50例先天性主动脉窦瘤的外科治疗

总结先天性主动脉窦瘤外科治疗经验。方法：先天性主动脉窦瘤５０例,合并室间隔缺损３１例,主动脉瓣脱垂１４例。行窦瘤切除修补术１７例,窦瘤切除加定夺缺修补１９例,窦瘤切除加主动脉瓣成形１２例,主动脉瓣替换２例。结果：全组无手术死亡,无残余分流。结论：心脏超声对ＣＡＳＶ诊断准确率高。     

Long-term results of Ionescu-Shiley valve in the tricuspid position

A retrospective analysis of the long-term results of using the Ionescu-Shiley pericardial bioprosthesis in the tricuspid position was carried out on 73 patients (8 men, 65 women). Of these procedures, ten were tricuspid valve replacement alone and the remainder were in combination with other valve procedures. The mean follow-up was 9.6 years (range, 4 to 18 years). The mean age of the patients was 53 years (range, 27 to 78 years). Seventy-one of the patients suffered tricuspid valve dysfunction from rheumatic heart disease. There were 13 postoperative deaths (within 30 days), giving a mortality rate of 17.8%. The actuarial survival at 10 years was 71% +/- 4.2%. Of the survivors, 49 (79.6%) were in functional class I or II. Primary tissue valve failure in the tricuspid position occurred in 1 patient 12 years after implantation and required reoperation. In another patient bioprosthetic tricuspid valve endocarditis developed. There was no incidence of thromboembolic complications. We conclude that the Ionescu-Shiley pericardial bioprosthesis was a satisfactory prosthesis in the tricuspid position in patients with acquired valvar dysfunction.     

Reoperation for residual defects following intracardiac repair for tetralogy of Fallot

Reoperation was carried out in two patients who had previously undergone correction for tetralogy of Fallot and presented with severe pulmonary hypertension. One patient who had undergone intracardiac repair five years earlier had a residual ventricular septal defect (VSD), right ventricular outflow (RVOT) obstruction, patent ductus arteriosus and severe pulmonary hypertension. The second patient, who had undergone intracardiac repair four years earlier, also had a residual VSD and RVOT obstruction. Both underwent VSD closure, RVOT resection and pulmonary valve replacement and did well postoperatively. We recommend aggressive surgical treatment in such patients even in the presence of pulmonary hypertension.     

Eleven years' experience with Carpentier-Edwards biological valves in relation to survival and complications

The Carpentier-Edwards porcine valve bioprosthesis was implanted in 299 patients (325 prostheses) from April 1976 to April 1982. The series consisted of aortic valve replacement in 150 patients, mitral valve replacement in 120, multiple valve replacement in 26, pulmonary valve replacement in 2 and tricuspid valve replacement in 1 patient. The postoperative follow-up was 100% complete. The total accumulated follow-up was 1956 patient-years. The early mortality was 6.4% (20 patients) and the late mortality was 22% (62 patients). Valve-related mortality was seen in 8 patients (2.7%): 1 paravalvular leak during the 1st 30 postoperative days and 7 late mortalities (1 endocarditis, 2 paravalvular leaks and 4 deaths during reoperation). Three operative deaths (1.5%) occurred. The overall patient survival including operative deaths was 78.5% +/- 5% at 5 years and 66% +/- 4% at 10 years. The incidence of the different complications were: thromboembolism in 5 patients (1.7%) with a risk of 0.3%, haemorrhage in 1 (0.3%) with a risk of 0.05%, endocarditis in 2 (0.7%) with a risk of 0.1%, and paravalvular leak in 11 patients (3.7%) with a risk of 0.6%. There was a high incidence of tissue failure during the last 6 years which occurred in 54 patients (18%) with a risk of 2.7%. Sixty-seven patients (22.5%) were reoperated upon during the 11 years with an annual risk of 3.4% and the main cause of reoperation was primary tissue failure. The Carpentier-Edwards biological valve was shown to be efficient during the first 5 years of implantation after which the incidence of tissue failure increased.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical strategy for severe tricuspid valve regurgitation complicated by advanced mitral valve disease: long-term outcome of tricuspid valve supra-annular implantation in eighty-eight cases

