右心室流出道的处理方法与法洛四联症矫治术后右心室功能的相关分析

The analysis of right ventricular outflow tract procedures for repair of tetralogy of Fallot and postoperative right ventticular funcfion

目的评价法洛四联症（TOF）右心室流出道（RVOT）处理方法与矫治术后右心功能变化的关系，以期提高矫治手术的中、远期效果。方法2003年1月至2006年1月，125例TOF患儿接受矫治手术，其中男66例，女59例；手术年龄1～5岁，平均（3．4±1．1）岁；体质量7～26kg，平均（15．2±5．7）kg。对照组选择20例同龄健康儿童。RVOT处理方法包括跨肺动脉瓣环补片加宽（M1组）67例，右心室漏斗部补片加宽（M2组）6例，经右心室切口非补片修复（M3组）18例，经右心房-肺动脉切口非补片修复（M4组）34例。采用脉冲多普勒（PDE）和组织多普勒超声心动图（TDI）评价右心室功能，选择三尖瓣环收缩期移位（TAPSE）、右心室心肌作功指数（MPI）作为右心室收缩功能指标，测定的三尖瓣瓣环处舒张早期峰速（Em），舒张晚期峰速（Am），计算Era／Am和E／Em比值作为右心室舒张功能指标。计量资料采用单因素方差分析，单因素分析有统计学意义的变量纳入logistic回归分析。计数资料采用χ^2检验。结果术后5年随访检查心脏超声发现，M1和M2组的MPI和E／Em显著高于M3和M4组。单因素分析显示，术前Nakata指数、既往分流手术、手术方式、肺动脉瓣反流和术后QRS时间是影响术后MPI的危险因素；术前Nakata指数、手术方式、肺动脉瓣反流和术后QRS时间是影响术后E／Em的危险因素。二元logistic遂步回归分析结果显示，手术方式和术后QRS时间是影响术后MPI的独立因素；术后肺动脉瓣反流是影响术后E／Em的独立因素。结论TOF术后右心室功能降低与RVOT处理方法有关，舒张功能的降低与术后肺动脉瓣的反流有明显的相关性，收缩功能的降低与手术中应用补片加宽右心室流出道和术后的QRS时间有明显的相关性。心脏超声多普勒技术在测定TOF术后右心室功能和评价术后中、长期疗效有重要的指导意义。

Objective To analyze the relation of right ventricular outflow tract （RVOT） procedures for repair of tetralogy of Fallot and postoperative right ventricular function in order to improve the postoperative results at mid-long term follow-up. Methods A total of 125 patients for data collection with repair of TOF between January 2003 and January 2006 were prospectively enrolled in the study. Among them, 66 were male and 59 were female. The ages ranged from 1 to 5 （3.4 ± 1. 1 ） years, weight from 7 to 26 （ 15.2 ± 5.7 ） kg. 20 healthy controls with a similar age and body weight were included. The type of RVOT procedure included transannular patch repair （ M1 ） in 67 patients, patch to infundibulum （ M2 ） in 6 patients, tranright-ventricle （RV） no patch repair （M3） in 18 patients and transatrial-transpulmonary no patch repair （M4） in 34 patients. Doppler echocardiogram and tissue Doppler imaging were performed to evaluate RV function. RV systolic function was evaluatedusing tricuspid annular plane systolic excursion （TAPSE） and index of myocardial performance （MPI）. RV diastolic function was evalnatedusing ratio of Em/Am and E/Era. Unvariate and logistic regression analysis were used to identify the affective factors. Results In five years fellow-up, MPI and E/Em were higher in patents with M1 and M2 than those in the patients with M3 and M4. Univariate analysis revealed Nakata index, previous shunt operation, operative techniques,postoperative pulmonary regurgitation and during of QRS as risk factors for MPI. In the multivariate analysis, operative techniques and during of QRS were risk factors for MPI. Univariate analysis revealed Nakata index, operative techniques, PR and during of QRS as risk factors for E/Em. In the multivariate analysis, PR was the risk factor for E/Em. Conclusion RV dysfunction is associated with the type of RVOT procedure, diastolic dysfunction is correlative with postoperative PR and systolic dysfunction is correlative with enlarge of RVOT with patch and during of QRS. Echocardiographic imaging is a simple and reliable method for assessment of RV function after repaired TOF.