小儿主动脉瓣下狭窄的外科治疗及疗效观察

Surgical treatment on subvaivular aortic stenosis in children

目的探讨小儿主动脉瓣下狭窄（subvalvularaorticstenosis，SAS）的外科治疗方法并观察其治疗效果。方法统计1990年1月至2010年12月我院收治并进行手术治疗的22例SAS，男15例，女7例，年龄8个月至15岁，平均（5．93±3．90）岁。随访时间1个月至13．5年，平均（7．30±5．60）年。22例中单纯SAS5例，合并其他心内畸形为：室间隔缺损16例，右室双腔2例，动脉导管未闭2例。22例患儿全部进行外科手术治疗，行单纯隔膜状狭窄或肌纤维环切除术18例，加左室肥厚心肌切除术3例。1例合并动脉导管未闭患儿先经左胸行动脉导管结扎术，随访6年后再次手术行单纯隔膜狭窄切除术。结果所有患儿手术顺利，22例中治愈19例（86．36％），复发3例（13．64％），无死亡病例。治愈病例中，临床症状均消失，经超声心动图检查，均未见主动脉瓣下狭窄复发，无左室到主动脉收缩期压力阶差。3例复发患儿随访时间分别为4年、10年、12年。结论小儿主动脉瓣下狭窄的外科治疗关键是彻底解除左室流出道梗阻，避免二尖瓣、主动脉瓣及传导束损伤。术中梗阻解除不彻底以及术后局部组织过度生长可能是SAS术后复发的重要因素。

Objective To study the results of surgical treatment on subvalvular aortic stenosis （SAS） in children. Methods 22 cases of SAS were included from January 1990 to December 2{）10. There were 15 males and 7 females. The age range was from 8 months to 15 years （mean 5.93 ± 3. 90 years） ,and the follow-up period ranged from 1 month to 13.5 years （mean 7. 30 ± 5.60 years）. Over- all, simple SAS were seen in 5 cases, while the others had other associated cardiac malformations： ven- tricular septal defect （VSD） in 16 cases, dual-chamber right ventricle in 2 cases, patent ductus arterio- sus （PDA） in 2 cases. All children underwent surgical treatment. Simple annular diaphragm-like steno- sis or muscle resection were done in 18 cases; left ventricular hypertrophy myocardial resection done in 3 cases; 1 patient with PDA had ligation first, and followed by surgical resection of simple diaphragm- like stenosis after 6 years. Results Successful surgery was carried out in all. 19 patients were cured （86.36 ~） with recurrence seen in 3 cases （13.64 ~）. There was no surgical mortality. Post-operative echocardiography showed no systolic pressure gradient from left ventricle to aorta in the successful ca- ses. For the 3 cases of recurrence, they were followed up for 4 years, 10 years, 12 years, respectively. Conclusions The key to successful surgical treatment on subvalvular aortic stenosis in children is com- plete removing of the stenosis of left ventricular outflow tract obstruction,and to avoid damage to the mitral valve, aortic valve and conduction bundle. Incomplete removal of stenosis and postoperative local tissue overgrowth may be important factors in SAS recurrence.