OBJECTIVE: Although annuloplasty has been the most commonly performed surgical modality for severe tricuspid regurgitation, tricuspid valve supra-annular implantation has been performed in our hospital for more than a decade. The aim of this study was to assess the long-term outcome of tricuspid valve supra-annular implantation in a subgroup of patients with severe tricuspid regurgitation, those who also had advanced mitral valve disease. METHODS: Mitral valve replacement in conjunction with tricuspid valve supra-annular implantation was performed on 88 patients at our hospital between 1984 and 1998. The patients (mean age 57 +/- 11 years) were followed up for an average of 7.2 +/- 4.5 years after the operation (range 0-14 years); total follow-up was 643.1 patient-years. All patients except 2 (97.6%) were included in the follow-up. We evaluated the mortality, the cause of death, survival, the freedom from structural valve deterioration and reoperation, postoperative complications, and long-term echocardiographic findings. RESULTS: Overall survival at 14 years was 69% +/- 7.7%. Freedom from structural valve deterioration at 14 years was 100% and from reoperation, 88% +/- 9. 4%. There were no instances of pulmonary thromboembolism or of complications associated with fatal arrhythmias. Echocardiography showed little residual tricuspid regurgitation, no atrophic and stenotic change in the native tricuspid valve, and no thrombus formation between native valve and the implanted bioprosthesis. CONCLUSIONS: The procedure's simplicity, the good long-term durability of the bioprosthesis, and the absence of fatal arrhythmias and pulmonary thromboembolism indicate that tricuspid valve supra-annular implantation is a useful procedure for patients with severe tricuspid regurgitation complicated by advanced mitral valve disease.     

Tricuspid valve surgery for functional tricuspid valve regurgitation associated with left-sided valvular disease.

OBJECTIVES: We have reviewed 260 patients who underwent initial tricuspid valve surgery for functional tricuspid valve regurgitation (TR) and analyzed independent predictors for early and late unfavorable results. MATERIALS AND METHODS: Between 1981 and 1998, 260 tricuspid valve operations were performed for functional TR. There were 94 males and 166 females with a mean age of 55 years. The tricuspid valve surgery procedures consisted of De Vega tricuspid annuloplasty in 240 patients, ring annuloplasty in four patients, and tricuspid valve replacement in 16 patients. The mean duration of follow-up was 7.8 years. RESULTS: Hospital mortality was 8.9% (23 patients). Late deaths occurred in 34 patients including cardiac-related late deaths in 26 patients. The survival rates were 83+/-2% at 5 years and 78+/-3% at 10 years. Late tricuspid valve reoperation was performed on 13 patients due to residual or recurrent TR in 12 patients and thrombosed tricuspid bileaflet mechanical valve in one patient. The tricuspid valve reoperation-free survival rate was 90+/-2% at 5 years and 84+/-3% at 10 years. The only predictor of hospital mortality was preoperative highly elevated right atrial pressure (P=0.01). Variables predictive of cardiac-related late death were preoperative New York Heart Association (NYHA) class IV (P=0.01) and poor left ventricular ejection fraction (LVEF) (P=0.02). Residual TR of more than grade 2+ early after tricuspid annuloplasty was a significant risk factor for late tricuspid valve reoperation (P=0.01). Preoperative TR of grade 4+ was predictive of early residual TR (P=0.04). CONCLUSIONS: Tricuspid valve surgery for functional TR can be performed with acceptable levels of early mortality. Cardiac-related late mortality after tricuspid surgery may be improved by earlier surgical treatment before NYHA class IV or deterioration of LVEF occurs. To prevent late tricuspid reoperation, it is important not to leave residual TR of grade 2+ or more after tricuspid annuloplasty.     

