全腔静脉肺动脉连接术开窗与否的早期效果评价

Early Result of Fenestration on Total Cavopulmonary Connection

目的总结全腔静脉肺动脉连接术(total cavopulmonary connection,TCPC)经房间隔开窗治疗复杂先天性心脏病的早期疗效。方法回顾性分析2010年1月至2013年12月阜外心血管病医院142例行TCPC患儿的临床资料。根据其是否行房间隔开窗分为2组:开窗组,71例,男44例、女27例,年龄(65.7±24.5)个月;未开窗组,71例,男42例、女29例,年龄(60.7±20.8)个月。比较两组患儿围术期资料。结果 142例患儿术后早期死亡4例(2.82%)。术前合并有中大量房室瓣反流(AVVI)并同期矫治的患儿行房间隔开窗的比例大大增加。两组患儿的机械通气时间、住ICU时间、早期死亡率及并发症发生率差异均无统计学意义(P>0.05),但开窗组较未开窗组患儿术后胸腔积液持续时间更短(9.1 d vs.13.1 d)、24 h容量需求亦更低[4.19 ml/(kg·h)vs.5.48 ml/(kg·h)]。对于术前平均肺动脉压(m PAP)≥12 mm Hg者,开窗组患儿术后早期中心静脉压(CVP)较未开窗组更低(P=0.046),维持相同的血压(收缩压80~90 mm Hg)开窗组所需的血管活性药评分(P=0.019)、24 h容量需求(P=0.041)均更低,胸腔积液持续时间更短(9.8 d vs.17.8 d,P=0.000)。对113例复诊患儿进行随访,平均随访时间(1.1±1.2)年,发现开窗患儿动脉血氧饱和度(Sp O2)为92.1%±3.5%,开窗患儿窗口自然闭合率为8.5%,无患儿发生严重紫绀(Sp O2<85%)、肢体栓塞及脑卒中。结论对TCPC患儿无需常规开窗,开窗与未开窗患儿均可获得满意的早期临床疗效,但对于合并有中大量AVVI并同期矫治、尤其是m PAP≥12 mm Hg的高危患儿应考虑行房间隔开窗,开窗有助于术后早期循环的稳定,缩短胸腔积液持续时间。

Objective To investigate the effect of fenestration on total cavopulmonary connection(TCPC) in the treatment of complex congenital heart disease.Methods We retrospectively analyzed the clinical data of 142 patients undergoing TCPC in Fu Wai Hospital between January 2010 and December 2013.The patients were divided into 2 groups depending on with fenestration or not.There were 71 patients including 44 males and 27 females at age of 65.7+24.5months in the fenestration group.There were also 71 patients with 42 males and 29 females at age of 60.7+20.8 months in the no fenestration group.Perioperative variables were compared between the two groups.Results Four patients(2.82%)died postoperatively.The fenestration significantly increased in the patients with atrioventricular valve regurgitation(AVVI).There were no statistical differences in duration of mechanical ventilation,ICU hospitalized time,early mortality and complications between the two groups(P>0.05).But there were statistical differences in the postoperative pleural effusion duration and 24 h capacity requirement(9.1 d versus 13.1 d,4.19 ml/(kg.h) versus 5.48 ml/(kg·h)) between the two groups.In the patients whose preoperative mPAP was more than 12 mm Hg,postoperative CVP was lower(P=0.046),maintaining the same blood pressure(SBP=80-90 mm Hg) of vasoactive drugs(P=0.019) and 24 h capacity requirement(P=0.041) were lower,pleural effusion duration was shorter(9.8 d versus 17.8 d,P=0.000) in the fenestration children.113 patients were followed up for 1.1 + 1.2 years.SpO_2 was 92.1%+3.5%in the fenestration children.Spontaneous closure occured in 8.5%of the patients.No severe cyanosis(SpO_2<85%),limb embolism,or stroke.Conclusion Fenestration should not be a routine in children of TCPC.Patients with fenestration or not can obtained satisfactory early clinical efficacy.Atrial septal fenestration should be considered in high-risk children with mPAP higher than 12 mm Hg or serious AVVI and be corrected at the same time.Fenestration contributes to stable circulation after TCPC surgery.It can shorten the duration of pleural effusion.