肺动脉单瓣在6月龄内法乐四联症一期根治术中的抗反流作用

Role of pulmonary monocusp on right ventricular outflow tract reconstruction during one-stage repair of tetralogy of Fallot under 6 months olddures

目的小婴儿法乐四联症根治术后急性肺动脉反流会进一步损害右心功能，影响患儿围手术期恢复，肺动脉单瓣可能是减轻肺动脉反流的有效手段，本研究旨在分析肺动脉单瓣在6月龄内法乐四联症一期根治术中的临床效果。方法2008年1月至2013年1月间行一期根治术的6月龄内法乐四联症患儿共126例，排除术后残余室间隔缺损5例，残余右室流出道梗阻3例，延迟关胸1例，术前复苏并急诊手术2例，中度三尖瓣反流2例，最终有113例患儿人选本研究。回顾分析其临床资料。其中，男69例，女44例；手术年龄2～6m，平均（4．6±1。3）m；体重3．5～10kg，平均（6．8±1．3）kg；术前血氧饱和度（Sp02）在56％～98％，平均86．4％±8．6％。所有病例按照右室流出道的重建方式分为A、B、C三组，A组为跨肺动脉瓣环扩大，并重建肺动脉单瓣组，共19例；B组为跨肺动脉瓣环扩大右室流出道组，共68例；C组为保留肺动脉瓣环组，共26例。我们将c组作为对照组，分别比较A、B两组和C组在术前状况，手术期，围手术期及术后随访期的差异性。结果B组早期死亡2例，其他两组无死亡。B组术后机械通气时间（2．30±1．41）d、ICU滞留时间（4．82±2．07）d均较C组（1．53±0．92）d和（3．09±1．12）d延长；B组术后出现中度及以上的肺动脉反流52例，C组为5例；B组术后24h尿量为（1．72±0．49）ml·kg-1·h-1较C组（2．41±0．99）ml·kg-1·h-1少；B组CVP为（12．76±2．06）mmH20较C组（10．59±1．94）mmH20升高；B组术后静脉利尿剂用量为（3．84±1．90）mg·kg-1·d-1，加用肾上腺素正兴肌力药物者29例，C组为（2．46±0．61）mg·kg-1·d-1和1例；上述参数比较，两组差异均有统计学意义（P〈O．05orP〈0．01）。A组和C组在体外循环时间，主动脉阻断时间，机械通气时间，ICU滞留时间，术后肺动脉反流程度，肾上腺素应用，术后尿量，速尿剂量，术后CVP上差异均无统计学意义（P〉O．05）。表明植入肺动脉单瓣后，术后恢复时间明显减少，与保留肺动脉瓣环组相似。结论肺动脉单瓣在6月龄内法乐四联症一期根治手术术后早期的抗反流效果是确切的，可以明显缩短围手术期恢复时间，减少正兴肌力药物应用，早、中期随访未发现血栓发生。

Objective To assess the role of pulmonary monocusp during one-stage repair of TOF under 6 months old. Methods Among a total of 113 one-stage repaired TOFs under 6 months old from January 2008 to January 2013, there were 69 boys and 44 girls with a mean operative age of（4. 6 ± 1. 3） （2-6） months. The mean body weight was （6.8 ± 1.3） （3.5-10） kg. And the mean preoperative SpO2 was 86. 4% ± 8. 6% （56%-98%）. They were divided into 3 groups of A, B and C according to the approaches of right ventricular outflow tract（RVOT）construction- Group A （n= 19） underwent transannular patch and pulmonary monocusp, Group B （n = 68） transannular patch enlargement and Group C （n = 26） valve sparing patch as control. Three groups were compared to analyze the discrepancy of condition before, during and after operation. Results Two deaths occurred in group B while no death in other two groups. Ventilation time in group B was（2. 30 ± 1.41）days and ICU stay duration（4. 82 ± 2.07）days. They were longer than group C [（1.53 ± 0. 92）, （3.09 ± 1.12） days]. Fifty-two patients in group B had more than moderate pulmonary regurgitation after surgery while only 5 in group C. Urine volume during the first postoperative 24 hour in group B was（1.72 ±0. 49）ml.kg-1 · h-1 and it was less than group C（2. 41 ± 0. 99）ml·kg-1 ·h-l; CVP in group B was （12. 76 ± 2. 06）mmH20 and it was higher than group C（10. 59 ± 1.94）mmH20. The dose of diuretics was （3. 84 ± 1.90） mg·kg-1. d-t in group 13. Twenty-nine patients required epinephrine while the dose of diuretics was（2. 46 ± 0. 61）mg·kg-1 ·d-1 in group C and only one needed epinephrine. There was statistically significant difference（P〈0. 05 or P〈0. 01）. As compared to group C, group A had similar values of bypass and cross-clamp time, ventilation and ICU stay, pulmonary regurgitation, urine volume during the first postoperative 24 hour and dose of diuretics. It indicated that group A recovered more quickly than group B after pulmonary monocusp implantation. Conclusions Monocusp plays an effective role of reducing pulmonary regurgitation during one-stage repair of TOF under 6 months old. And it can decrease the duration of perioperative recovery and the dosing of diuretics and epinephrine. There is no occurrence of thrombosis or endocarditis during early and mid-term follow- ups.