单心室外科治疗中房室瓣反流的处理

Surgical management of atrioventricular valve regurgitation in single-ventricle

目的 探讨单心室外科治疗中对中、重度房室瓣反流的处理时机和方法.方法 2006年6月至2011年10月23例合并中至重度房室瓣反流的单心室患儿（者）接受了房室瓣修复或置换手术.男17例,女6例.年龄2.1 ～22.0岁.体质量12.5 ～59.0 kg.全体病例中,A型单心室3例、B型17例、C型2例、D型1例.1例C型者有两组房室瓣,22例只有一组房室瓣.房室瓣反流重度18例,中度5例.12例在本次处置房室瓣反流之前,完成了第一阶段的手术：双向Glenn手术11例,主动脉-右肺动脉分流手术1例.两次手术相距7～ 96个月,中位数39个月.本组行房室瓣机械瓣置换7例;房室瓣机械瓣置换及双向Glenn手术5例;房室瓣机械瓣置换及全腔静脉-肺动脉连接（TCPC）术3例;房室瓣修复及双向Glenn术4例;房室瓣修复及TCPC术2例;房室瓣修复、双向Glenn、及全肺静脉异位引流矫治术1例;房室瓣修复、双向Glenn、肺动脉环束以及全肺静脉异位引流矫治术1例.结果 本组房室瓣置换的比例为65.2％.中度房室瓣反流者5例全部行房室瓣修复;重度房室瓣反流者18例中仅3例可以作房室瓣修复（P=0.002）.全组病例院内死亡3例,占13％.8例行房室瓣修复者均早期生存.房室瓣置换者死亡20％.生存患儿（者）随访0.8 ～6.3年,无死亡.结论 单心室合并房室瓣反流,需要在心肌受损前外科处理.中度反流时应为处理房室瓣反流的最佳时期.单心室房室瓣重度反流进行房室瓣置换具有良好的效果.

Objective The aim of this article is to review and analyze the timing and surgical management of mediate and severe atrioventricular valve regurgitation（AVVR） in single-ventricle patients.Methods Between June 2006 and October 2011,twenty-three cases of single-ventricle patients accompanied with AVVR underwent atrioventricular valve plasty or replacement.There were 17 males and 6 females.Their ages ranged from 2.1 to 22.0 years,and their weight from 12.5 to 59.0 kg.There were 3 cases of A type of single ventricle,17 of B type,2 of C type,and 1 of D type.All cases had one atrioventricular valve except one of D type with 2 groups of atrioventricular valves.There were 18 patients with sever AVVR and 5 with the moderate.Before the management of AVVR,12 patients had undergone the first stage palliation,including B-D Glenn procedure 11 cases and A-P shunt 1 case.The periods between the two stages operations were 7-96 months.Among the all,there were 7 cases of atrioventricular valve replacement ; 3 cases of atrioventricular valve replacement and TCPC ; 5 cases of atrioventricular valve replacement and B-D Glenn procedure ; 2 cases of atrioventricular valve repair and TCPC ; 4 cases of atrioventricula repair and B-D Glenn procedure; 1 case of atrioventricular valve repair,B-D Glenn procedure and TAPVC repair; 1 case of atrioventricular valve repair,B-D Glenn procedure,PA Banding and TAPVC repair.Results In this group,there were 65.2% patients who underwent atrioventricular valve replacement.The ones with moderate regurgitation underwent atrioventricular valve repair.Only 3 of the 18 cases with severe regurgitation could underwent atrioventricular valve repair（P =0.002）.Three cases died.The mortality was 13%.All cases undergone atrioventricular valve repair were alive.The mortality of atrioventricular valve replacement was 20%.All the post-operative alive were followed up.Their follow-up period were between 0.8-6.3 years,withoud a dead case.Conclusion The regurgitation with single ventricle should be managed before the image of myocardium occurred.It is the best time to manage the atrioventricular valve when the regurgitation was moderate.The atrioventricular valve replacement is effective to the cases of single ventricle with severe AVVR.