自体心包修复儿童主动脉瓣狭窄9例病例系列报告

Surgical repair of aortic stenosis by using autologous pericardium in pediatric population : a report of 9 cases

目的总结并分析以自体心包修复儿童先天性主动脉瓣狭窄的手术方法和早期预后。方法纳入2013年7月至2015年6月在复旦大学附属儿科医院行自体心包主动脉瓣成形术的先天性主动脉瓣狭窄患儿,收集患儿的一般资料,围手术期情况,并发症,术前、术中、术后和随访时的超声心动图资料。结果符合本文纳入标准的9例患儿进入本文分析,男6例,女3例,年龄4月龄至9岁。术前超声提示,三叶式和二叶式主动脉瓣分别为3例和6例;重度狭窄6例,中度狭窄1例,重度狭窄伴中度返流2例。9例均以自体心包再造或扩大主动脉瓣瓣叶。术后即刻与术前超声心动图比较:主动脉瓣最大跨瓣压差[(31.6±9.4)mm Hg vs(73.0±22.2)mm Hg,P=0.000]和主动脉瓣平均跨瓣压差[(15.8±18.3)mm Hg vs(35.8±18.3)mm Hg,P=0.004]均下降。术后随访24~48(32±8)月,无死亡和再干预病例,未见严重不良事件,未见主动脉瓣重度狭窄或重度反流、升主动脉狭窄或扩张、主动脉瓣瓣环狭窄与扩张、瓣膜脱垂或瓣膜赘生物病例;3例患儿分别在随访18、24和12个月时出现瓣叶活动僵硬,瓣叶开放不完全。术后左室后壁厚径均呈下降趋势;末次随访时,8例患儿左室后壁厚径Z值(Z-LVPWd)均下降至正常水平(<2)。结论以自体心包修复主动脉瓣可改善先天性主动脉瓣狭窄患儿的血流动力学,手术风险低,术后早期疗效可,避免或延缓儿童主动脉瓣置换术,减少施行ROSS手术机会。

Objective To summarize the surgical technique of repairing congenital aortic valve stenosis by using autologous pericardium and analyze its early outcomes in children. Methods A total of children with congenital aortic stenosis who underwent autologous pericardial aortic valvuloplasty at the Children＇s Hospital of Fudan University from July 2013 to June 2015 were collected for clinical inlonnation,including general informations,perioperative conditions,complications , preoperative, intraoperative, postoperative color echocardiograph data,and follow-up information. Results 9 children according with the inclusion criteria for this article were analyzed There were 6 males and 3 females, aged from 4 months to 9 years old. Preoperative color echocardiograph showed tricuspid aortic valve （ n =3 ）,bicuspid aortic valve（ n = 6） ; severe aortic valve stenosis （ n = 6 ）, moderate aortic valve stenosis （n =1） and severe aortic valve stenosis with moderate aortic valve re-gurgitation （ n = 2）. The surgical procedures of 9 patients were all based on reconstruction aortic valve （ reconstructed leaflets or expand leaflets） by autologous pericardium. Compared to the preoperative echocardiograph, immediately postoperative echocardiography results showed that aortic valve peak pressure gradient[（31.6±9.4）mmHg vs （73.0±22.2）mmHg,P = 0.000]and aortic valve average pressure gradient[（15.8±18.3） mmHg vs（5.8±18.3）mmHg, P = 0.004] were decreased significantly. 24？48（32±8）months were followed up after operation,no death events or reoperation events or adverse event were recorded, and there was no patient with severe aortic stenosis or sever aortic regurgitation , ascending aortic stenosis or dilatation, aortic valvular ring stenosis or dilatation. And there were no patients with aortic valve prolapse or aortic valve vegetation.3 patients encountered with aortic valve stiffness and restriction of aortic valve open at the18,24 and 12 months after operation respectively.The left ventricular posterior wall diameter was decreased in all patients, and except for 1 case,the Z-LVPWd of rest 8 patients was at normal level upon the last follow- up. Conclusion Using autologous pericardium to repair aortic valve lesions can improve the hemodynamics of children with congenital aortic valve stenosis, the risk of this operation is low and the short-term results are excellent. Furthermore, this operation technique can avoid or put off the valve replacement operation and reduce the operation of Ross procedure.