保留肺动脉瓣在婴幼儿法洛四联症根治术中的意义

The significance of pulmonary valve-sparing in the radical operation of tetralogy of Fallot in infants

目的探讨婴幼儿法洛四联症(TOF)根治术中保留肺动脉瓣的意义。方法 2017年6月-2018年3月,我院共实施TOF一期根治手术87例,依据术前心脏彩超(/CT)初步筛选出53例肺动脉瓣环Z值在-1～-3的患儿为试验对象。最终入选对象40例,均为术中实测肺动脉瓣瓣环Z值在-1～-3的TOF患儿。选取20例行保留肺动脉瓣根治患儿为试验组,另取20例行传统的跨肺动脉瓣根治患儿为对照组。检测两组患儿手术前(T1)、术后当天(T2)、术后1d(T3)、术后1个月(T4)、术后3个月(T5)、术后6个月(T6)共6个时间点血清NT-proBNP浓度,并监测各时间点心脏彩超评估的右室Tei(RV-Tei)指数、右室/左室压力比(PRV/PLV)、右室流出道-肺动脉压力阶差变化,同时观测相关临床指标。结果对照组术后血管活性药物评分、呼吸机辅助时间、术后住院时间、低心排出量发生率均明显高于试验组(P<0.01),且有1例因持续严重的低心排于术后第3d死亡,临床转归试验组明显优于对照组。通过术后各时间点随访观察,试验组术后PRV/PLV和右室流出道-肺动脉压力阶差虽然高于对照组,但随时间推延,此两项指标逐渐下降,后期两组比较差异无统计学意义(P>0.05)。反应右心功能的指标RV-Tei指数和血清NT-proBNP术前两组无差异(P>0.05),术后各时间点比较差异明显(P<0.01),试验组显著低于对照组。结论婴幼儿TOF一期根治术中,保留肺动脉瓣可以减轻肺动脉瓣反流,有效保护右心功能,并有利于患儿临床恢复。

Objective To explore the significance of pulmonary valve-sparing in radical operation of tetralogy of Fallot(TOF)in infants.Methods From June 2017 to March 2018,87 cases of TOF primary radical operation were performed in our hospital.According to preoperative echocardiography(/CT),53 children with pulmonary valve ring Z-value between-1 and-3 were preliminarily screened as subjects.Forty patients with TOF whose pulmonary valve ring Z value was-1-3 were selected.Twenty children with preserved pulmonary valves were selected as the experimental group,and another 20 children with traditional transpulmonary valves as the control group.Serum NT-proBNP levels were measured before operation(T1),on the day after operation(T2),on the first day after operation(T3),one month after operation(T4),three months after operation(T5)and six months after operation(T6)in both groups.The right ventricular Tei(RV-Tei)index,right ventricular/left ventricular pressure ratio(PRV/PLV),right ventricular outflow tract-pulmonary artery pressure gradient were measured by echocardiography at each time point.Relevant clinical indicators were also observed.Results The vasoactive drug score,ventilator assisted time,hospital stay and low cardiac output rate in the control group were significantly higher than those in the experimental group(P<0.01).One patient in the control group died on the third day after operation due to persistent severe low cardiac output.The clinical outcome of the experimental group was significantly better than that of the control group.Through follow-up observation at various time points after operation,the PRV/PLV and right ventricular outflow tract-pulmonary artery pressure gradient of the experimental group were higher than those of the control group,but with time,these two indicators gradually decreased,and there was no significant difference between the two groups in the later period(P >0.05).There was no difference in RV-Tei index and NT-proBNP between the two groups before operation(P >0.05),but there was significant difference at different time points after operation(P<0.01),and the experimental group was significantly lower than the control group.Conclusion Preservation of pulmonary valve can reduce pulmonary regurgitation,protect right ventricular function and facilitate clinical recovery in infants undergoing primary TOF radical operation.