完全性肺静脉异位引流治疗经验及术后肺静脉梗阻发生的危险因素分析

The management of total anomalous pulmonary venous connection and risk factors for postoperative pulmonary venous obstruction

目的探讨完全性肺静脉异位引流(TAPVC)的治疗经验及术后肺静脉梗阻(PVO)发生的危险因素。方法回顾性分析阜外华中心血管病医院儿童心脏中心2018年1月至2020年12月诊断为TAPVC的125例患儿临床资料。其中手术治疗116例。根据术后是否出现PVO分为2组, 采用t检验或χ^(2)检验比较2组围术期的临床资料, 并采用Logistic回归分析TAPVC术后PVO的危险因素。结果 116例手术患儿中男73例(62.9%), 女43例(37.1%);心上型58例(50.0%), 心内型35例(30.2%), 心下型15例(12.9%), 混合型8例(6.9%);手术中位年龄3.0(1.2, 7.0)个月;中位体质量5.0(4.0, 6.8) kg。手术患儿死亡13例, 死亡率11.2%;发生术后PVO 18例(15.9%)。术后发生PVO组和无PVO组的Darling分型(心上型27.8%比56.6%, 心内型27.8%比31.6%, 心下型27.8%比10.5%, 混合型16.6%比5.3%, χ^(2)=8.571, P=0.036)、存在术前PVO(83.3%比21.1%, χ^(2)=25.293, P<0.01)、有共汇(55.6%比81.1%, χ^(2)=6.049, P=0.014)、术前危重状态(83.3%比31.6%, χ^(2)=12.938, P<0.01)、体外循环时间[(128.800±47.254) min比(106.700±37.288) min, t=-2.094, P=0.039]、延迟关胸(27.8%比5.3%, χ^(2)=6.227, P=0.013)、术后1 d吻合口流速[1.0(0.9, 1.4) m/s比0.9(0.8, 1.1) m/s, Z=-2.004, P=0.045]、术后1周吻合口流速[1.4(1.3, 1.8) m/s比0.9(0.7, 1.1) m/s, Z=-4.446, P<0.001]、机械通气时间[121.0(76.8, 246.9) h比91.5(60.4, 135.9) h, Z=-1.989, P=0.047]比较, 差异均有统计学意义。将上述参数纳入Logistic回归分析, 结果显示存在术前PVO(OR=797.179, 95%CI:8.074~78 712.270, P=0.004)及术后1周吻合口流速加快(OR=11 848.376, 95%CI:23.746~5 912 017.803, P=0.003)是发生术后PVO的危险因素。结论本中心关于TAPVC的外科手术结果令人满意, 术前存在PVO及术后早期吻合口流速增快是发生术后PVO的高危因素。

Objective To discuss the treatment strategies and experiences of total anomalous pulmonary venous connection(TAPVC)and study the risk factors for postoperative pulmonary venous obstruction(PVO).Methods Clinical data of 125 children with TAPVC in the Children Heart Center of Fuwai Central China Cardiovascular Hospital from January 2018 to December 2020 were included in this study and analyzed retrospectively.Of the 125 cases,116 were treated surgically.They were divided into 2 groups according to whether PVO appeared after repair of TAPVC.The t-test or chi-square test was used to compare the clinical data of the 2 groups,and Logistic regression analysis was adopted to analyze the risk factors for postoperative PVO.Results Among the 116 patients undergoing surgery,including 73 males(62.9%)and 43 females(37.1%),and according to Darling′s classification,there were 58 cases(50.0%)of supracardiac,35 cases(30.2%)of intracardiac,15 cases(12.9%)of infracardiac and 8 cases(6.9%)of mixed.The median age and body weight during surgery were 3.0(1.2,7.0)months and 5.0(4.0,6.8)kg.There were 13 deaths(11.2%),and recurrent PVO was observed in 18 patients(15.9%).Statistically significant diffe-rences were observed in terms of Darling′s classification(supracardiac 27.8%vs.56.6%,intracardiac 27.8%vs.31.6%,infracardiac 27.8%vs.10.5%,mixed 16.6%vs.5.3%,χ^(2)=8.571,P=0.036)of PVO group and non-PVO group after operation preoperative PVO(83.3%vs.21.1%,χ^(2)=25.293,P<0.01),with confluence(55.6%vs.81.1%,χ^(2)=6.049,P=0.014),preoperative critical state(83.3%vs.31.6%,χ^(2)=12.938,P<0.01),cardiopulmonary bypass time[(128.800±47.254)min vs.(106.700±37.288)min,t=-2.094,P=0.039],delayed thoracic closure(27.8%vs.5.3%,χ^(2)=6.227,P=0.013),and anastomotic velocity at 1 day after operation[1.0(0.9,1.4)m/s vs.0.9(0.8,1.1)m/s,Z=-2.004,P=0.045],anastomotic velocity at 1 week after operation[1.4(1.3,1.8)m/s vs.0.9(0.7,1.1)m/s,Z=-4.446,P<0.001],and mechanical ventilation time[121.0(76.8,246.9)h vs.91.5(60.4,135.9)h,Z=-1.989,P=0.047].All of these data were included in the Logistic regression analysis.The results showed that preoperative PVO(OR=797.179,95%CI:8.074-78712.270,P=0.004)and increased anastomotic flow velocity at 1 week after operation(OR=11848.376,95%CI:23.746-5912017.803,P=0.003)were associated with postoperative PVO.Conclusions Surgical correction in patients with TAPVC with a biventricular anatomy in this center is satisfactory.Preoperative PVO and early anastomotic flow velocity increase after operation are the high risk factors for postoperative PVO.