主动脉瓣下隔膜的外科矫治

目的总结主动脉瓣下隔膜的外科治疗经验及临床疗效。方法回顾性分析2009年3月至2013年9月北京安贞医院32例主动脉瓣下隔膜行主动脉瓣下隔膜切除术的临床资料，其中男22例，女10例；年龄0．5～14．0（3．6±3．2）岁；体重5．5～43．0（17．2±9．5）kg。32例中单纯主动脉瓣下隔膜7例，非单纯主动脉瓣下隔膜25例，其中合并室间隔缺损21例，合并二尖瓣关闭不全和动脉导管未闭各1例；动脉导管封堵术后和主动脉缩窄矫治术后再发主动脉瓣下隔膜各1例。18例合并不同程度的主动脉瓣关闭不全。结果术前超声心动图漏诊1例。全组体外循环时间（71．7±21．7）min，主动脉阻断时间（48．7±15．1）min，住ICU时间（2．2±1．7）d，术后住院时间（7．9±2．5）d。全组无手术死亡。术后发生Ⅱ°房室传导阻滞1例，于术后第6d恢复。所有患儿随访2～54个月，单纯主动脉瓣下隔膜患儿术后主动脉瓣关闭不全有6例好转，非单纯主动脉瓣下隔膜患儿主动脉瓣关闭不全术后有5例好转（P=0．003）；4例术前中度主动脉瓣关闭不全的单纯主动脉瓣下隔膜患儿中术后有3例转为轻度，1例转为微量反流；3例轻度反流中2例术后转为微量反流。8例术前轻度主动脉瓣关闭不全非单纯SM患儿中3例转为微量反流，术前3例中度反流中各有1例转为轻度和微量反流。随访期间全组均无主动脉瓣下隔膜再发。结论主动脉瓣下隔膜超声诊断易遗漏，一经诊断应尽早手术治疗；术中操作要求精细；术后因有再发可能，需定期随访观察。

Surgical Treatment of Subaortic Membrane

Objective To summarize clinical experience and results of surgical treatment of subaortic membrane （SM）. Methods Clinical data of 32 SM patients who underwent surgical resection of SM between March 2009 and September 2013 in Beijing Anzhen Hospital were retrospectively analyzed. There were 22 male and 10 female patients with their age of 0.5-14.0 （3.6± 3.2 ） years and body weight of 5.5-43.0 （ 17.2 ± 9.5 ） kg. Among the 32 patients, 7 patients had isolated SM, and 25 patients had other intracardiac lesions including ventricular septal defect in 21 patients, mitral regurgitation in 1 patient,patent ductus arteriosus （PDA） in 1 patient, SM occurrence after PDA occlusion in 1 patient and surgical correction for coarctation of the aorta in another patient. Eighteen patients had aortic insufficiency （AI） in different degree. Results SM diagnosis was missed by preoperative echocardiography in 1 patient. Mean cardiopulmonary bypass time was 71.7± 21.7 minutes, aortic cross-clamping time was 48.7± 15.1 minutes, ICU stay was 2.2 ± 1.7 days, and postoperative hospital stay was 7.9±2.5 days. There was no in-hospital death in this group. Postoperatively, 1 patient had second-degree atrioventricular block which returned to sinus rhythm 6 days after the operation. All the patients were followed up for 2-54 months after discharge. During follow-up, AI of 6 patients with isolated SM was relieved, and AI of 5 SM patients with other intracardiac lesions was relieved （P=0.003）. Among the 7 patients with isolated SM, preoperative moderate AI in 4 patients changed to mild AI in 3 patients and trivial AI in 1 patient, and preoperative mild AI in 3 patients changed to trivial AI in 2 patients. Among the 25 patients with other intracardiac lesions, preoperative mild AI in 8 patients changed to trivial AI in 3 patients, and preoperative moderate AI in 3 patients changed to mild AI in 1 patients and trivial AI in another patient. There was no SM recurrence during follow-up in this group. Conclusion SM diagnosis may be missed by preoperative echocardiography, and early surgical correction is needed once the diagnosis is established. Meticulous surgical techniques are necessary during the operation. Postoperative SM recurrence may happen, so regular follow-up is required after discharge.