牛颈静脉带瓣补片在复杂先天性心脏病患者右心室流出道重建中的应用

Right Ventricular Outflow Tract Reconstruction with Valved Bovine Jugular Vein Patch in Patients with Complex Congenital Heart Disease

目的评价牛颈静脉带瓣补片应用于重建右心室流出道的近期效果。方法回顾性分析2009年5月至2010年3月武汉亚洲心脏病医院行牛颈静脉带瓣补片重建右心室流出道60例患者的临床资料,男42例,女18例;年龄5个月～33(6.2±8.9)岁,其中34例<1岁;体重(27.5±24.0)kg。术前临床诊断为法洛四联症38例,右心室双出口合并肺动脉狭窄22例。所有患者均行一期完全修复术,有4例因为侧枝循环较多,术前采取介入侧枝封堵。全组患者肺动脉瓣瓣环直径均小于正常值2个标准差,均采取跨瓣环补片重建右心室流出道。随访时间18～26(21.2±4.6)个月。结果手术无死亡,也无因流出道严重狭窄和严重肺动脉瓣反流需再次手术者。有3例患者术后早期因为侧枝循环较多,拔除气管内插管后出现肺水肿,再次气管内插管;4例患者因出血需二次开胸止血,其他患者术后均顺利康复出院。体外循环时间(84.0±22.0)min,主动脉阻断时间(42.0±12.0)min。术后即刻右心室流出道压力阶差(18.0±4.5)mm Hg,术后最后一次随访的经胸超声心动图检查提示,右心室流出道压力阶差为(19.2±5.4)mm Hg,两者差异无统计学意义(P>0.05)。术后即刻肺动脉瓣反流程度:轻微反流32例(1+),轻度反流28例(2+);术后最后一次随访的经胸超声心动图检查提示,反流程度:轻微28例(1+),轻度27例(2+),中度5例(3+);两者反流程度差异无统计学意义(P>0.05)。牛颈静脉带瓣补片及瓣叶组织均未见钙化,瓣叶活动良好。无牛颈静脉血栓形成及感染性心内膜炎发生。结论对法洛四联症和右心室双出口合并肺动脉狭窄的患者,牛颈静脉带瓣补片是右心室流出道跨瓣环重建的一种良好材料,无相关的严重并发症发生,近期右心室流出道压力阶差没有明显增加,肺动脉瓣抗反流性能良好;远期效果还需进一步随访观察。

Objective To evaluate early results of valved bovine jugular vein patch for reconstruction of the right ventricular outflow tract（RVOT）.Methods From May 2009 to March 2010,a total of 60 patients with complex congenital heart diseases underwent reconstruction of RVOT with valved bovine jugular vein patch in Wuhan Asia Heart Hospital.There were 42 males and 18 females with their mean age of 6.2±8.9 years（ranging from 5 months to 33 years） and mean body weight of 27.5±24.0 kg,and 34 patients were less than 1 year.Preoperative clinical diagnosis included tetralogy of Fallot（n=38） and double outlet of right ventricle with pulmonary stenosis（n=22）.All the patients underwent one-stage surgical repair.Before operation,4 patients underwent catheter intervention for their major aortopulmonary collaterals.The diameters of pulmonary arterial ring of all the patients were 2 standard deviation less than normal range,and trans-annular patch was chosen for RVOT reconstruction.All the patients were postoperatively followed up for 18 to 26 months（mean 21.2±4.6 months）.Results There was no in-hospital death.And no second surgical intervention was needed for conspicuous RVOT stenosis or pulmonary regurgitation.Three patients needed reintubation for lung edema after extubation as a result of major aortopulmonary collaterals.Four patients underwent reexploration for postoperative bleeding.And all the other patients were discharged uneventfully.Mean cardiopulmonary bypass time was 84.0±22.0 min,and mean aortic cross-clamping time was 42.0±12.0 min.Mean RVOT gradient right after surgery was 18.0±4.5 mm Hg,which was not statistically different from mean RVOT gradient of 19.2±5.4 mm Hg measured by transthoracic echocardiography at their last postoperative follow-up（P0.05）.The degree of pulmonary regurgitation right after surgery was trivial in 32 patients（1＋）,mild in 28 patients（2＋）,which were not statistically different from the degree of pulmonary regurgitation at their last postoperative follow-up： trivial in 28 patients（1＋）,mild in 27 patients（2＋）,and moderate in 5 patients（3＋）.Calcification was not observed on the valved bovine jugular vein patch and valve cusp,and the valve cusp motioned well.No thrombosis or endocarditis was observed on the valved bovine jugular vein.Conclusions For patients with tetralogy of Fallot or double outlet of right ventricle（DORV） and pulmonary stenosis,valved bovine jugular vein patch is a good choice for trans-annular reconstruction of RVOT.There is no severe postoperative complication related to bovine jugular vein,the RVOT pressure gradient does not increase significantly,and anti-regurgitation result is satisfactory in short-term follow-up.Further follow-up is required to evaluate its long-term outcome.