完全性房室隔缺损的外科治疗

目的 总结完全性房室隔缺损的手术方法和临床经验，以提高手术疗效。方法 27例完全性房室隔缺损患者，年龄88天～24岁。合并右心室双出口、肺动脉瓣狭窄和镜像右位心1例，动脉导管未闭1例，继发孔型房间隔缺损1例，左上腔静脉残留2例，重度肺动脉高压13例，中度肺动脉高压14例。手术均采用双补片法修补，室间隔缺损采用Gore—Tex补片修补，房间隔缺损采用自体心包补片修补。结果 术后早期死亡2例，其中1例死于脑出血，1例死于右侧心力衰竭。所有患者术后均为窦性心律，无完全性房室传导阻滞。随访23例，随访时间2个月～10年，均为窦性心律，无死亡。复查心脏彩色超声心动图提示：二尖瓣轻度反流6例，中度反流2例，心功能均较术前增强。结论 完全性房室隔缺损患者早期行手术治疗，防止肺血管阻塞性病变的发生、发展，术中注意防止左心室流出道狭窄，矫治二尖瓣反流是提高手术疗效的关键。     

Results of Left Atrioventricular Valve Reoperations Following Previous Repair of Atrioventricular Septal Defects

Abstract   Objectives: We report results of left atrioventricular valve reoperations (LAVVR) following atrioventricular septal defect (AVSD) repair and examine variables predictive of outcome. Methods: Multiple demographics and operative variables were analyzed to determine factors affecting survival and reoperation. Results: Forty patients following partial (n = 9) or complete (n = 31) AVSD repair underwent 47 LAVVR (1992-2005). Median age was 0.87 years (24 days-7.7 years) at initial AVSD repair and 3.15 years (84 days-13.6 years) at subsequent LAVVR with median interval between AVSD repair and LAVVR of 1.76 years (1 day-12.9 years). First LAVVR included repair (n = 20) or replacement (n = 20). Operative mortality was 10% and five-year survival was 76 ± 6%. Significant risk factors were complete AVSD (p < 0.001), valve replacement (p < 0.001) for early death, and young age at time of LAVVR (p = 0.03) for late death. Five-year freedom from LAVV re-intervention was 100% for replacement versus 55 ± 13% for repair (p = 0.006). Overall, ejection fraction increased to 61 ± 3% versus 42 ± 2% preoperatively (p < 0.01), and left-ventricle end-diastolic dimension Z-score decreased to 0.05 ± 0.36 versus 3.1 ± 0.3 preoperatively (p < 0.01). Eighty-seven percent of children were in New York Heart Association class I/II at latest follow-up. Conclusions: LAVVR results in significant clinical improvement and lasting recovery in ventricular chamber function and size. Valve repair offers survival advantage and should be aggressively attempted; however, it is only achievable in 50% of cases. Valve replacement is necessary in cases associated with complex LAVV morphology or following repair failure. At intermediate follow-up, patients continue to be at risk of major valve-related morbidity, requirement for re-intervention, and cardiac death. (J Card Surg 2010;25:74-78)     

Modified-Single Patch vs Double Patch Repair of Complete Atrioventricular Septal Defects

Event-free survival is similar after complete atrioventricular septal defect repair with either the modified single-patch (MSP) or double-patch technique despite MSP patients being younger and smaller at the time of repair.

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婴幼儿完全性房室通道矫治术后快速康复

目的探讨婴幼儿完全性房室通道(CAVSD)伴肺动脉高压(PAH)患者矫治术后快速康复(fast track,FT)治疗的可行性和安全性。方法自2006年1月至2009年3月阜外心血管病医院小儿心脏外科中心共收治CAVSD矫治术后婴幼儿患者51例,男24例,女27例;年龄4~36个月(12.5±8.9个月)。均按照快速康复临床管理路径行快速康复治疗。分析患者二次气管内插管率,住PICU时间,比较手术前后肺动脉压下降程度。结果 51例患者中有21例(41.17%)行快速康复治疗,均在术后8 h内拔除气管内插管。术后患者平均肺动脉压(MPAP)显著下降(39.59 mm Hg vs.24.50 mm Hg,t=5.514,P0.05),住PICU时间2.05±0.87 d(18 h~3 d)。1例48 h后因肺部感染二次气管内插管,插管原因与快速康复无关。随访3~6个月,21例患者心功能良好,无二次手术和死亡患者。结论快速康复治疗对部分伴PAH的CAVSD矫治术患者是安全、可行的,能够减少住ICU的天数;但对重度PAH患者的快速康复治疗需要更大样本的研究。     

