣反流程度有4例（30.77%,4/13例）较术前加重,7例无变化,2例较术前减轻,反流程度均未达到中度以上。logistic回归分析结果显示：术前较小的Ao/PA瓣窦直径比值、较长的随访时间与术后主动脉瓣反流加重有关。结论快速二期动脉转位术后主动脉瓣反流发生率较高,远期无死亡,无再手术,生存情况良好,但仍需定期随访,密切观察吻合口和主动脉瓣的关闭情况。

Objective To investigate the long-term complications and preventions of rapid two-stage arterial switch operation through long-term follow-up.Methods We reviewed the clinical information of 21 patients of rapid two-stage arterial switch operation from September 2002 to September 2007 in Shanghai Children＇s Medical Center.Among them,there were 13 males and 8 females with an average age of 75 d（29-250 d） and an average weight of 5 kg（3.5-7.0 kg）.The data of left ventricle training period and the data before and after the two-stage arterial switch operation were analyzed,and the risk factors influencing the aortic valve regurgitation were analyzed by the logistic multivariable regression analysis.Results The late diameter of anastomosis of pulmonary and aortic artery were increased compared with those shortly after operation（0.96±0.30 cm vs.0.81±0.28 cm,t=-1.183,P=0.262;1.06±0.25 cm vs.0.09±0.21 cm,t=-1.833,P=0.094）,but there was no significant difference.The late velocity of blood flow across the anastomoses was not accelerated,which indicated no obstruction.The late heart function was better than that shortly after operation,while there was no significant difference between left ventricular ejection fraction（LVEF） during these two periods（62.88%±7.28% vs.67.92%±7.83%,t=1.362,P=0.202）.The late left ventricular end diastolic dimension（LVDd） was significantly different from that shortly after operation（2.16±0.30 cm vs.2.92±0.60 cm,t=-5.281,P=0.003）.Compared with earlier period after operation,the thickness of left ventricular posterior wall thickness（LVPWT）was also increased（0.39±0.12 cm vs.0.36±0.10 cm,t=0.700,P=0.500）,but there was no significant difference.The postoperative aortic valve regurgitation was worsened in 4 patients（30.77%,4/13）,not changed in 7 patients and alleviated in 2 patients compared with that before operation.There was no severe regurgitations during the follow-up.The logistic regression analysis showed that the small pre-operative diameter ratio of aortic valve to pulmonary valve and long follow-up time were two risk factors for the aggravation of aortic regurgitation.Conclusion There is a relatively high aortic regurgitation rate after rapid twostage arterial switch operation,but there is no later death or re-operation and the survival conditions are satisfactory.All patients must be followed up periodically to check the anastomosis of pulmonary and aortic arteries and the aortic valve.