合并异位心及左室流出道狭窄的矫正型大动脉转位分流术后再次手术策略研究

The operative strategy after palliative shunt for corrected transposition of great artery(cTGA)with left ventricular outflow tract obstruction and cardiac malpostion

目的探索合并异位心及左室流出道狭窄的矫正型大动脉转位患者姑息性分流术后的二次手术治疗策略。方法回顾性分析2011年6月至2019年5月连续性收治的姑息性分流术后合并异位心及左室流出道狭窄的矫正型大动脉转位54例患者的临床资料。所有患者均双心室发育均衡,按手术方式分为两组:一个半心室组,行一个半心室矫治术者24例,男16例、女8例,平均年龄(5.4±2.2)岁;单心室组,行单心室矫治术者30例,男19例、女11例,平均年龄(8.6±6.2)岁。通过电话随访并预约复查获取随访资料。结果术前两组间体循环系统瓣膜反流率和体循环系统心室射血分数差异无统计学意义。单心室组的体外循环时间、主动脉阻断时间和机械通气时间均显著短于一个半心室组,但迁延性胸腔积液发生率明显高于一个半心室组。无院内死亡。一个半心室组中位随访时间49(17~83)个月,随访率93.9%,随访死亡1例。单心室组中位随访时间47(12~85)个月,随访率90.9%,随访死亡1例。随访终点时一个半心室组体循环系统心室射血分数显著性高于单心室组,而且心功能分级(NYHA)Ⅲ级和Ⅳ级比例低于单心室组,差异有统计学意义(P<0.05)。两组术后生存率及免除再干预率差异无统计学意义(P>0.05)。结论对于姑息性分流术后的合并异位心及左室流出道狭窄的矫正型大动脉转位患者,一个半心室矫治术是理想的二次手术治疗策略选择。

Objective To explore the operative strategy after palliative shunt for correcting congenitally corrected transposition of great artery(cTGA)patients with left ventricular outflow tract obstruction(LVOTO)and cardiac malpostion.Methods We retrospectively analyzed the clinical data of 54 patients with onsecutive cTGA with LVOTO and cardiac malpositon from June 2011 to May 2019.The patients were devided into two groups.There were 24 patients(16 males and 8 females at mean age of 5.4±2.2 years)who underwent one and a half ventricle repair as a one and half ventricle group.And there were 30 patients(19 males and 11 females at age of 8.6±6.2 years)who underwent one ventricle repair operation as a one ventricle group.Follow-up data were collected by telephone interviews.Results There was no statistical difference in systemic atrioventricular valve regurgitation and systemic ventricular ejection fraction between the two groups(P>0.05).Compared with one and a half ventricle group,the cardiopulmonary bypass time(CPB)time,mechanical ventilation time and intensive care unit stay were significant shorter than those in the one ventricle group(P<0.05),but prolonged pleural effusions developed more frequently in the one ventricle repair group(P<0.05).There was no in-hospital death but 1 follow-up death in each group.The follow-up time was 49(17-38)months in the one and half ventricle group at follow-up rate of 93.9%,and 47(12-85)months at follow-up rate at 90.9%in the one ventricle group.One and a half ventricle group had better systemic ventricular ejection fraction(EF)than that in the one ventricle repair group.And the rate of heart function(NYHA)classⅢand classⅣin one and a half ventricle group was lower than that in the ventricle group.No significant difference of survival and freedom from re-intervention probability between the two groups was found.Conclusion For patients of correction of cTGA with LVOTO and cardiac malposition after palliative shunt,the one-and-a-half ventricular repair procedure is ideal operative strategy.