左室训练术对矫正性大动脉转位合并三尖瓣关闭不全的影响

目的左室退化先天性矫正性大动脉转位患者常常合并不同程度的三尖瓣关闭不全,左室训练术可有效的提高形态学左心室的后负荷，改善形态学左心室的功能，本文进一步评价左室训练术对三尖瓣功能的可能影响。方法2005年5月至2011年5月，24例左室退化先天性矫正性大动脉转位患儿行左室训练术，男性13例，女性11例，年龄3．73±4．35岁（0．17-22岁），体重15．71±10．95kg（5．1—61kg），其中合并三尖瓣关闭不全23例（轻度11例，中度7例，重度5例）。术前经超声心动网，心血管造影或心导管检查确诊，形态学左室舒张末径21．56±6．60mm（8-32mm），形态学左室后壁厚度4．29±1．52mm（2-7mm），形态学左室与形态学右室压力比0．41±0．12（0．12-0．65）。手术均采用胸骨上端小切口或胸骨正中切口，在全麻下完成左室训练术。结果全组患者无住院死亡．出院时超声心动图检查：5例患者三尖瓣关闭不全消失，三尖瓣仍存在不同程度关闭不全18例（轻度12例，中度4例，重度2例），其中：9例患者TR程度均较术前减轻，双心室结构和功能良好，室间隔位置较术前略向形态学右心室侧移位，形态学左室舒张末径较术前略增大。术后随访1月-35月，无远期死亡。所有患儿一般情况好，生命体征平稳，心功能I—II级，8例患者三尖瓣关闭不全消失，三尖瓣存在不同程度关闭不全14例（轻度8例，中度4例，重度2例），其中：8例患者TR程度均较术前显著减轻，形态学左室舒张末径26．17±7．11mm（14—40mm），形态学左心室后壁厚度4．95±1．44mm（4—9mm）。结论左室训练术可改善左室退化先天性矫正性大动脉转位患者三尖瓣关闭不全的程度，其原因可能与左室训练术增加形态学左心室压力负荷及增加形态学左心室后壁厚度，形态学左心室腔扩大，室间隔向形态学右心室侧移位，形态学右心室腔相对缩小，三尖瓣叶对合改善，三尖瓣反流减轻。

The Effects of the Morphologic Left Ventricle Retraining Procedure on the Tricuspid Valve Regurgitation in Patients with Congenitally Corrected Transposition of the Great Arteries

Objective Congenitally corrected transposition of the great arteries（CCTGA） is associated with tricuspid valve regurgitation（TR）, the morphologic left ventricle （mLV） retraining procedure is a safe and effective method to train the mLV with good results, this study was performed to evaluate the effects of the morphologic left ventricle retraining procedure on the degree of TR .Methods between May 2005 and May 2011, 24 patients with the CCTGA having a deconditioned mLV anomaly underwent left ventricle retraining procedure by means of pulmonary artery banding in Fu Wai hospital, there are 13 males and 11 female with ages ranging from 0.17 to 22 （mean ,3.73±4.35） years and weight ranging from 5.1 to 61 （mean ,15.71±10.95） kg. 23 patients had TR （mild 11 ,moderate 7, severe 5）. preoperatively assessed by echocardiography and cardiac catheterization, The mLV end diastolic diameter （mLVEDd） was 21.56±6.60 mm （8-32mm）, the posterior wall thickness of the mLV was 4.29±1.52 mm（2-7mm）, the morphologic left ventricle to the morphologic right ventricle （mLV/mRV） pressure ratio was 0.41±0.12（0.12-0.65） .the left ventricle retraining procedure was performed through a medline sternotomy approach with upper partial pericardiotomy or median stemotomy under general anesthesia without circulatory arrest. Results there was no in- hospital death, echocardiography before discharge showed that TR was disappeared in 5 patients ,18 patients still had TR （mild 12,moderate 4, severe 2） but there was a tendency for a reduction and TR in 9 patients were decreased obviously, the interventricular septum moved partially to the midline position, mLVEDd was increased slightly .follows-up（1 to 35months） ,there was no late complications and death, the survivals was in the good general condition and NYHA class I - II, TR was disappeared in 8 patients, 14 patients still had TR （mild 8,moderate 4, severe 2） and TR in 8 patients is decreased obviously, the mLVEDd was 26.17±7.11 mm （14-40mm）, the posterior wall thickness of the mLV was 4.95±1.44mm （4-9mm）, mLV/mRV pressure ratio was 0.72±0.16 （0.52-0.98）. Conclusions the morphologic left ventricle retraining procedure can palliate the TR in patients with the CCTGA having a deconditioned mLV obviously, and the possible mechanism is that pressure load of the mLV are increased after surgery, the mLV cavity is then dilated, and the ventricular septum bows into the mRV, the mRV cavity is then decreased, these geometric alteration potentially lead to a more overlap of the TV, and TR is palliated.