心下型完全性肺静脉异位引流外科治疗的中远期疗效及危险因素分析

Middle-to-long-term outcomes of surgical correction of infra-cardiac total anomalous pulmonary venous connection and the related risk factors

目的分析心下型完全性肺静脉异位引流的手术治疗效果,并探讨影响预后的相关危险因素。方法回顾性分析2002年1月至2017年1月在复旦大学附属儿科医院心血管中心确诊为心下型完全性肺静脉异位引流的59例患儿的临床资料,其中男41例,女18例;手术时中位年龄23(10,49)d;手术时中位体重3.5(3.2,4.1)kg。59例患儿均接受完全性肺静脉异位引流根治术,术中常规横断垂直静脉,应用Sutureless技术24例。统计分析患儿术前、术中相关资料以及肺静脉形态与手术疗效,计量资料采用独立样本t检验、Mann-Whitney U检验分析,计数资料采用χ^(2)检验或Fisher精确检验。结果59例患儿体外循环时间为(109±37)min,主动脉阻断时间为(51±13)min。术后延迟关胸33例,术后早期死亡4例,中远期随访5~20年。术后未发生肺静脉狭窄(pulmonary vein stenosis,PVS)42例,发生PVS 17例;2例家属放弃再干预后死亡;再干预5例,其中2例再干预后死亡。与非PVS患儿相比,PVS患儿中采用Sutureless技术比例低,Y形共同肺静脉比例、延迟关胸比例较高、术后机械通气时间显著延长,差异有统计学意义(P<0.05)。Y形共同肺静脉组患儿术后3、6、12个月未发生PVS占比为3/8、3/8、3/8,非Y形共同肺静脉组患儿术后3、6、12个月未发生PVS占比分别为26/29、24/29、24/29,两者比较差异有统计学意义(P=0.07)。结论心下型完全性肺静脉异位引流根治术治疗效果总体良好,共同肺静脉形态与术后肺静脉狭窄相关。改良Sutureless技术能改善心下型完全性肺静脉异位引流的手术疗效和远期预后。

Objective To explore retrospectively the clinical efficacy of infra-cardiac total anomalous pulmonary venous drainage(TAPVD)and to examine the related prognostic factors.Methods From January 2002 to January 2017,the relevant clinical data were retrospectively reviewed for 59 children with infra-cardiac TAPVD.There were 41 boys and 18 girls with a median age of 23(10-49)days and a median weight of 3.5(3.2-4.1)kg.Radical operation of TAPVD was performed.During operation,vertical vein was transected routinely and Sutureless technique applied(n=24).Perioperative data,pulmonary vein morphology and surgical efficacy were statistically analyzed.The measurement data were analyzed by independent sample T and Mann-Whitney U tests.And counting data were analyzed by χ^(2) or Fisher's exact test.Results Cardiopulmonary bypass time was(109±37)min and aortic occlusion time(51±13)min.During a follow-up period of(5-20)years,there were delayed chest closure(n=33)and early mortality(n=4).Postoperative pulmonary vein stenosis(PVS)was absent(n=42)and present(n=17).Two deaths occurred after family members gave up re-intervention.Among 5 re-intervened cases,2 children died.As compared with non-PVS counterparts,the proportion of using Sutureless technique was lower while the proportions of Y-shaped common pulmonary vein and delayed chest closure were higher in PVS children.And postoperative mechanical ventilation time became significantly prolonged with statistical significance(P<0.05).At Month 3/6/12 post-operation,the proportion of children of Y-shaped common pulmonary vein without PVS was 3/8,3/8 and 3/8 while the proportion of children of non-Y-shaped common pulmonary vein without PVS 26/29,24/29 and 24/29 respectively.The inter-group differences were statistically significant(P=0.07).Conclusions Modified Sutureless technique is efficacious for infra-cardiac TAPVD.And the morphology of common pulmonary vein is correlated with postoperative restenosis.