Benzaquen Bruno S, Webb Gary D, Colman Jack M, Therrien Judith
Toronto Congenital Cardiac Centre for Adults, Toronto General Hospital, Heart and Stroke Richard Lewar Centre of Excellence, University of Toronto, Toronto, Ontario, Canada.
Am Heart J. 2004 Mar;147(3):E8. doi: 10.1016/j.ahj.2003.09.015.
After the Mustard or Senning procedure, adults with transposition of the great arteries may have right ventricular failure and require consideration of new therapies. A 2-stage arterial switch operation (ASO) may be performed as an alternative to heart transplantation. This procedure is relatively successful in children, but little is known about the 2-stage ASO in adults. We report our experience in adults undergoing pulmonary arterial banding as the first stage of a planned 2-stage arterial switch procedure after a failed Mustard operation.
Three adult patients with systemic right ventricular failure late after Mustard procedures embarked, through pulmonary artery banding, on a course toward a 2-stage arterial switch at the Toronto General Hospital. Baseline clinical characteristics as well as preoperative hemodynamics were reviewed. Immediate perioperative and postoperative events, hemodynamic measurements, and clinical outcomes were also recorded. Two patients were banded acutely such that their morphologic left ventricular to right ventricular (LV/RV) systolic pressure ratios were >0.65 after the initial banding procedure. The subpulmonary left ventricle failed in both cases. In contrast, the third patient had a more gradual approach to pulmonary artery banding (PAB), with an initial LV/RV pressure ratio of 0.5, which eventually led to a successful conversion to an arterial switch procedure.
Our evidence suggests that in adult patients expected to undergo a 2-stage arterial switch procedure after a failed Mustard operation, acute PAB achieving near-systemic subpulmonary LV pressure leads rapidly to ventricular failure and failure of this treatment strategy. A more gradual approach to PAB may be required to achieve a successful outcome.
在进行Mustard或Senning手术后，大动脉转位的成人可能会出现右心室衰竭，需要考虑新的治疗方法。两阶段动脉调转术（ASO）可作为心脏移植的替代方法。该手术在儿童中相对成功，但对于成人两阶段ASO了解甚少。我们报告了在Mustard手术失败后，对计划进行两阶段动脉调转术的成人患者进行肺动脉环扎术作为第一阶段的经验。
三名Mustard手术后晚期出现体循环右心室衰竭的成年患者，在多伦多综合医院通过肺动脉环扎术开始了两阶段动脉调转术的进程。回顾了基线临床特征以及术前血流动力学。还记录了围手术期即刻和术后事件、血流动力学测量结果以及临床结局。两名患者进行了急性环扎，使得在初始环扎术后其形态学左心室与右心室（LV/RV）收缩压比值>0.65。在这两个病例中，肺下左心室均衰竭。相比之下，第三名患者采用了更渐进的肺动脉环扎术（PAB）方法，初始LV/RV压力比值为0.5，最终成功转变为动脉调转术。
我们的证据表明，对于预计在Mustard手术失败后进行两阶段动脉调转术的成年患者，急性PAB使肺下左心室压力接近体循环压力会迅速导致心室衰竭以及该治疗策略失败。可能需要采用更渐进的PAB方法才能取得成功的结果。
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