动脉转位术的临床应用

目的 总结动脉转位术(arterial switch operation，ASO)治疗完全型大动脉转位(transposition of the great arteries，TGA)和右心室双出口伴肺动脉瓣下室间隔缺损(VSD)的临床经验。方法 采用ASO治疗小儿先天性心脏病32例，其中TGA22例，伴室间隔完整型(intact ventricular septum，IVS)9例，伴VSDl3例；右心室双出口伴肺动脉瓣下VSD(Taussig—Bing)10例。结果TGA／IVS9例中死亡1例，TGA／VSD13例中死亡4例，Taussig-Bing10例死亡3例，总手术死亡率25％(8／32)。术后随访3个月～2年，所有患者紫绀消失，活动能力明显增强。1例Taussig—Bing术前二尖瓣轻-中度反流，术后仍为中度反流；2例TGA主动脉和肺动脉瓣上狭窄，压差40mmHg(1kPa=7．5mmHg)，1例肺动脉瓣下狭窄和残余VSD，3个月后再次手术治愈。结论 ASO已广泛应用于TGA的纠治，手术效果满意；应用于右心室双出口肺动脉瓣下VSD的早期纠治，不但可防止发生肺血管阻塞性病变，而且避免了心内修补左心室流出道梗阻的远期并发症。     

Tricuspid valve supra-annular implantation in adult patients with Ebstein's anomaly

BACKGROUND: Tricuspid valve supra-annular implantation (TVSI) has been performed for adult patients with Ebstein's anomaly at our hospital for several decades. TVSI is characterized by reliable reduction of tricuspid annulus size without affecting the conduction system; by prevention of residual tricuspid regurgitation (RTR) through preservation of the native tricuspid valve; and by implantation of the bioprosthesis at a supra-annular site. METHODS: Ten adult patients with Ebstein's anomaly underwent TVSI. The right ventricular diameter and residual tricuspid regurgitation were evaluated by echocardiography preoperatively, at discharge, 1 year after the operation, and over the long term (12.4 +/- 5.5 years). Actuarial survival rate, actuarial freedom from structural valve deterioration rate, and postoperative occurrence of arrhythmia were also evaluated. RESULTS: The actuarial survival rate at 19 years was 76 +/- 15%. Tricuspid regurgitation disappeared in 8 patients just after operation. Right ventricular diameter was significantly smaller at discharge than preoperatively (63 +/- 11 vs 37 +/- 9, p < 0.01), and there were no significant differences between values at discharge and at follow-up. The actuarial freedom from structural valve deterioration rate and the reoperation rate were both 100%. There were no fatal complications related to arrhythmia or thromboembolism. CONCLUSIONS: TVSI is useful for adult patients with Ebstein's anomaly. The absence of complications related to fatal arrhythmia and thromboembolism, good durability of the bioprosthesis, and a simple operative procedure are merits of this therapy.     

Closure of Isolated Ventricular Septal Defect with Detachment of the Tricuspid Valve

Detachment of the septal leaflet of the tricuspid valve is an alternative technique for obtaining complete visualization of a perimembranous ventricular septal defect (VSD) in cases where the VSD is obscured by the chordae tendineae or a pouch formation of the septal leaflet. This method presents theoretical concerns because it has the potential for causing postoperative valvular insufficiency. We therefore evaluated valvular function in patients who underwent VSD closure with detachment of the tricuspid valve. In a consecutive series of 153 patients who underwent VSD closure using a transatrial approach, 13 had incision of the tricuspid valve. Follow-up echocardiographic studies were performed on these patients at least 1 year following operation. There were no operative deaths. Color Doppler echocardiography revealed no residual shunt in any of these patients. Ten patients had no evidence of tricuspid stenosis or regurgitation. One patient had trivial tricuspid regurgitation. Moderate tricuspid regurgitation was observed in two patients of these, one patient was a small infant who had a VSD complicated by pulmonary hypertension. The other patient had a VSD with a mitral cleft, pulmonary hypertension, and Down's syndrome. The incised tricuspid valve was resus-pended by solely running sutures. In conclusion, detachment of the tricuspid valve is a safe and useful method for adequate exposure of a VSD. However, this method should be avoided in patients with Down's syndrome and in small infants. Furthermore, repair of the incised valve should not be performed using only running sutures.     

