del Castillo Sylvia L, Moromisato David Y, Dorey Frederick, Ludwick Joseph, Starnes Vaughn A, Wells Winfield J, Jeffries Howard E, Wong Pierre C
Division of Critical Care Medicine, Department of Pediatrics, Childrens Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, CA, USA.
Pediatr Crit Care Med. 2006 Mar;7(2):132-7. doi: 10.1097/01.PCC.0000200999.89777.92.
Neonates with ductal-dependent single-ventricle congenital heart disease palliated with a modified Blalock-Taussig shunt (mBTS) commonly have retrograde diastolic flow in the aorta, which may place them at increased risk of mesenteric ischemia. Recently, palliation with a right ventricle-to-pulmonary artery conduit, known as the Sano procedure, has been shown to eliminate retrograde diastolic flow, theoretically leading to better systemic perfusion.
To compare the changes in superior mesenteric artery (SMA) and celiac artery velocities and flow after a bolus enteral feed in patients with single-ventricle congenital heart disease palliated with an mBTS vs. those palliated with the right ventricle-to-pulmonary artery conduit.
Prospective clinical study.
Cardiothoracic intensive care unit and pediatric ward of a tertiary care children's hospital.
A total of 27 patients with single-ventricle congenital heart disease (15 with mBTS, 12 with Sano) after stage-1 palliation.
Doppler ultrasound of the SMA and celiac artery was performed 30 mins before and after a bolus enteral feed.
SMA and celiac artery peak systolic flow velocity, mean flow velocity, and time-velocity integral were measured. After a bolus enteral feed, 8 of 15 infants palliated with an mBTS had retrograde diastolic flow through the SMA yet demonstrated significant increases in all variables of both the SMA and celiac artery flow velocities (SMA peak systolic flow velocity: 0.96 +/- 0.33 vs. 1.2 +/- 0.4 m/sec, p = .01). Those palliated with the Sano procedure did not demonstrate SMA retrograde diastolic flow but also did not have any significant changes in their mesenteric flow variables (SMA peak systolic flow velocity: 0.79 +/- 0.16 vs. 0.89 +/- 0.26 m/sec, p = .2).
Postprandial retrograde diastolic flow was observed in the majority of patients palliated with an mBTS vs. none of the patients in the Sano group. However, contrary to expectations, postprandial mesenteric blood flow velocities in those palliated with an mBTS are significantly higher than in Sano patients, although the increase is not as high as that historically seen in normal neonates. This may place this population at risk for mesenteric ischemia and feeding intolerance in the postoperative period, and the risk may be even greater for those neonates palliated with a right ventricle-to-pulmonary artery conduit.
采用改良布莱洛克-陶西格分流术（mBTS）姑息治疗的导管依赖性单心室先天性心脏病新生儿，主动脉通常存在舒张期逆向血流，这可能使他们发生肠系膜缺血的风险增加。最近，采用右心室至肺动脉导管的姑息治疗方法，即所谓的 sano 手术，已被证明可消除舒张期逆向血流，理论上可带来更好的体循环灌注。
比较采用 mBTS 姑息治疗与采用右心室至肺动脉导管姑息治疗的单心室先天性心脏病患者在给予肠内推注喂养后，肠系膜上动脉（SMA）和腹腔动脉的速度及血流变化。
前瞻性临床研究。
一家三级儿童专科医院的心胸重症监护病房和儿科病房。
总共 27 名单心室先天性心脏病患者（15 例采用 mBTS，12 例采用 sano 手术），均为一期姑息治疗后。
在肠内推注喂养前 30 分钟和喂养后，对 SMA 和腹腔动脉进行多普勒超声检查。
测量 SMA 和腹腔动脉的收缩期峰值流速、平均流速和时间-流速积分。在给予肠内推注喂养后，15 例采用 mBTS 姑息治疗的婴儿中有 8 例通过 SMA 出现舒张期逆向血流，但 SMA 和腹腔动脉流速的所有变量均显著增加（SMA 收缩期峰值流速：0.96±0.33 对 1.2±0.4 米/秒，p = 0.01）。采用 sano 手术姑息治疗的患者未出现 SMA 舒张期逆向血流，但其肠系膜血流变量也无任何显著变化（SMA 收缩期峰值流速：0.79±0.16 对 0.89±0.26 米/秒，p = 0.2）。
采用 mBTS 姑息治疗的大多数患者在餐后出现舒张期逆向血流，而 sano 组患者均未出现。然而，与预期相反，采用 mBTS 姑息治疗的患者餐后肠系膜血流速度显著高于 sano 手术患者，尽管增加幅度不如正常新生儿历史上所见。这可能使该人群在术后发生肠系膜缺血和喂养不耐受的风险增加，对于采用右心室至肺动脉导管姑息治疗的新生儿，这种风险可能更大。
