Warner Kenneth G, O'Brien Patrick K H, Rhodes Jonathan, Kaur Avnit, Robinson Davida A, Payne Douglas D
Division of Cardiothoracic Surgery, Tufts-New England Medical Center and Boston Floating Hospital, Tufts University School of Medicine, Boston, Massachusetts 02111, USA.
Ann Thorac Surg. 2003 Oct;76(4):1066-71; discussion 1071-2. doi: 10.1016/s0003-4975(03)00748-3.
Insertion of a competent pulmonary valve has been advocated to reduce right ventricular volume overload associated with pulmonary regurgitation (PR) after repair of tetralogy of Fallot. However the indications, proper timing, and long-term benefits of restoring pulmonary valve function remain controversial.
Thirty-six patients (aged 15.2 +/- 9.2 years) underwent pulmonary valve implantation (31 homografts, 5 heterografts) 12.2 +/- 6.9 years after tetralogy repair. Additional surgical procedures included pulmonary artery augmentation (n = 14), closure of septal defects (n = 10), and cryoablation and endocardial resection of ventricular tachycardia (n = 2).
All patients have had clinical improvement in their exercise capacity. Preoperative and postoperative bicycle ergometry tests in 6 patients demonstrated significant improvement in the percent of predicted peak workload (68.5% +/- 19.8% to 80.7% +/- 17.4%, p < 0.015). One midterm death occurred in a 38-year-old patient with a history of ventricular tachycardia who died suddenly 2 years after pulmonary valve insertion. Postoperative echocardiographic measurements were available in 34 patients at a mean follow-up of 5 years. There was a 30% reduction in right ventricular end-diastolic diameter indexed to body surface area after surgery (30.1 +/- 10.2 to 18.6 +/- 6.0 mm/m(2), p < 0.0001). Two patients required conduit replacements at 1 and 9 years postoperatively.
Timely insertion of a competent pulmonary valve in children, adolescents, and young adults with significant PR after tetralogy of Fallot repair results in subjective and objective improvement in exercise capacity and is associated with reduction in right ventricle size.
对于法洛四联症修复术后的患者，提倡植入功能良好的肺动脉瓣以减轻与肺动脉反流（PR）相关的右心室容量负荷过重。然而，恢复肺动脉瓣功能的适应证、合适时机及长期益处仍存在争议。
36例患者（年龄15.2±9.2岁）在法洛四联症修复术后12.2±6.9年接受了肺动脉瓣植入术（31例同种异体移植物，5例异种异体移植物）。额外的外科手术包括肺动脉扩大术（n = 14）、室间隔缺损修补术（n = 10）以及室性心动过速的冷冻消融和心内膜切除术（n = 2）。
所有患者的运动能力均有临床改善。6例患者术前和术后的自行车测力计测试显示，预测峰值工作量百分比有显著改善（68.5%±19.8%至80.7%±17.4%，p < 0.015）。一名有室性心动过速病史的38岁患者在肺动脉瓣植入术后2年突然死亡，为中期死亡病例。34例患者术后接受了超声心动图测量，平均随访时间为5年。术后以体表面积计算的右心室舒张末期内径减少了30%（30.1±10.2至18.6±6.0 mm/m²，p < 0.0001）。2例患者分别在术后1年和9年需要更换管道。
对于法洛四联症修复术后伴有严重PR的儿童、青少年和年轻成人，及时植入功能良好的肺动脉瓣可使运动能力在主观和客观上得到改善，并使右心室大小减小。