Methods for Repair of Simple Isolated Ventricular Septal Defect

One hundred fifteen consecutive patients underwent repair of a variety of "isolated" simple ventricular septal defects (VSD), from February 1985 through December 1989. In no patient was a ventriculotomy required to accomplish the ventricular septal defect closure. There were no instances of permanent complete atrioventricular dissociation, and there have been no reoperations for residual or recurrent VSD. Postoperative echocardiographic and Doppler studies were performed in each patient and revealed good surgical results. There was one hospital death. The technical strategies used to accomplish the repair are described. These include methods for transatrial, transaortic, and transpulmonary approach to VSD closure. Enabling methodologies described include detaching the septal leaflet of the tricuspid valve to enhance VSD exposure in patients wherein the defect is obstructed by the tricuspid valve with "aneurysm of the membranous septum." Also, splitting of the VSD patch in order to manage tricuspid valve chordal straddling is outlined.     

Follow-up after surgical closure of congenital ventricular septal defect.

OBJECTIVES: The purpose of this retrospective study was to assess long-term outcome of children after surgical closure of a ventricular septal defect (VSD). MATERIAL AND METHODS: Between January 1992 and December 2001 a consecutive series of 188 patients (100 females) were operated for closure of a VSD. Temporary tricuspid valve detachment (TVD) was applied in 46 patients (24%) to enhance exposure of the defect using transatrial approach. Pre-operative baseline characteristics showed that the detached group was younger (0.79+/-1.8 vs 2.1+/-3.5 years, p=0.002) and had a lower weight (6.5+/-6.4 vs 10.0+/-11.0 kg, p=0.009). RESULTS: There was no difference in cross-clamp time (temporary TVD 36.2+/-11.3 vs non-temporary TVD 33.6+/-13.1 min, p=0.228). Postoperative echocardiography showed that 67 patients (36%) had trivial/minimal regurgitation, 10 patients (22%) from the temporary TVD group vs 57 patients (40%) from the non-detached group (p=0.02). There was no tricuspid stenosis. Hospital mortality comprised two patients (1%). One patient died due to a pulmonary hypertensive crisis and one in relation to an acute patch dehiscence for which an emergency reoperation was necessary. At first postoperative echocardiography no shunting was detected in 113 patients, trivial shunting in 73 and significant shunting in none. Multivariate logistic regression analysis revealed that weight at operation was a predictive factor for the occurrence of residual shunting (OR 0.95, C.I. 0.91-0.99). One patient with conduction disturbances needed a permanent DDD-pacemaker. Three patients were lost to follow-up. Mean follow-up time was 2.6 years (range 0.1-9.4). During follow-up no reoperations were necessary for closing a residual VSD. One patient died 7 months postoperative due to a bronchopneumonia. During follow-up in 37 (51%) of the 73 patients the trivial shunting disappeared spontaneously at a median time of 3.9 years. According to actuarial analysis all trivial shunting had disappeared at 8.4 years. CONCLUSION: Trivial residual shunting disappeared spontaneously at a median follow-up time of 3.9 years. During follow-up no patient needed to be reoperated for residual VSD. TVD proved to be a safe method to enhance the exposure of a VSD.     

What is necessary for improvement of arterial switch operation?

