239例小儿室间隔缺损修补术后残余分流的近中期随访

Early-to mid-term follow-up of residual shunt after ventricular septal defect repair in children:an analysis of 239 cases

目的:探讨小儿室间隔缺损(ventricular septal defect,VSD)修补术后残余分流的发生原因、常见部位、预后、影响预后的因素及干预时机。方法:回顾性分析2013年1月至2017年1月重庆医科大学附属儿童医院行VSD修补术后239例残余分流患者的临床资料,包括患者性别、手术年龄、体质量、术前左右心室压差、术前VSD分流方向、补片材料、体外循环时间、残余分流的大小及部位、残余分流的血流速度,运用单因素及多因素Cox回归分析患者预后的影响因素。结果:239例残余分流患者均未再次干预,155例(64.85%)残余分流自行愈合;84例(35.15%)未愈合。小于4 mm残余分流219例,153例(69.86%)自愈;大于4 mm残余分流20例,2例(10%)自愈(P<0.005)。单因素Cox分析结果表明,术前左右心室压差(P=0.028)、体外循环时间(P=0.006)、残余分流大小(P=0.003)、残余分流血流速度(P=0.00)是影响患者预后的因素(P<0.05);而多因素Cox回归分析显示体外循环时间(P=0.017)、残余分流血流速度(P=0.019)是影响患者预后的主要因素。结论:残余分流常见于补片上下缘及肌部。残余分流小于4 mm大多可自行愈合,残余分流血流速度、体外循环时间是影响预后的主要因素。残余分流大于4 mm且随访1年以上未见减小,或合并临床症状者,需积极干预。

Objective:To investigate the causes,common locations,prognosis,prognostic factors,and intervention timing of residual shunt after ventricular septal defect(VSD)repair in children. Methods:A retrospective analysis was performed for the clinical data of239 patients with residual shunt who underwent VSD repair in The Affiliated Children’s Hospital of Chongqing Medical University from January 2013 to January 2017,including sex,age at the time of surgery,body weight,preoperative pressure difference between the left and right ventricles,preoperative VSD shunt direction,patch material,cardiopulmonary bypass time,size and location of residual shunt,and blood flow velocity of residual shunt. Univariate and multivariate Cox regression analyses were used to identify the influencing factors for prognosis. Results:No intervention was performed for 239 patients with residual shunt;among these patients,155(64.85%)achieved spontaneous healing of residual shunt and 84(35.15%)did not achieve healing. Of all patients,219 had a residual shunt of <4 mm,among whom 153(69.86%)achieved spontaneous healing,and 20 had a residual shunt of >4 mm,among whom only 2(10%)achieved spontaneous healing. The univariate Cox regression analysis showed that preoperative pressure difference between the left and right ventricles(P=0.028),cardiopulmonary bypass time(P=0.006),size of residual shunt(P=0.003),and blood flow velocity of residual shunt(P=0.00)were influencing factors for prognosis(P<0.05),and the multivariate Cox regression analysis showed that cardiopulmonary bypass time(P =0.017) and blood flow velocity of residual shunt(P=0.019) were the main influencing factors for prognosis. Conclusion:Residual shunt is commonly observed in the upper and lower edges of the patch and the interventricular septum. Most patients with a residual shunt of <4 mm can achieve spontaneous healing,and blood flow velocity of residual shunt and cardiopulmonary bypass time are the main influencing factors for prognosis. Active intervention should be performed for patients with a residual shunt of >4 mm which does not decrease during follow-up for more than 1 year or those with clinical symptoms.