体-肺动脉分流术后早期分流失效的危险因素分析

目的分析影响体-肺动脉分流术后早期分流失效的危险因素,以提高手术效果。方法回顾性分析2002年2月至2010年12月期间沈阳军区总医院189例行体-肺动脉分流术患者的临床资料,其中男87例,女102例;年龄3个月～50(5.3±6.2)岁;体重3～56(17.7±11.0)kg。术前临床诊断为法洛四联症合并肺动脉狭窄94例,室间隔缺损合并肺动脉闭锁51例,室间隔完整的肺动脉闭锁4例,功能性单心室合并肺动脉狭窄10例,功能性单心室合并肺动脉闭锁6例,右心室双出口合并肺动脉狭窄6例,完全型大动脉转位合并肺动脉狭窄8例,完全型大动脉转位合并肺动脉闭锁10例。手术方式包括中央分流术105例,改良Blalock-Taussig分流术61例,墨尔本分流术23例。结果术后早期死亡13例(6.9%),术中发生严重低血压和心律失常12例(6.3%),术后严重低心排血量10例(5.3%),术后24 h内分流失效10例(5.3%)。单因素分析结果显示,低体重(P=0.027)、分流管直径<4 mm(P=0.025)、术中不良事件(严重低血压和心律失常,P=0.002)是24 h内分流失效的危险因素。多因素logistic逐步回归分析结果显示,术中不良事件(P=0.017)是24 h内分流失效的独立危险因素。结论对于年龄小、低体重和肺动脉发育细小的患者,术中预防严重低血压和心律失常,采用4 mm以上的分流管,可明显提高分流术后效果。

Risk Factors for Early Shunt Dysfunction after Systemic-pulmonary Shunt

Objective To analyze the risk factors for early shunt dysfunction after systemic-pulmonary shunt in order to improve early postoperative outcomes.Methods We retrospectively analyzed the clinical records of 189 patients who underwent systemic-pulmonary shunt in General Hospital of Shenyang Military District between February 2002 and December 2010.There were 87 males and 102 females with their age ranging from 3 months to 50(5.3±6.2)years,and body weight ranging from 3 to 56(17.7±11.0)kg.There were 94 patients with tetralogy of Fallot(TOF)and pulmonary artery stenosis,51 patients with pulmonary atresia(PA)and ventricular septal defect,4 patients with PA and intact ventricular septum,10 patients with functional single ventricle(SV)and pulmonary stenosis(PS),6 patients with SV and PA,6 patients with double outlet right ventricle and PS,8 patients with transposition of the great arteries(TGA)and PS,and 10 patients with TGA and PA.The surgical procedures included central aorto-pulmonary shunt(Waterston)in 105 patients,modified Blalock-Taussig shunt in 61 patients and Melbourne shunt in 23 patients.Results Early postoperative death occurred in 13 patients(6.9%).There were 12 patients(6.3%)with intra-operative severe hypotension or arrhythmia,10 patients(5.3%)with postoperative severe low cardiac output,and 10 patients(5.3%)with early shunt dysfunction within the first 24 h postoperatively.Univariate analysis identified low body weight(P=0.027),shunt size with diameter < 4 mm(P=0.025)and severe intra-operative adverse event(hypotension or arrhythmia with P=0.002)were risk factors for early shunt dysfunction.In multivariate analysis,intra-operative adverse event was an independent risk factor for early shunt dysfunction(P=0.017).Conclusion Early outcomes after systemic-pulmonary shunt can be significantly improved by preventing intra-operative severe hypotension or arrhythmia and choosing shunt size larger than 4 mm,especially for patients with young age,low body weight,and poorly-developed pulmonary artery.