Karamlou Tara, Silber Ilana, Lao Robin, McCrindle Brian W, Harris Louise, Downar Eugene, Webb Gary D, Colman Jack M, Van Arsdell Glen S, Williams William G
Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.
Ann Thorac Surg. 2006 May;81(5):1786-93; discussion 1793. doi: 10.1016/j.athoracsur.2005.12.039.
We evaluated outcomes in patients requiring late reoperation after tetralogy of Fallot (ToF) repair to identify risk factors for arrhythmia and determine whether arrhythmia surgery decreased the risk of subsequent death or recurrent arrhythmia.
Review was performed of all ToF patients from 1969 to 2005 undergoing reoperation late (> 1 year) after repair. Patients with associated lesions, except pulmonary atresia, were included. A total of 249 patients had 278 reoperations. Procedures at initial reoperation included pulmonary valve replacement (PVR) in 217, ablation in 63, and tricuspid valve repair/replacement in 46. Pre-reoperative arrhythmias were present in 75, including supraventricular tachycardia (SVT) in 31, ventricular tachycardia (VT) in 34, and SVT+VT in 10 patients.
Median age at reoperation was 23 years (range, 1 to 63). Ten-year survival after reoperation was 93%, and was independent of arrhythmia status (p = 0.86). Arrhythmia patients were characterized by older age at initial repair and at late reoperation, tricuspid and pulmonary regurgitation, and longer QRS duration (p < 0.001 for all). Risk factors for post-reoperative recurrent arrhythmia were longer QRS duration and not having PVR. Longer QRS duration, with a cut-point of more than 160 msec, was associated with recurrent SVT (p = 0.004). Supraventricular tachycardia ablation improved arrhythmia-free survival (75% versus 33%, p < 0.001) but VT ablation did not (96% versus 95%, p = 0.50). However, recurrent VT occurred in only 3 patients (10%).
Late mortality in patients undergoing reoperation after ToF repair is not impacted by pre-reoperative arrhythmia. Prolongation of QRS identifies patients at risk for recurrent VT and SVT, but recurrent VT is uncommon. Early PVR, and surgical ablation in patients with SVT, decreases arrhythmic risk.
我们评估了法洛四联症（ToF）修复术后需要晚期再次手术的患者的预后，以确定心律失常的危险因素，并确定心律失常手术是否降低了随后死亡或复发性心律失常的风险。
对1969年至2005年期间所有ToF修复术后晚期（>1年）接受再次手术的患者进行回顾性研究。纳入伴有相关病变的患者，但不包括肺动脉闭锁患者。共有249例患者进行了278次再次手术。初次再次手术的操作包括217例肺动脉瓣置换术（PVR）、63例消融术和46例三尖瓣修复/置换术。75例患者术前存在心律失常，其中31例为室上性心动过速（SVT），34例为室性心动过速（VT），10例为SVT+VT。
再次手术时的中位年龄为23岁（范围1至63岁）。再次手术后10年生存率为93%，且与心律失常状态无关（p = 0.86）。心律失常患者的特征为初次修复和晚期再次手术时年龄较大、三尖瓣和肺动脉反流以及QRS时限较长（所有p值均<0.001）。术后复发性心律失常的危险因素为QRS时限较长和未进行PVR。QRS时限延长，切点超过160毫秒，与复发性SVT相关（p = 0.004）。室上性心动过速消融术改善了无心律失常生存率（75%对33%，p < 0.001），但室性心动过速消融术未改善（96%对95%，p = 0.50）。然而，仅3例患者（10%）发生复发性VT。
ToF修复术后再次手术患者的晚期死亡率不受术前心律失常的影响。QRS时限延长可识别复发性VT和SVT的高危患者，但复发性VT并不常见。早期PVR以及对SVT患者进行手术消融可降低心律失常风险。
