两种手术方法对肺动脉闭锁伴室间隔缺损预后影响的探讨

One-stage surgical treatment of pulmonary atresia with ventricular septal defect

目的对近年来本院实施的肺动脉闭锁伴室间隔缺损(PA/VSD)一期根治术患儿手术方式及右室流出道重建方法进行总结,结合术后院内各项指标进行比较分析;对比同期一期姑息PA/VSD手术的术后生存率、并发症等情况,藉此对一期手术方案的选取进行评价。方法本院2008年1月至2014年3月施行单纯PA/VSD一期根治手术129例为根治组,收集患儿性别、手术时年龄、身高、体重、术前经皮氧饱和度、McGoon、Nakata指数、手术方式、右室流出道重建材料、术中体外循环、主动脉阻断时间、术后置CICU时间、住院时间、术后最大正性肌力药物评分、院内并发症及死亡率情况;另外收集本院120例P/VSD一期姑息手术患儿相应资料作为对比,为姑息组。结果一期根治组早期院内死亡10例,病死率7.8%;术前McGoon指数1.6±0.5,体外循环时间(130.0±45.6)min;主动脉阻断时间(77.2±23.5)min;呼吸机支持时间(87.0±92.8)h;住院时间(22.6±11.4)d。一期姑息组院内死亡11例,病死率9.2%;McGoon指数1.2±0.3,体外循环时间(89.7±46.4)min;呼吸机支持时间(47.4±50.5)h;住院时间(18.6±7.0)d;结论术前McGoon≥1.2,SpO_2≥75%可视为一期根治术的适应证;术中监测RVP/LVP比值是预防术后早期院内死亡的重要方法;对于伴有粗大主肺动脉侧支(MAPCAs)的患儿,提倡采取早期根治手术。

Objetive To summarize the one-stage complete procedures of pulmonary atresia with ven-tricular septal defect （PA /VSD）in recent years,explore the reconstruction methods of right ventricular outflow tract,make a comparative analysis with index after procedure and compare the situations with others palliative procedures at the same time.Methods Retrospective reviews were conducted for 129 cases of one-stage com-plete procedures from January 2008 to March 2014.The relevant parameters included gender,age,height, weight,preoperative percutaneous oxygen saturation,McGoon index,Nakata index,surgical procedure,recon-struction materials of right ventricular outflow tract,cardiopulmonary bypass （CPB）time,aortic clamping time and hospital stay length and postoperative inotropic score.Comparisons were made with 120 cases of palliative procedures at the same time.Results The mortality rate of one -stage complete procedure group was 7.8%and the mortality rate of palliative procedures was 9.2%.Significant inter-group differences existed in McGoon index,SpO2 ,CPB time and ventilation time.Cardiac intensive care unit （CICU）,hospitalization duration, CPB time,ACC time and McGoon index were significantly associated with the occurrence of low cardiac output syndrome. Conclusions Preoperative McGoon index ≥1.2,SpO2≥75% may become an indication for radi-cal surgery.And monitoring of RVP/LVP ratio prevents early hospital mortality.For concurrent major aortopul-monary collateral artery,early radical surgery should be promoted.