小儿粗大动脉导管未闭合并功能性二尖瓣反流的外科治疗疗效

Surgical treatment for large ductus arteriosus with functional mitral regurgitation in children

背景单纯粗大动脉导管未闭(patent ductus arteriosus,PDA)常采用介入封堵或外科结扎手术治疗,近远期效果良好。当存在大量左向右分流时左心室容量负荷过重,左心室及二尖瓣瓣环扩大致二尖瓣反流(mitral valve regurgitation,MR),进一步引起左心室容量负荷过重,导致二尖瓣反流加重。目的总结先天性粗大动脉导管未闭患儿合并二尖瓣反流的外科治疗策略和随访结果,为此类患儿的治疗提供临床经验。方法回顾性分析2014年1月-2018年1月解放军总医院第一医学中心心血管外科的粗大PDA合并MR的手术患儿共45例,其中男性患儿21例,女性患儿24例,年龄4个月~12岁(4.0±8.2)岁。动脉导管直径8~14(11.7±3.4)mm,分别采用左胸后外侧切口直接PDA结扎,正中开胸体外循环下二尖瓣成形同期PDA结扎术及分期手术的外科治疗策略,比较患儿围术期及中远期并发症、术后MR反流程度、左心室舒张末期直径(left ventricular end-diastolic diameter,LVEDD)及左心室射血分数(left ventricular ejection function,LVEF)等指标。结果45例手术患儿无术后死亡,44例MR程度较术前明显减轻或消失。1例因残余分流合并二尖瓣大量反流,术后2年行体外循环二尖瓣成形并PDA结扎术。1例术后因低心排综合征行主动脉内球囊反搏辅助5 d后康复。术前合并二尖瓣大量反流者,PDA结扎术后左心室较术前明显缩小,但LVEF较术前明显降低,术后3个月左心室收缩功能恢复。结论对于小儿粗大动脉导管未闭合并功能性MR,单纯行PDA结扎可有效减少左心容量负荷,改善MR程度,降低同期手术风险,中远期效果良好,是可供选择的治疗策略。

Background Patent ductus arteriosus(PDA) is usually treated with interventional closure or surgical ligation, with good results. When there is a large left to right shunt that cause the left ventricular volume overload, the left ventricle and mitral valve annulus enlarges and causes mitral valve regurgitation, which will further lead to the overload of left ventricular volume, thus aggravating mitral valve regurgitation. Objective To summarize the surgical treatment strategies and follow-up results of children with congenital large patent ductus arteriosus(PDA) with mitral valve regurgitation(MR), and provide clinical evidence for the treatment of this kind of patients. Methods Clinical data about 45 children with large PDA and functional MR were retrospectively analyzed in our department from January 2014 to January 2018. There were 3 kinds of surgical treatment strategy, including directly PDA ligation via posterolateral incision, traditional PDA ligation and mitral valve repair under extracorporeal circulation, and twostage surgical treatment strategy. Then the perioperative and long-term complications, postoperative degree of MR, left ventricular end-diastolic diameter(LVEDD), and left ventricular ejection function(LVEF) were compared. Results There were 21 males and 24 females, with age ranged from 4 months to 12 years. The average diameter of ductus was(11.7 ± 3.4) mm(range: 8-14 mm). No case died after surgery, and the degree of MR reduced significantly or disappeared in 44 cases after surgery. One child underwent mitral valve repair and PDA ligation due to residual shunt combined with severe MR at 2 years after surgery. One child received intra-aortic balloon pump due to low cardiac low syndrome, and recovered at 5 days after surgery. In children with mitral valve regurgitation, the left ventricle decreased significantly after surgery, and the LVEF also decreased compared to preoperation;all differences were statistically significant(P< 0.05). However, the LVEF recovered at 3 months after surgery. Conclusion For children with large PDA and functional mitral regurgitation, PDA ligation can reduce left ventricular volume preload effectively,improve mitral regurgitation, reduce the risk of simultaneous surgery, with a satisfied long-term effect, which can be an alternative treatment strategy.