McMahon C J, Ravekes W J, Smith E O'Brian, Denfield S W, Pignatelli R H, Altman C A, Ayres N A
Lillie Frank Abercrombie Division of Pediatric Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX 77030, USA.
Pediatr Cardiol. 2004 Jul-Aug;25(4):329-35. doi: 10.1007/s00246-003-0483-6.
The objectives of this study were to evaluate changes in dimension of the neo-aortic annulus, aortic root, and aortic anastomosis following arterial switch operation (ASO) and to identify risk factors for developing abnormal neo-aortic root enlargement and aortic regurgitation (AR). Prior studies report development of neo-aortic root dilatation and AR in a small subset of patients after ASO. Predisposing factors for neo-aortic root dilatation and development of moderate/severe AR are poorly understood. We performed a retrospective review of all patients with d-transposition of the great arteries (d-TGA) or double-outlet right ventricle with subpulmonary ventricular septal defect (VSD) who underwent ASO from May 1986 to January 2001. Serial echocardiograms were reviewed to measure neo-aortic annulus, root, and anastomosis diameter (z scores) and to determine progression of AR. Potential risk factors were assessed for developing neo-aortic root enlargement and AR. There were 119 patients (44 female and 75 male): 73 patients had simple d-TGA, 36 had d-TGA with ventricular septal defect, and 10 had a Taussig-Bing heart. The median duration of follow-up was 65 months (range, 12-180). The median neo-aortic root (z = 0.55+/-2.2; p < 0.01) and aortic annulus dimensions (z = 1.57+/-1.75; p < 0.01) were significantly increased over the study period. Aortic anastomosis diameter correlated with growth of the ascending aorta (z = 0.55+/-1.24). Development of severe neo-aortic root enlargement was associated with prior pulmonary artery (PA) banding (p < 0.01), the presence of a VSD (p = 0.03), and Taussig-Bing anatomy (p < 0.01) but was independent of coronary arterial anatomy, coronary arterial transfer technique, or associated lesions (p > 0.05). At latest follow-up, there was no or trivial AR in 88 patients, mild AR in 29 patients, and moderate to severe AR in 3 patients. Risk factors for developing mild or worse AR included severe or rapid neo-aortic root dilatation (p < 0.01). Only 3 patients required surgical intervention for AR. Despite the significant prevalence of neo-aortic root enlargement at intermediate follow-up after ASO, there is a low incidence of significant AR. Prior PA banding, the presence of VSD, and Taussig-Bing anatomy are risk factors for severe root enlargement. Surgical intervention for AR was rare (2%), however, serial surveillance of such patients is vital to monitor for neo-aortic root enlargement and potential aortic valve dysfunction.
本研究的目的是评估动脉调转术（ASO）后新主动脉瓣环、主动脉根部和主动脉吻合口尺寸的变化，并确定发生新主动脉根部异常扩大和主动脉瓣反流（AR）的危险因素。既往研究报道，在一小部分接受ASO的患者中出现了新主动脉根部扩张和AR。新主动脉根部扩张以及中重度AR的诱发因素尚不清楚。我们对1986年5月至2001年1月期间接受ASO的所有大动脉d型转位（d-TGA）或右心室双出口合并肺动脉下室间隔缺损（VSD）的患者进行了回顾性研究。回顾系列超声心动图以测量新主动脉瓣环、根部和吻合口直径（z值），并确定AR的进展情况。评估了发生新主动脉根部扩大和AR的潜在危险因素。共有119例患者（44例女性和75例男性）：73例患者为单纯d-TGA，36例为合并室间隔缺损的d-TGA，10例为陶西格-宾氏心脏。随访的中位时间为65个月（范围12 - 180个月）。在研究期间，新主动脉根部的中位尺寸（z = 0.55±2.2；p < 0.01）和主动脉瓣环尺寸（z = 1.57±1.75；p < 0.01）显著增加。主动脉吻合口直径与升主动脉的生长相关（z = 0.55±1.24）。严重的新主动脉根部扩大与既往肺动脉（PA）环扎术（p < 0.01）、VSD的存在（p = 0.03）以及陶西格-宾氏解剖结构（p < 0.01）相关，但与冠状动脉解剖结构、冠状动脉转移技术或相关病变无关（p > 0.05）。在最近一次随访时，88例患者无AR或仅有微量AR，29例患者有轻度AR，3例患者有中重度AR。发生轻度或更严重AR的危险因素包括严重或快速的新主动脉根部扩张（p < 0.01）。只有3例患者因AR需要手术干预。尽管在ASO后的中期随访中新主动脉根部扩大的发生率较高，但显著AR的发生率较低。既往PA环扎术、VSD的存在以及陶西格-宾氏解剖结构是严重根部扩大的危险因素。AR的手术干预很少见（2%），然而，对此类患者进行系列监测对于监测新主动脉根部扩大和潜在的主动脉瓣功能障碍至关重要。