We report long-term results of the arterial switch operation (ASO) and postoperative complications related to operative procedure. Between 1998 and 2007, ASO were performed in 42 patients [transposition of the great arteries (TGA) with intact ventricular septum:21, TGA with ventricular septal defect (VSD):13, Taussig-Bing anomary (TBA):7, and double outlet right ventricle with noncommitted VSD:1]. Hospital death occurred in 1 patient (2.4% mortality rate) due to low cardiac output syndrome (LOS) caused by prolonged aortic clamp, who had TGA with VSD, coactation of aortic arch and right ventricular outflow obstruction. Four patients required re-operation (freedom from re-operation rate was 84.7%). Two had pulmonary stenosis and 1 needed right ventricular outflow tract (RVOT) reconstruction with transannular patch. His pulmonary valve used for previous VSD closure was diminished. The other required muscle resection of RVOT. Five patients presented grade II or more neo-aortic insufficiency and 2 of them were TBA. Both these TBA, rerouting of left ventricular outflow tract (LVOT) to the aorta was challenging, they showed LVOT obstruction postoperatively. One underwent aortic valve plasty and the other had residual VSD closure. None had coronary event or abnormality in coronary arteriography. Selection of surgical procedure should be based on morphologic features in order to improve surgical outcome.     

Late right heart reconstruction following repair of tetralogy of Fallot.

Twenty-two symptomatic patients underwent a total of 28 reoperative procedures after initial surgical repair of tetralogy of Fallot. Sixteen of the patients were considered to have unfavorable anatomy of the right ventricular outflow tract (RVOT) or pulmonary artery at the time of initial repair. Pulmonary or tricuspid valve replacement, or replacement of both valves, utilizing a xenograft bioprosthesis was performed in 1 of the 22 initial repairs, 7 of the 22 first reoperations, and 5 of the 6 second reoperations. Ultimately, 14 patients received transannular RVOT patches. The interval between the first and second reoperations for 6 patients who required 2 late reconstructive procedures was 5.8 years. No operative deaths occurred. There were 2 late deaths (1 sudden and 1 due to aspiration). Actuarial survival probability (+/- standard error of the mean) 16 years after initial repair was 72 +/- 21%. Eighteen of the 20 current survivors in the present series are completely asymptomatic without physical restrictions; the other 2 are considered to be in New York Heart Association Functional Class II. No xenograft bioprosthetic dysfunction has occurred to date, but cumulative valve follow-up is limited (13 patient-years). In selected patients, earlier pulmonary or tricuspid valve replacement or replacement of both of these valves can provide some degree of protection against recurrent deterioration.     

Reoperation for tricuspid regurgitation after total correction of tetralogy of Fallot.

BACKGROUND: The aim of this study is to review the outcome of reoperation for severe tricuspid regurgitation after repair of tetralogy of Fallot. METHODS: Between 1972 and 2000, 12 patients underwent reoperation on the tricuspid valve after total correction of tetralogy of Fallot. The mean age at the time of reoperation was 17 years (range, 1 to 39 years). The mean interval between the initial correction and the reoperation was 7.8 years (range, 10 days to 19 years). The functional class was New York Heart Association class II in 2 patients and class III or IV in 10. Six patients underwent tricuspid valve repair, and the others underwent tricuspid valve replacement. RESULTS: Hospital mortality was 16.7% (2/12). Three patients (30%, 3/10) required a second reoperation 1.6, 9.2, and 15.6 years after the most recent reoperation with no deaths. The reasons for second reoperation were failure of the tricuspid valve repair in two and a thrombosed valve in one. There were two late deaths. Mean overall event-free actuarial survival at 10 years was 46.3%. CONCLUSION: Reoperation for severe tricuspid regurgitation after total correction of tetralogy of Fallot was associated with a high operative mortality and disappointing long-term results. Tricuspid regurgitation after corrective surgery for tetralogy of Fallot must be diagnosed promptly and cured, as tolerance is poor because of postoperative right ventricular insufficiency.     

