小儿先心术后肺静脉再狭窄二次干预

Clinical research of reintervention for children with pulmonary venous restenosis

目的总结及评估先天性心脏病手术后肺静脉再狭窄二次干预的治疗经验及临床疗效。方法回顾并分析2009年9月至2018年1月收治的53例先天性心脏病手术后肺静脉再狭窄的患儿临床资料,其中男34例,女19例;年龄2~77个月,平均(15.1±13.2)个月;体质量3.7~17.3kg,平均(7.9±3.3)kg;术前肺静脉流速1.89~3.07m/s,平均(2.28±0.40)m/s。首次手术疾病种类包括43例完全性肺静脉异位引流(心上型14例,心下型20例,心内型2例及混合型7例)、8例部分性肺静脉异位引流以及2例先天性肺静脉狭窄。手术方法分布:原位心包无缝线技术(sutureless)吻合34例(带蒂心包21例,左心耳下翻13例),牛心包扩大10例,钝性扩大5例,球囊扩张3例及支架置入1例。结果所有患儿术后早期肺静脉流速(1.12±0.23)m/s,较术前明显降低。住院死亡4例(7.5%)。49例出院后随访3~98个月,中远期超声心动图结果显示肺静脉吻合口及内径均生长,生长速度(0.022±0.014)cm/月(P<0.05),血液流速(1.25±0.28)m/s;4例术后再次出现不同程度的回流梗阻(流速>1.6m/s),目前无需再次手术,仍在随访中。结论先天性肺静脉畸形术后肺静脉再狭窄发生率较高,应在梗阻发生早期进行二次干预治疗,sutureless缝合、牛心包扩大及钝性扩大等再干预方法治疗术后肺静脉均有明显生长,肺静脉球囊扩张术后早期效果良好,但再狭窄率较高,中远期仍需严密随访。

Objective The purpose of this report is to summarize and evaluate the clinical effect and experience of reintervention for children with pulmonary venous restenosis. Methods The clinical data of 53 patients with pulmonary venous restenosis who received reintervention at SCMC from September 2009 to January 2018 were retrospectively analysed, including 34 males and 19 females with mean age of(15.1±13.2)months(2-77 months) and mean weight of(7.9±3.3)kg(3.7-17.3 kg). The mean preoperative pulmonary venous velocity was(2.28±0.40)m/s(1.89-3.07 m/s). Primary disease included 43 cases of total anomalous of pulmonary venous drainage(14 supracardiac type, 20 infracardiac type, 2 intracardiac type and 7 mix type), 8 cases of partial anomalous of pulmonary venous drainage and 2 cases of primary pulmonary venous stenosis. The distribution of reintervention methods were shown as follow: 34 cases of sutureless technique(21 cases with pedicle pericardium and 13 cases with left auricle tissue), 10 cases of bovine pericardium enlargement, 5 cases of blunt enlargement, 3 cases of balloon dilatation and 1 case of stent implantation. Results The early postoperative pulmonary venous velocity was (1.12±0.23) m/s. There were 4 in-hospital deaths with a mortality of 7.5%. 49 survivors were under a follow-up of 3-98 months. The echocardiography showed pulmonary venous anastomosis and diameter have grown after reintervetion with a mean growth speed of(0.022±0.014)cm/month(P<0.05) and a mean velocity of(1.25±0.28)m/s;4 patients occured varying degrees of pulmonary venous obstruction(>1.6 m/s) but no one need reoperation at present. More than 90% patients exhibited an improvement of NYHA functional class from Ⅲ or Ⅳ preoperatively to Ⅰ or Ⅱ at follow-up. Conclusion Pulmonary venous restenosis is a common complication after primary pulmonary malformations operation. The reintervetion should be performed in early period of pulmonary venous obstruction. Pulmonary venous anastomoses after sutureless technique, bovine pericardium enlargement and blunt enlargement have grown obviously;although balloon dilatation has a good effect at early period of postoperation, it also has a high restenosis rate and needs a strict mid- and long-term follow-up.