小儿瓣膜术后残余瓣膜问题再次干预理念探究

Clinical research of reintervention for children with postoperative valve disease

目的探讨评估儿童瓣膜病变术后残余瓣膜问题再次干预时机以及预后疗效。方法回顾性分析2004年1月至2019年3月上海儿童医学中心心胸外科收治139例复杂先天性心脏病术后存在残余瓣膜问题患儿的临床资料,其中男85例,女54例;年龄8~175个月;体质量6.2~75.9 kg。首次术后随访2~133个月,彩色超声心动图结果显示主动脉瓣残余问题40例,二尖瓣残余问题49例,三尖瓣残余问题32例及肺动脉瓣残余问题18例。所有患儿均接受外科手术再次干预,手术方法包括瓣膜置换术47例,瓣膜成形术40例,瓣环成形术23例及瓣膜重建术29例。结果术后早期住院死亡6例(4.3%),其中包括主动脉瓣2例,二尖瓣2例,三尖瓣1例,肺动脉瓣1例,死亡原因主要为急性心功能衰竭,多脏器功能不全及严重低氧血症。中远期随访死亡3例(术后8~26个月),其中2例主动脉瓣关闭不全患儿,1例二尖瓣关闭不全,死亡原因主要为心功能不全和心源性休克。术后生存患儿随访(4~148个月),彩色超声心动图随访结果显示92.3%的瓣膜狭窄患儿术后血流过瓣流速明显下降(P<0.05);84.9%的瓣膜关闭不全患儿反流程度较术前减轻,均保持在轻中度以内;中远期随访过程中,仍有6例患儿因瓣膜反流加重或再狭窄行第三次手术,主动脉瓣3例、肺动脉瓣2例、二尖瓣1例,其中3例主动脉瓣患儿均行瓣膜置换术。中期随访存活患儿心功能恢复良好,83.1%的患儿NYHA分级达到Ⅱ级以上。中远期随访四类瓣膜患儿术后生存率均达到90%以上。结论儿童瓣膜病变复杂多样,术后易发生残余瓣膜关闭不全或瓣膜狭窄等问题。二次干预指征选择应更加侧重患儿临床症状及心功能情况,根据瓣膜解剖特点选择合适手术方式,能有效解决瓣膜结构异常,促进心功能恢复,改善患儿生存质量。

Objective The purpose of this report was to discuss and evaluate the timing and outcome of reintervention for children with postoperative valve disease.Methods The clinical data of 139 patients with postoperative valve disease who received reintervention at SCMC from Sep.2004 to Mar.2019 were retrospectively analysed,including 85 males and 54 females.The age ranged from 8-175 months,and the weight ranged from 6.2-75.9 kg.With a mid-long term follow-up(2-133 months),the echocardiography result showed:40 cases of aortic valve disease,49 cases of mitral valve disease,32 cases of tricuspid valve disease and 18 cases of pulmonary valve disease.All patients underwent reintervetion treatment,the distribution of reintervention methods were shown as follow:47 cases of valve replacement,40 cases of valvuloplasty,23 cases of annuloplasty and 29 case of valve reconstruction.Results There were 6 in-hospital deaths with a mortality of 4.3%.The death cases included 2 cases of aortic disease,2 cases of mitral disease,1 case of tricuspid disease and 1 case of pulmonary disease.The early postoperative causes of death were acute myocardial failure,multiple organ failure and severe hyoxemia.Three delayed deaths occurred 8-26 months after operation because of cardiac insufficiency and cardiac shock.All survivors were under a follow-up of 4-148 months.The echocardiography showed the velocity of 92.3%valve stenosis patients had decreased significantly(P<0.05);the insufficient grades of 84.9%patients had reduced and maintained under morderate degree.6 cases occurred aggravated insufficiency or stenosis and received reoperation in mid-term follow-up included 3 cases of aortic valve,2 cases of pulmonary valve and 1 case of mitral valve.The cardiac function of survival patients has been improved after reintervtion,83.1%patients maintained cardiac function at NYHAⅠ/Ⅱat follow-up.The long-term survival rates of 4 valve disease were all over 90%.Conclusion The anatomical structure of chilidren’s valve is complicated and various,valve insufficiency and stenosis often occured after operation.The timing of reintervetion should focus on clinic symptom and cardiac function.The operation should be individually designed according to valve anatomy,which could effectly correct abnormal valve structure,promote cardiac function and improve living quality.