Repair of the Left AV Valve in Atrioventricular Septal Defect in Adults

A bstract Background : This study examined the septal cleft and septal commissure of the left atrioventricular (AV) valve, which are two different anatomical structures. Methods : We presented 36 cases of adult partial atrioventricular septal defect. A distinction was made between patients based on the anatomy of the anterior leaflet of the left AV valve. The left AV valve appeared to be normal or to have minimal radial openings from the free edge of the anterior leaflet of the left AV valve in 10 patients (28%). There was a septal commissure structure in 8 (22%), and a septal cleft structure in 18 (50%) patients. In the commissure type anatomy, leaflet coaptation was usually adequate and no or mild degree of left AV regurgitation existed preoperatively. Cleft type structure usually was associated with some degree of left AV regurgitation. Attempts were made to close the septal clefts and leave the septal commissures unsutured during the repair of the partial AV septal defects. Results : We have not found any increase of left AV regurgitation in patients with commissures during the follow-up period. Closure of the cleft successfully eliminated regurgitation. Long-term results for septal cleft and septal commissure after repair of partial AV septal defect were excellent with survival of 100% and freedom from reoperation of 100% at mean 6.5 years. Conclusions : Septal cleft and septal commissure should be considered two different structures. Repairing procedures for left AV valve abnormalities associated with partial AV septal defect should only be done in patients who have cleft type of leaflet structure.     

Transatrial-Transpulmonary Repair of Atrioventricular Septal Defect with Right Ventricular Outflow Tract Obstruction

A bstract Twenty patients had a repair of an atrioventricular septal defect with tetralogy of Fallot (n = 13) or double outlet right ventricle (n = 7). Mean age was 3.5 years. Surgical technique included transatrial-transpulmonary resection of right ventricular outflow tract obstruction and transatrial two patch repair of the atrioventricular septal defect. Ten patients required a transannular patch and one patient had a right ventricle-pulmonary artery conduit placed. There was no hospital mortality, and mean hospital stay was 15 days. One patient had late sudden death of unknown cause. Six patients have required reoperation because of residual ventricular septal defect (VSD), mitral incompetence, residual right ventricular outflow tract obstruction, and/or conduit stenosis. No patient was reoperated on because of left ventricular outflow tract obstruction. Fifteen patients are asymptomatic, one has exertional dyspnea, and two have intermittent occasional bronchospasm. The transatrial-transpulmonary two patch repair and extensive relief of right ventricular outflow tract obstruction have given good immediate results. Reoperation rate has been high mainly due to residual VSD and mitral incompetence. ( J Card Surg 1993; 8:622–627 )     

Results for Surgical Correction of Complete Atrioventricular Septal Defect: Associations with Age,Surgical Era,and Technique

Abstract Background: This study was conducted to evaluate the outcomes of patients undergoing complete atrioventricular septal defect (CAVSD) repair with particular attention to age at surgery, surgical era, and technique. Methods: One hundred and forty‐seven patients undergoing CAVSD repair between November 2002 and February 2012 were grouped according to surgical era and technique. Group I (age: 9.4 ± 5.0 months; weight: 6.8 ± 1.7 kg) consisted of 45 patients, operated before August 2006, and was divided into subgroup Ia (31 patients; two‐patch repair) and subgroup Ib (14 patients; modified single‐patch repair). One hundred and two patients operated after August 2006 were included in Group II (age: 5.2 ± 3.1 months; weight: 4.9 ± 2.6 kg), and was divided into subgroup IIa (59 patients; two‐patch repair) and subgroup IIb (43 patients; modified single‐patch repair). Groups were compared with regard to perioperative variables and postoperative data. Results: There were 19 early and five late deaths. Overall mortality was significantly higher in Group I, compared to Group II (p < 0.01). Comparison of Groups Ia to Ib and IIa to IIb revealed no statistically significant difference in mortality or morbidity. Age >8 months and preoperative common atrioventricular valve (CAVV) regurgitation ≥ moderate were significant risk factors for mortality and morbidity. After 40.8 ± 24.4 months, 99 (80.4%) of 123 (83.7%) survivors were asymptomatic without any medication, and 24 (19.5%) have mild symptoms. Conclusion: Our current results indicate that younger patient age and better preoperative CAVV functions were the main factors for a favorable outcome after surgical correction of CAVSD; and outcomes did not differ by the surgical technique. (J Card Surg 2012;27:745‐753)