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 )     

Transposition of the great arteries and ventricular septal defect: results with the Senning operation and closure of the ventricular septal defect in infants

From May, 1978, to July, 1982, 46 infants ranging in age from 12 days to 12 months and in weight from 2.1 to 8.4 kg underwent repair of dextrotransposition of the great arteries (D-TGA) and ventricular septal defect (VSD) using a Senning repair and closure of the VSD. Ventricular septal defects were classified as membranous (47.8%), malaligned (28.3%), atrioventricular (AV) canal type (13.0%), subarterial (2.2%), muscular (2.2%), and multiple (6.5%). Hospital mortality was 15.2% and late mortality, 5.1%. Postoperative complications included tricuspid regurgitation (mild in 3 and severe, requiring tricuspid valve replacement, in 3), residual VSD (pulmonary/systemic flow ratio of greater than 2:1) in 3 patients (2, AV canal type and 1, multiple VSDs), pulmonary venous obstruction in 3 patients, and permanent complete heart block in 4 patients (2, AV canal type of VSD also requiring tricuspid valve replacement). Lung biopsy studies showed reversible Heath-Edwards and morphometric changes. No patient was seen with Heath-Edwards III or greater changes. In 10 patients, right ventricular end-diastolic pressures and pulmonary artery pressures at rest were within normal limits one year after operation. As the operative mortality of atrial inversion and arterial switch operations for D-TGA with VSD tends to become comparable, more extensive follow-up data, including cardiac catheterization and coronary arteriography in a large number of patients, will be necessary to establish the superiority of one approach over the other.     

Tricuspid valve replacement with the St. Jude Medical valve: 19 years of experience.

OBJECTIVE: The choice of the valve substitute in the tricuspid position remains controversial. A St. Jude Medical valve is a choice of valve substitute and its lower thrombogenicity and excellent hemodynamic performance have been reported even in the tricuspid position. However, little is known of the long-term durability of the St. Jude Medical valve in the tricuspid position. Our long-term experience of tricuspid valve replacement showed the higher thrombogenicity than we had expected, therefore, this study was done to reconsider our strategy for valve choice. METHODS: This study reviewed 23 patient who underwent 25 tricuspid valve replacements with the St. Jude Medical valves from 1980 to 1997. The mean age was 40 years. Eleven patients (48%) were men. There were four in-hospital deaths (17%). The remaining 19 patients were all alive and followed from 2.2 to 19.0 years (mean 11.8 years). RESULTS: The overall survival, including hospital mortality, was 83%, 10 and 15 years after surgery. Valve thrombosis occurred in six patients. Freedom from valve thrombosis was 78 and 70%, 10 and 15 years after surgery, respectively. The linearized rate of the valve thrombosis was 2.9%/patient-years. Six patients required reoperation. The mean interval to reoperation was 9.5 years. Freedom from reoperation was 83% and 75%, 10 and 15 years after surgery, respectively. The linearized rate of the reoperation was 2.8%/patient-years. No structural valve deterioration was found. Echocardiographic study showed that the function of the St. Jude Medical valve without valve-related complications was well maintained. CONCLUSIONS: The higher thrombogenicity of the St. Jude Medical valve in the tricuspid position altered our choice of valve substitutes from the St. Jude Medical valve to a bioprosthesis which is lack of need for anticoagulant therapy except for juvenile patients who are able to maintain potent anticoagulant therapy.     

107例大动脉转换术的冠状动脉解剖类型和治疗结果

目的总结分析近年来107例大动脉转换术的冠状动脉解剖分类和手术结果，以进一步提高大动脉转换术的手术成功率。方法2000年1月至2004年9月，采用大动脉转换术纠治完全性大血管错位室隔完整型（TGA／IVS）44例，完全性大血管错位伴室间隔缺损（TGA/VSD）38例，右室双出口伴肺动脉瓣下室间隔缺损、肺动脉高压（Taussig-Bing）25例，其中冠状动脉畸形28例，占全组28％。结果大动脉转换术107例中死亡17例，总病死率15．88％。其中TGA/IVS组死亡4例，病死率9．02％；TGA／VSD组死亡8例，病死率21．05％；Taussig-Bing组死亡5例，病死率20．00％。90例术后随访6个月～4年，VSD残余漏3例，2例分别在术后1个月和2个月自愈，1例同时伴右室流出道梗阻，术后3个月再次手术治愈。肺动脉瓣上狭窄2例尚在随访中。其余病儿活动良好，无任何心肌缺血表现。结论冠状动脉畸形的变异很多，分型比较困难，Leiden方法简单，易掌握。Taussig-Bing的冠状动脉畸形发生率较高，TGA／VSD的冠状动脉畸形达40％左右，进行Switch手术时应注意。     

