三尖瓣处理技术在远离型右心室双出口矫治患儿中的应用效果

The Efficacy of Combined Tricuspid Management Technique in Biventricular Repair for Children With Double Outlet Right Ventricle Complicating With Non-committed Ventricular Septal Defect

目的:探讨三尖瓣处理技术在远离型右心室双出口矫治患儿中应用的安全性和疗效。方法:于2008年1月至2019年1月回顾性分析连续入组我院接受双心室矫治并同期行三尖瓣结构处理的40例远离型右心室双出口患儿,其中男性24例,女性16例,平均年龄(4.3±2.6)岁,平均体重(21.4±10.5)kg,术中均对三尖瓣采取了圆锥乳头肌转移、三尖瓣隔前交界瓣下腱索转移、三尖瓣隔前交界折叠等技术处理,同期进行圆锥切除,室间隔缺损扩大,记录术中及院内情况。出院后每6个月通过电话或门诊随访。结果:39例患儿手术成功,1例(2.5%)患儿早期死亡,死因为肺部感染、呼吸衰竭。39例患儿术后无早期心室内隧道梗阻和传导阻滞发生。术中三尖瓣操作包括:圆锥乳头肌转移25例,隔前交界瓣下腱索转移10例,隔前交界折叠5例。术中经食道超声心动图检查:患儿左心室流出道均通畅,3例患儿可见室水平残余分流1~2 mm;4例患儿室间隔缺损补片中央开窗3~5 mm。主动脉阻断时间(95±34)min及体外循环时间(143±50)min,呼吸机使用时间(45.5±28.5)h,重症监护病房时间(5.2±3.7)d。平均随访(6.1±5.0)年(6个月~11年),无晚期死亡,未发现明显的心室内隧道梗阻及再手术病例。结论:对于三尖瓣瓣下结构影响内隧道建立的远离型右心室双出口,应用合适的三尖瓣处理技术,能够降低心室内隧道梗阻的发生率,且不会造成三尖瓣反流或狭窄,不会增加死亡率及并发症。

Objectives:Biventricular repair for double outlet right ventricle with non-committed ventricular septal defect(DORVncVSD)remains surgical challenges since the location of tricuspid valve often preclude the establishment of intra-ventricular baffle.We aimed to share the experience of the surgical repair for DORVncVSD in combination with the tricuspid management technique.Methods:40 consecutive patients with DORVncVSD,who underwent anatomical repair and concomitant tricuspid structural management from January 2008 to January 2019,were included in this study and their clinical data were retrospectively analyzed.The tricuspid management technique included anterolateral papillary muscle transfer,chordae transfer,anterolateral commissure transfer and commissure folding.Results:The mean age and weight at repair was(4.3±2.6)years and(21.4±10.5)kg,respectively.The CPB time was(143±50)min and aortic cross-clamp time was(95±34)min.Tricuspid anterolateral papillary muscle transfer was performed in 25 patients,chordae transfer performed in 10 patients,anterolateral commissure folding performed in 5 patients.There was one early death due to lung infection and respiratory failure and intra-ventricular baffle obstruction and conduction blocker were not observed in this patient cohort early post operation.There was no death and baffle obstruction and no case requiring reoperation during the(6.1±5.0)year follow-up period.Conclusions:Tricuspid management procedures concomitant to biventricular repair for children with DORVncVSD can reduce intra-cardiac tunnel obstruction without the risk of inducing tricuspid insufficiency and stenosis,without the increase of mortality and morbidity in this patient cohort.