婴幼儿动脉导管未闭合并瓣膜返流的外科治疗

Surgical treatment of patent ductus arteriosus and valve regurgitation in infant

目的 探讨手术治疗对婴幼儿动脉导管未闭（PDA）合并二尖瓣返流（MR）、三尖瓣返流（TR）的治疗效果.方法 2009年5月至2014年4月我院共20例PDA合并MR、TR患儿施行了手术治疗,其中男性5例、女性15例,年龄1～29（10.07±8.66）个月,体重2.5～12.0 （7.35±3.30）kg;PDA直径3～12（6.55±2.28）mm,管型17例、窗型2例、漏斗型1例.轻度MR 12例,中度返流5例,重度返流3例;合并三尖瓣轻度返流10例,三尖瓣中度返流1例.20例患者均通过左侧胸入路结扎PDA,未处理二尖瓣、三尖瓣.结果 围术期无死亡病例,术后呼吸机辅助呼吸时间1～61（12.4±16.76）h;监护时间16～240（55.00±63.67）h.术后2例患者在拔出气管内插管后出现呼吸急促,氧饱和度下降,再次插管,经过监护治疗恢复顺利.其余患者均恢复顺利,无其他并发症.随访20例均超过1年时间.随访期间,全组MR均有不同程度的减轻,其中3例二尖瓣重度返流改善为中度返流1例和轻度返流2例;5例二尖瓣中度返流改善为无返流3例和轻微返流2例;12例二尖瓣轻度返流改善为无返流7例和轻微返流5例.合并11例TR改善为无返流7例、轻微返流4例.患儿术后1周、术后3个月、术后1年左室舒张末期内径（LEVDD）较术前明显减小,差异有统计学意义（P＜0.05）.患儿心胸比值术后1年较术前明显减小,差异有统计学意义（P＜0.05）.结论 PDA合并MR、TR的婴幼儿对二尖瓣、三尖瓣的处理应行保守治疗,单纯结扎PDA便可获得良好的效果.

Objective To summarize the experiences of surgical strategy for infant with patent ductus ar- teriosus （PDA） accompanied by mitral and tricuspid regurgitation. Methods The clinical data of 20 children with PDA accompanied by mitral and tricuspid regurgitation from May 2009 to Apr 2014 were retrospectively analyzed. All of them underwent surgical treatment in Children＇s Hospital of Shanghai. There were 5 male patients and 15 female patients with average age of 1-29（10.07±8.66）months and average weight of 2.5-12.0（7.35±3.30）kg. The average diameter of PDA was 3-12 （6.55±2.28）mm. There were 17 children with duct-type PDA, 2 children with window-type PDA, and one child with funnel-type PDA. There were 12 children withmild mitral regurgitation （MR）, 5 children with moderate MR, and 3 children with severe MR. Meanwhile, there were 10 children with- mild tricuspid regurgitation（TR） and one child with moderate TR. All children underwent PDA ligation through left posterolateral thoracotomy without any management for the mitral valve. Results There was no in-hospital death. The average ventilation time in intensive care unit（ICU） was 1-61（12.4±16.76）hours and the average postopera- tive care time was 16-240 （55.00±63.67）hours. Except the fact that 2 children were reintubated because of asth- ma, all other children recovered uneventfully without any postoperative complication. All the 20 children were fol- lowed up for more than one year. During follow-up, all of them had their MR level ameliorated in different degree. Preoperative severe MR in 3 children changed into moderate MR in one child and mild MR in 2 children. Preoperative moderate MR in 5 children changed into none MR in 3 children, trivial MR in 2 children. Preoperative mild MR in 12 children changed into none MR in 7 children, trivial MR in 5 children. Preoperative MR with TR in 11 children changed into none MR in 7 children, trivial MR in 4 children. The LEVDD was significantly lower in 1 week, 3 months and 1 year after the surgical operation than that before surgical operation （P〈0.05）. The car- clio-thoracic ratio was significantly lower compared with that before surgical operation （P〈0.05）. Conclusion For infants with PDA and valve regurgitation, conservative treatment strategy should be carried out. Moreover, simple PDA ligation can lead to satisfactory clinical outcome.