d'Udekem d'Acoz Yves, Pasquet Agnes, Lebreux Laurent, Ovaert Caroline, Mascart Françoise, Robert Annie, Rubay Jean E
Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, and the Public Health School, Université Catholique de Louvain, Brussels, Belgium.
Ann Thorac Surg. 2003 Aug;76(2):555-61; discussion 561. doi: 10.1016/s0003-4975(03)00434-x.
The aim of this study was to determine the relative role of pulmonary insufficiency and right ventricular outflow tract damage in the genesis of late symptoms related to right ventricular dilatation.
In a retrospective study we compared the late outcomes of patients who had undergone operations known to generate pulmonary insufficiency, namely, transventricular repair of tetralogy of Fallot and pulmonary commissurotomy for isolated pulmonary stenosis.
In our institution, between 1964 and 1984, a total of 44 patients were found to have had an isolated pulmonary commissurotomy and 189 survived a transventricular repair of tetralogy of Fallot. Of these patients, 134 had patching of the right ventricle and 55 direct closure of a right ventriculotomy. Follow-up was 94% complete after a mean of 22 +/- 7 years. On echocardiography, patients with isolated commissurotomy had similar degrees of moderate and severe pulmonary insufficiency as tetralogy of Fallot patients who had a right ventricular patch (p > 0.2). However, freedom from adverse events related to right ventricular dilatation was far better (log rank p < 0.001) in patients with isolated commisurotomy.
Pulmonary insufficiency is not the only determinant of late symptomatic right ventricular dilatation after repair of tetralogy of Fallot. Pulmonary insufficiency seems much more deleterious in patients who have had right ventricular outflow tract patching. Long-term pulmonary insufficiency alone is responsible for a slight degree of right ventricular dilatation, but symptoms may develop much later if the contractility of the pulmonary infundibulum is preserved. The pulmonary infundibulum may be essential for right ventricular ejection, and for maintaining pulmonary valve competence.
本研究的目的是确定肺功能不全和右心室流出道损伤在与右心室扩张相关的晚期症状发生过程中的相对作用。
在一项回顾性研究中，我们比较了接受已知会导致肺功能不全手术的患者的晚期结局，即法洛四联症的经心室修复术和孤立性肺动脉狭窄的肺动脉瓣交界切开术。
在我们机构，1964年至1984年间，共发现44例患者接受了孤立性肺动脉瓣交界切开术，189例在法洛四联症的经心室修复术后存活。这些患者中，134例行右心室补片修补术，55例行右心室切开术直接缝合。平均22±7年后随访完成率为94%。超声心动图显示，孤立性交界切开术患者的中度和重度肺功能不全程度与行右心室补片修补术的法洛四联症患者相似（p>0.2）。然而，孤立性交界切开术患者与右心室扩张相关的不良事件发生率要低得多（对数秩检验p<0.001）。
肺功能不全不是法洛四联症修复术后晚期有症状的右心室扩张的唯一决定因素。在有右心室流出道补片修补术的患者中，肺功能不全似乎更具危害性。单独的长期肺功能不全只会导致轻微程度的右心室扩张，但如果肺动脉漏斗部的收缩功能得以保留，症状可能会在很久以后才出现。肺动脉漏斗部可能对右心室射血以及维持肺动脉瓣功能至关重要。