先天性心脏病术中心脏瓣膜的保护和矫治

目的 总结先天性心脏病术后因瓣膜功能不全再手术的经验。方法 回顾分析先天性心脏病术后再行瓣膜手术13例患者的临床资料,其中室间隔缺损修补术后8例,部分心内膜垫缺损修补术后3例,法洛四联症和房间隔缺损修补术后各1例。第1次手术时即存在二尖瓣轻～中度关闭不全6例,主动脉瓣关闭不全1例;新出现瓣膜功能异常6例,其中2例因补片漏致三尖瓣关闭不全,2例因前叶腱索断裂致三尖瓣关闭不全,1例因残留右心室流出道狭窄继发三尖瓣关闭不全,1例因伤及主动脉瓣并发二尖瓣和三尖瓣关闭不全。13例中,行二尖瓣置换6例,三尖瓣置换2例,主动脉瓣置换1例,行主动脉瓣置换并二尖瓣、三尖瓣成形1例,三尖瓣成形3例。同时修补残余漏,疏通右心室流出道。结果 术后发生低心排综合征3例。2例术后早期分别死于脑气栓和呼吸循环衰竭。11例术后痊愈出院,随访1～8年,心功能良好。结论 先天性心脏病矫治术中应注意心脏瓣膜的保护,合并的瓣膜功能异常应积极修补,及时地再手术可取得良好效果。     

双心室矫治室间隔缺损远离型右室双出口单中心15年经验

目的总结单中心双心室矫治室间隔缺损远离型右室双出口的15年经验,探讨双心室矫治的合适方法,分析再手术的危险因素。方法回顾性分析2005~2019年于我院连续入组162例接受双心室矫治的室间隔缺损远离型右室双出口患儿的临床资料。根据内隧道建立的路径将患儿分为两组:110例患儿术中行室间隔缺损连接至主动脉内隧道[A组,男75例、女35例,平均年龄(3.6±3.2)岁];52例患儿行室间隔缺损连接至肺动脉内隧道[B组,男30例、女22例,平均年龄(2.8±2.7)岁]。为了建立通畅的心室内隧道,同期进行的操作包括室间隔缺损扩大、圆锥肌肉切除、三尖瓣腱索或乳头肌转移等。结果全组行双心室矫治的患儿早期死亡9例(5.6%),早期心室内隧道梗阻6例(3.7%)。经过(7.5±7.0)年的随访,8例(4.9%)患儿发生晚期死亡,A组的1年、5年、10年、15年生存率分别为92.7%、91.1%、91.1%、85.4%,B组分别为92.2%、85.2%、85.2%、85.2%,两组差异无统计学意义(P=0.560)。随访发现10例(6.2%)迟发性心室内隧道梗阻,8例接受了再次手术。两组比较A组患儿有更多的迟发性心室内隧道梗阻(A组9例vs.B组1例,P=0.017)及总体心室内隧道梗阻(A组15例vs.B组1例,P=0.001)。两组患儿的早期死亡率和晚期死亡率差异无统计学意义(P=0.386、0.223)。A组中同期进行三尖瓣操作46例,其中1例发生左室流出道梗阻,是否同期行三尖瓣操作的术后左室流出道梗阻发生率差异具有统计学意义(1/46 vs.15/64,P=0.004),并不会造成三尖瓣反流或狭窄。Rastelli术后患儿因右室流出道病变再手术率明显高于REV手术和双根部调转术,两者差异具有统计学意义(5/14 vs.0/38,P<0.001)。结论双心室矫治室间隔缺损远离型右室双出口可以取得令人满意的远期结果。室间隔缺损连接至主动脉内隧道较室间隔缺损连接至肺动脉内隧道左室流出道梗阻发生率更高。同期进行三尖瓣处理可降低内隧道梗阻发生率。