法洛四联症右心室流出道疏通的临床经验

Clinical experience of dredging right ventricular outflow tract in tetralogy of fallot

目的探讨法洛四联症(tetralogy of fallot,TOF)根治术中右心室流出道疏通的最佳直径。方法回顾性分析2011年1月至2016年12月我院心脏外科行TOF根治术的儿童病例308例,2011年1月至2013年12月201例患儿(A组)均采取右心室流出道疏通直径等同于标准肺动脉瓣环直径;2014年1月至2016年12月107例患儿(B组)采取右心室流出道疏通直径大于标准肺动脉瓣环直径3 mm。所有出院患者术后随访12~36个月。结果A组有17例患者术后出现右心室流出道残余梗阻致低心排血量综合征(low cardiac output syndrome,LCOS),多普勒测右心室流出道流速3.1~4.8(3.8±0.4)m/s,跨肺动脉瓣压差均大于50mmHg,其中6例右心室流出道流速超过4.5m/s,再次手术行右心室流出道疏通术;术后早期死亡5例,随访余12例未发现右心室流出道残余梗阻进一步发展,且均较术后早期明显改善。B组术后无右心室流出道残余梗阻,跨肺动脉瓣压差均小于50mmHg,术后早期死亡2例。随访两组出院患者无三尖瓣、肺动脉瓣大量反流,生长发育良好,心功能均达Ⅰ~Ⅱ级。结论TOF右心室流出道疏通直径等同于标准肺动脉瓣环直径造成术后残余梗阻发生率较高,大于标准肺动脉瓣环直径3mm可有更好的疗效。

Objective To investigate the optimal diameter of right ventricular outflow tract during the radical operation of tetralogy of fallot(TOF).Methods A retrospective analysis of 308 children undergone TOF radical surgery from January 2011 to December 2016 in our hospital.Among them,201 children from January 2011 to December 2013 (group A)were equal to the diameter of the standard pulmonary valvular ring in the right ventricular outflow tract and 107 children's from January 2014 to December 2016 (group B)had diameter of right ventrieular outflow over 3 mm greater than standard pulmonary valve ring diameter.All patients were followed up for 12-36 months.Results In group A,there were 17 patients with Low cardiac output syndrome(LCOS)caused by right ventricular outflow tract obstruction;Doppler right ventricular outflow tract flow velocity was 3.1-4.8(3.8±0.4)m/s and pulmonary artery valve pressure difference was greater than 50 mm Hg;6 cases'right ventricular outflow velocity exceeded 4.5 m/s and underwent right ventrieular outflow passage dredging again;5 cases died early postoperatively and 12 cases were followed up and further development improved significantly compared with early postoperative period.In group B there was no right ventricular outflow tract residual obstruction and the pressure difference across the pulmonary artery was less than 50 mm Hg;2 cases died early postoperatively.All the discharged patients had no three cusp and pulmonary valve regurgitation.Their growth and development were good and their cardiac functions were Ⅰ~Ⅱ grade.Conclusion The incidence of postoperative residual obstruction of the diameter of TOF right ventricular outflow tract equal to that of the standard pulmonary artery ring diameter is higher than that of the standard pulmonary valvular ring diameter over 3 mm.