右室双出口心室内隧道修补术的优化

目的对心室内隧道修补术的适应证和方法提出优化意见。方法120例右室双出口(DORV)患者接受心室内隧道修补手术，采用纵行切开右室流出道，用一补片作右心室内隧道，连接室间隔缺损与主动脉口，引导左心室血在补片下进入主动脉，根据解剖情况扩大右室流出道和肺动脉。另有2例内隧道通过右房切口建立；对限制性室间隔缺损．同时扩大室间隔缺损直径。结果术后发生低心排37例，总住院死亡为20例(16．7％)，近5年死亡3例(6．0％)，其中室间隔缺损远离大动脉开口的DORV病例行心室内隧道修补手术死亡率明显高于室间隔缺损在主动脉下。结论心室内隧道修补术选择受室间隔缺损解剖位置的影响，但术前心内探查三尖瓣与肺动脉瓣间距离至关重要；通过右房切口建立心内隧道并采用连续缝合的方法，有利于术中心肌保护。

Optimized Surgical Indication and Management of Intraventricular Tunnel Repair of Double-Outlet Right Ventricle

Objective In order to optimize the surgical indications and managements of double-outlet right ventricle(DORV)repaired with intraventricular tunnel, the case selection, anatomical features, surgical managements and results were reviewed. Methods One hundred and twenty patients with DORV underwent intraventricular tunnel repair (IVR). The intraventricular tunnels were built through-right ventricular incision in most of patients. A patch graft was used to connect the ventricular septal defect(VSD) to the aorta, which the blood stream from the left ventricle to the aorta. The right ventricular outflow tract and pulmonary artery were enlarged in some cases. The intraventricular tunnels were built through the right atrium in 2 patients. Some restrictive VSDs were enlarged during operations. Results Low cardiac output occurred in 37 patients postoperatively. The whole hospital mortality rate was 16.7%. Three patients died in recent 5 years (6.0%). The hospital mortality rate of DORV with non-committed VSD is much higher than that of DORV with subaortic VSD. Conclusion The choice of IVR is dependent on the site of VSD. A longer tricuspid-pulmonary valvular distance than the diameter of the aorta is the key for the choice of IVR. The intraventricular tunnels built through the right atrium with running suture may provide better myocardial protection.