左室训练术治疗先天性矫正型大动脉转位的临床疗效分析

目的评价左室训练术治疗先天性矫正型大动脉转位(cCTGA)的临床疗效。方法 2005年5月至2011年5月,阜外心血管病医院对24例左心室退化的cCTGA患者行左室训练术,其中男13例,女11例;年龄0.17～22.00(3.73±4.35)岁;体重5.10～61.00(15.71±10.95)kg。主要合并畸形:三尖瓣关闭不全(TR)23例(轻度11例、中度7例、重度5例),限制型室间隔缺损18例,房间隔缺损5例,卵圆孔未闭5例,动脉导管未闭4例,肺动脉瓣轻度狭窄5例,主动脉弓缩窄1例。术前经超声心动图、心血管造影或心导管检查确诊,形态学左心室舒张期末内径(mLVEDD)8～32(21.56±6.60)mm,形态学左心室(mLV)后壁厚度2～7(4.29±1.52)mm,形态学左心室与形态学右心室(mRV)压力比(PmLV/mRV)0.12～0.65(0.41±0.12)。手术均采用胸骨上端小切口或胸骨正中切口,在全身麻醉下完成肺动脉环缩术。结果术毕测压PmLV/mRV 0.57～0.93(0.76±0.10);全组患者无住院死亡,出院时超声心动图检查提示:双心室结构和功能良好,室间隔位置较术前略向mRV侧移位,mLVEDD较术前略增大,TR较术前减轻。术后随访1～35个月,无远期死亡。所有患者一般情况好,生命体征平稳,心功能分级(NYHA)Ⅰ～Ⅱ级,mLVEDD 14～40(26.17±7.11)mm,mLV后壁厚度4～9(4.95±1.44)mm,PmLV/mRV 0.52～0.98(0.72±0.16),TR较术前明显减轻,其中14例患者完成二期心房大动脉双调转术。结论左室训练术应用于左心室退化的cCTGA患者安全有效,mLV压力负荷及后壁厚度增加,mLV腔扩大,且TR显著减轻。

Outcomes of Morphologic Left Ventricle Retraining Procedure for Congenitally Corrected Transposition of the Great Arteries

Objective To evaluate clinical experiences and long-term outcome of morphologic left ventricle(mLV) retraining for congenitally corrected transposition of the great arteries(cCTGA).Methods From May 2005 to May 2011,24 patients with cCTGA anomaly underwent left ventricle retraining by means of pulmonary artery banding in Fu Wai Hospital.There were 13 males and 11 females with their age of 0.17-22.00(3.73±4.35)years and body weight of 5.10-61.00(15.71±10.95)kg.Major concomitant malformations included tricuspid valve insufficiency(TR)in 23 patients(mild in 11 patients,moderate in 7 patients,severe in 5 patients),restrictive ventricular septal defect in 18 patients,atrial septal defect in 5 patients,patent foramen ovale in 5 patients,patent ductus arteriosus in 4 patients,mild pulmonary stenosis in 5 patients,and aortic coarctation in 1 patient.All the patients were preoperatively diagnosed by echocardiography,cardiovascular angiography or cardiac catheterization.The mLV end diastolic diameter(mLVEDD) was 8-32(21.56±6.60)mm,posterior wall thickness of mLV was 2-7(4.29±1.52)mm,mLV to morphologic right ventricle(mRV)pressure ratio(mLV/mRV)was 0.12-0.65(0.41±0.12).Pulmonary artery banding operation was performed through upper partial sternotomy or median sternotomy without circulatory arrest.Results The mLV/mRV pressure ratio reached to 0.57-0.93(0.76±0.10)under direct pressure monitoring after surgery.There was no in-hospital death in this group.Echocardiography before discharge showed that the structure and function of the two ventricles were good,the interventricular septum moved partially towards mRV,mLVEDD was increased slightly,and there was a tendency of reduced TR.Postoperative follows-up was from 1 to 35 months,and there was no late death during follow-up.All the patients were in good general condition with stable vital signs and New York Heart Association(NYHA)class Ⅰ-Ⅱ.The mLVEDD was 14-40(26.17±7.11)mm,posterior wall thickness of mLV was 4-9(4.95±1.44)mm,mLV/mRV pressure ratio was 0.52-0.98(0.72±0.16),and TR was significantly decreased.Fourteen patients successfully underwent staged complete double-switch procedure.Conclusion Left ventricle retraining is a safe and effective method to train mLV for cCTGA patients.Pressure load and posterior wall thickness of mLV are increased,mLV cavity is dilated,and TR is significantly reduced after the surgery.