经皮支架置入治疗复杂先天性心脏病术后残余肺动脉狭窄的远期随访

A long-term follow-up study of percutaneous stent implantation for residual pulmonary artery stenosis after complicated congenital heart disease

目的探讨支架置入治疗复杂先心病术后残余肺动脉狭窄的远期安全性、有效性。方法回顾性分析1996年1月至2020年1月在本中心确诊复杂先心病术后残余肺动脉狭窄并接受支架置入术治疗的41例患儿的症状、体征、超声心动图、心脏CT、心导管、6 min步行试验距离、BNP等检查结果。本组41例患儿,男30例,女11例,置入支架时年龄1.3~14.5岁,平均(6.1±3.6)岁,体质量8~43 kg,平均(18.9±9.4)kg。比较术前、术后随访期间靶血管直径、跨狭窄处压力阶差、心功能情况等,评估支架置入治疗肺动脉狭窄的远期效果。结果41例患儿均随访,无死亡,随访过程中无支架断裂、动脉夹层、肺栓塞等严重不良事件。中位随访7.1年(3.1~13.8年)。截至2023年1月,超声心动图结果显示41例患儿靶血管直径由术前(3.9±1.5)mm升至(6.0±1.5)mm,P<0.05;跨狭窄处压差由术前(51.4±19.1)mmHg下降至(33.1±19.7)mmHg(1 mmHg=0.133 kPa),P<0.05;心脏螺旋CT显示靶血管内径与远端血管内径之比由术前0.4±0.2增加至0.9±0.3,P<0.05。所有患儿无生长发育落后,无反复肺部感染,心功能(NYHA分级)Ⅰ级39例(95.1%),Ⅱ级2例(4.9%),学龄期患儿6 min步行距离462~633 m,平均(529.9±57.1)m,呼吸评分0.5~1.0分,下肢用力评分6~12分。远期不良事件5例,包括靶血管再狭窄4例(9.7%),支架内部分栓塞1例(2.4%);其中2例再狭窄患儿因反复靶血管狭窄、对侧肺动脉高压分别于支架置入术后4、13年行外科肺动脉支架去除术、肺动脉成形术,其余3例患儿临床症状、心功能良好,仍在随访,暂未作进一步干预。Cox多因素生存分析提示支架置入术前右心室收缩压是发生终点事件的危险因素(P<0.05)。结论经皮支架置入术治疗复杂先心病术后残余肺动脉狭窄能有效缓解右心压力超负荷,改善肺血流,稳定心功能,改善复杂先心病患者的远期预后,降低再次手术开胸比例,远期疗效稳定。

Objective To investigate the long-term safety and effectiveness of stent implantation for residual pulmonary artery stenosis after complicated congenital heart disease.Methods The symptoms,signs,echocardiography,cardiac CT,cardiac catheterization,six-minute walking distance,and BNP of 41 patients diagnosed from January 1996 to January 2020.In this group,41 patients,30 males and 11 females,aged 1.3-14.5 years old,mean(6.1±3.6)years old,and weighed 8-43 kg,mean(18.9±9.4)kg,compared the diameter of the target vessel,pressure difference across stenosis,cardiac function before and postoperative follow-up,and evaluated the long-term effect of stent implantation in the treatment of pulmonary artery stenosis.Results All 41 patients were not lost to follow-up,no death,and there were no serious adverse events such as stent fracture,artery dissection and pulmonary embolism during follow-up.The median follow-up time was 7.1 years(3.1 to 13.8 years).As of January 2023,the echocardiographic results showed that the diameter of the target vessels in 41 patients increased from preoperative(3.9±1.5)mm to(6.0±1.5)mm(P<0.05),the pressure difference across the stenosis decreased from preoperative(51.4±19.1)mmHg to(33.1±19.7)mmHg(1 mmHg=0.133 kPa,P<0.05);Heart spiral CT showed that the ratio of target vessel diameter to distal vessel diameter increased from preoperative 0.4±0.2 to 0.9±0.3(P<0.05).All patients had no slow growth and development,no recurrent lung infection,39 patients(95.1%)had gradeⅠcardiac function,and 2 patients(4.9%)had gradeⅡcardiac function.As children in school age,the walking distance of 6 min was 462 to 633 m,mean(529.9±57.1)m,the respiratory score was 0.5-1,and the lower limb force score was 6-12.There were 5 long-term adverse events,including 4 cases of target vessel restenosis(9.7%),and 1 case(2.4%),two of the patients with restenosis with repeated target vessel stenosis and lateral pulmonary hypertension were surgically intervention:stent removing and pumonary expanding,after 4,13 years of stent implantation.And the others were still in follow-up,and no further intervention was made.The Cox multivariate survival analysis suggested that right ventricular systolic blood pressure was a risk factor for endpoint events before stent implantation(P<0.05).Conclusion The treatment of residual pulmonary artery stenosis after complicated congenital heart disease after percutaneous stent implantation can effectively relieve the right heart pressure overload,improve pulmonary blood flow,stabilize cardiac function,improve the long-term prognosis of patients with complicated congenital heart disease,reduce the chest opening rate of reoperation,and have stable long-term curative effect.