肺动脉环缩术的临床应用

Clinical Application of Pulmonary Artery Banding

目的总结肺动脉环缩术(pulmonary artery banding,PAB)作为一种姑息治疗手段在治疗先天性心脏病中的临床应用经验。方法 1997年1月至2010年11月北京阜外心血管病医院对138例先天性心脏病患者施行PAB,其中男87例,女51例;年龄(22.2±26.5)个月;体重(7.5±4.6)kg。按施行PAB的目的不同,将138例患者分为3组,心室训练组(组1)55例、单心室矫治过渡组(组2)32例和双心室延迟矫治组(组3)51例。术中、术后分别观察3组患者相应的临床指标,并进行随访。结果 PAB术后院内死亡7例,手术死亡率5.1%。另有3例患者需要再次手术调整环缩带的松紧程度。组1手术死亡1例。55例患者中有36例完全型大动脉转位(D-TGA)患者于年龄(19.6±29.5)个月时接受PAB(29例同期行Blalock-Taussig分流术),平均训练时间42 d,83.3%(30/36)的患者成功施行动脉转位术治疗;另19例矫正型大动脉转位(cTGA)患者,在年龄(45.3±27.2)个月时行PAB治疗,中位训练时间9个月,42.1%(8/19)的患者成功施行双调转术治疗。组2患者手术死亡2例。32例于年龄(14.1±14.9)个月时行PAB治疗,平均肺动脉压较术前明显降低[(23.00±7.40)mm Hg vs.(34.00±10.00)mm Hg],脉搏血氧饱和度(SpO2)亦较术前降低(83.30%±6.30%vs.92.60%±5.90%)。中位间隔时间2年,18.8%(6/32)的患者接受了单心室类矫治术。组3患者手术死亡4例,于年龄(20.6±25.6)个月时行PAB治疗,肺动脉收缩压与体循环收缩压的比值较术前明显降低(0.46±0.15 vs.0.81±0.14),SpO2亦较术前降低(85.00%±10.00%vs.93.10%±7.60%)。中位间隔时间6个月,23.5%(12/51)的患者施行了双心室矫治术。结论 PAB虽然是一种风险较高的姑息治疗手段,但在保护肺血管床、实施心室功能训练、完成复杂先天性心脏病的分期矫治方面仍具有不可缺少的重要作用。

Objective To summarize our clinical experience of pulmonary artery banding（PAB） for the treatment of complex congenital heart diseases as a palliative procedure.Methods From January 1997 to November 2010,138 patients with complex congenital heart diseases underwent PAB in Fu Wai Hospital.There were 87 male patients and 51 female patients with their age of 22.2±26.5 months and average body weight of 7.5±4.6 kg.All the 138 patients were divided into 3 groups according to the purpose of PAB：left ventricular retraining（group 1,n=55）,initial procedure for functional single ventricle with unobstructed pulmonary blood flow（group 2,n=32） and initial palliative procedure followed by later biventricular repair（group 3,n=51）.The intraoperative and postoperative clinical parameters of all participants were observed,and follow-up was made for these 3 groups of patients.Results The in-hospital mortality of PAB was 5.1%（7/138）.Three patients underwent re-banding procedure to adjust the size of banding.In group 1,there was 1 postoperative death.Among the 55 patients,36 patients with dextro-transposition of great arteries received PAB at an average age of 19.6±29.5 months,29 patients of whom underwent concomitant modified Blalock-Taussig shunt.After an average training interval for 42 days,83.3% of them（30/36）successfully received arterial switch operation.The other 19 patients in group 1 with isolated corrected transposition of great arteries received PAB at an average age of 45.3±27.2 months.After an average training interval for 9 months,42.1% of them（8/19） successfully received double-switch operation.In group 2,there was 2 postoperative death.Thirty-two patients with functional single ventricle and unobstructed pulmonary blood flow received PAB at an average age of 14.1±14.9 months.Their postoperative mean pulmonary artery pressure decreased significantly from 34.00±10.00 mm Hg to 23.00±7.40 mm Hg,and their oxygen saturation of blood（SpO2） significantly decreased from 92.60%±5.90% to 83.30%±6.30%.After a median interval of 2 years,18.8% of them（6/32） underwent right heart bypass operation.In group 3,there was 4 postoperative death.Fifty-one patients received PAB at an average age of 20.60±25.60 months.After PAB procedure,the ratio of systolic pulmonary artery pressure and systolic blood pressure significantly decreased from 0.81±0.14 to 0.46±0.15,and their SpO2 significantly decreased from 93.10%±7.60% to 85.00%±10.00%.After a median interval of 6 months,23.5% of them（12/51） received biventricular repair.Conclusion Although PAB is a palliative procedure with comparatively high risks,it still plays an indispensable role in terms of protecting pulmonary vascular beds,retraining ventricular function and two-stage surgical correction for the treatment of complex congenital heart diseases.