先天性心脏病术后患儿继发主动脉瓣下狭窄的原因及外科治疗效果分析

Outcomes and causes of secondary subaortic stenosis in children after congenital heart disease surgical treatment

目的总结广东省儿童医院心脏中心10年间先天性心脏病(congenital heart disease,CHD)术后出现主动脉瓣瓣下局灶性狭窄的形成原因及手术效果。方法回顾性分析广东省儿童医院心脏中心2011年1月至2021年12月,共14例因CHD术后继发主动脉瓣瓣下狭窄行再次手术患儿的临床资料,其中男10例,女4例。CHD诊断主要包括主动脉缩窄,主动脉弓中断、右心室双出口、部分性房室间隔缺损等。矫治CHD时患儿月龄为1个月(3 d~10个月);矫治主动脉瓣下狭窄时患儿的月龄为32(8~72)个月。体质量为(11.5±5.9)kg。与前次手术矫治的间隔时间为22(6~71)个月。结果所有患儿均为隔膜型狭窄,均行单纯纤维嵴切除术;体外循环时间为83(57~163)min,主动脉阻断时间为39(27~104)min。住院时间为(11.5±6.0)d;矫治术前主动脉跨瓣压差60(40~115)mmHg(1mmHg=0.133 kPa),矫治术后主动脉跨瓣压差(9.6±4.2)mmHg,无严重并发症,无住院患儿死亡。术前有临床症状的患儿,术后临床症状消失,心功能正常,随访中无死亡患儿。1例患儿随访过程中主动脉瓣下狭窄逐渐加重,术后6年再次行左心室流出道狭窄矫治术。结论CHD术后继发主动脉瓣下狭窄发生原因是左心室流出道血流动力学紊乱,形成剪切力,刺激左心室流出道纤维肌肉增生所致。主动脉瓣下狭窄矫治有效,早期手术可获得良好的远期效果,但有可能会再次狭窄,要积极进行长期随访。

Objectives To summarize and analyze the outcomes and causes of focal stenosis under the aortic valve in children after congenital heart disease(CHD)operation in Heart Center of Guangdong Children′s Hospital during 10 years.Methods Clinical data of 14 children with subaortic valve stenosis secondary to CHD surgery in Heart Center of Guangdong Children′s Hospital from January 2011 to December 2021 were retrospectively analyzed.There were 10 males and 4 females.The diagnosis of CHD mainly included coarctation of the aorta,interruption of the aortic arch,double outlet of the right ventricle,partial atrioventricular septal defect,etc.The age at the treatment of CHD was 1 month(3 d-10 months);the age at the treatment of subaortic stenosis was 32(8-72)months.The average body weight of the children was(11.5±5.9)kg.The interval duration from the previous surgical correction was 22(6-71)months.Results All the patients had septal stenosis and underwent simple fibrous crest surgery.Cardiopulmonary bypass dura⁃tion was 83(57-163)min and aortic occlusion duration was 39(27-104)min.The hospital stay duration was(11.5±6.0)d.The aortic transvalvular pressure difference before correction was 60(40-115)mmHg(1 mmHg=0.133 kPa),and the aortic valve pressure difference after correction was(9.6±4.2)mmHg.There were no serious complications and no hospital death case.For patients with preoperative clinical symptoms,the clinical symptoms disappeared after surgery,and the cardiac function was normal,and there were no deaths during follow-up.One patient had subaortic stenosis gradually aggravated during the follow-up,and underwent left ventricular outflow tract stenosis correction again 6 years after operation.Conclusions The cause of secondary subaortic stenosis after CHD surgery is the hemodynamic disorder of the left ventricular outflow tract,which is related to the formation of shear force.The correction of subaortic steno⁃sis is effective,and early surgery can achieve good long-term results;but there is a possibility of restenosis,and long term follow-up is required.