Griselli Massimo, McGuirk Simon P, Ofoe Victor, Stümper Oliver, Wright John G C, de Giovanni Joseph V, Barron David J, Brawn William J
Department of Paediatric Cardiac Surgery, Diana, Princess of Wales Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom.
Eur J Cardiothorac Surg. 2006 Dec;30(6):930-5. doi: 10.1016/j.ejcts.2006.08.007. Epub 2006 Oct 17.
This study evaluated the requirement for surgical reoperation and catheter-based reintervention to central pulmonary arteries (CPAs) following Norwood Procedure (NP). We sought to identify the influence of various surgical techniques employed during NP on subsequent interventions.
Between 1993 and 2004, 226 patients underwent Stage II following NP. Ninety-eight patients (43%) had completion of Fontan circulation (Stage III) and a further 107 (47%) are on course for Fontan completion with 21 (9%) inter-stage deaths. During NP, the aortic arch was reconstructed without additional material (n = 91, 40%) or with a pulmonary homograft patch (n = 135, 60%). Pulmonary blood flow was supplied by modified Blalock-Taussig shunt (n = 177, 78%) or right ventricle to pulmonary artery conduit (RV-PA; n = 49, 22%). The CPAs defect was closed directly (n = 69, 31%) or with a patch (n = 157, 69%). Complete resection of coarctation was performed in 126 patients (56%).
Ninety-seven patients (43%) required surgical reoperation to CPAs during Stage II. Actuarial freedom from reoperation was 60+/-3%, 52+/-4% and 50+/-4% at 1, 5 and 10 years, respectively. On multivariable analysis, NP with RV-PA increased risk of reoperation (LR 8.3, 5.3-13.2; p < 0.001). Forty-one patients (18%) required catheter-based reintervention on CPAs. Actuarial freedom from reintervention was 98+/-1%, 72+/-4% and 58+/-6% at 1, 5 and 10 years, respectively. CPA problems were almost exclusively limited to the proximal Left pulmonary artery. On multivariable analysis, catheter-based reintervention became more common with time. Complete resection of coarctation increased risk of reintervention (LR 3.9, 1.6-9.6; p < 0.005). Arch reconstruction and CPAs repair techniques did not affect risk of reoperation or reintervention on CPAs.
CPA stenoses and hypoplasia need surgical attention in approximately half of all patients undergoing the NP. The need for reoperation is increased when using the RV-PA conduit technique (although the majority of these are performed as part of the Stage II procedure). Catheter reinterventions are almost exclusively confined to the left CPA and are increased when the arch is shortened by resection of the coarctation tissue at time of NP.
本研究评估了诺伍德手术（NP）后再次进行外科手术以及经导管对中央肺动脉（CPA）进行再次干预的必要性。我们试图确定NP期间采用的各种手术技术对后续干预的影响。
1993年至2004年间，226例患者在NP后接受了二期手术。98例患者（43%）完成了Fontan循环（三期），另有107例患者（47%）正在进行Fontan手术，其中21例（9%）在两期手术之间死亡。在NP期间，主动脉弓在未使用额外材料的情况下进行重建（n = 91，40%）或使用肺动脉同种异体移植补片进行重建（n = 135，60%）。肺血流由改良的Blalock-Taussig分流术提供（n = 177，78%）或右心室至肺动脉管道（RV-PA；n = 49，22%）。CPA缺损直接关闭（n = 69，31%）或使用补片关闭（n = 157，69%）。126例患者（56%）进行了主动脉缩窄的完全切除。
97例患者（43%）在二期手术期间需要对CPA进行再次手术。1年、5年和10年的再次手术无事件生存率分别为60±3%、52±4%和50±4%。多变量分析显示，采用RV-PA的NP增加了再次手术的风险（LR 8.3，5.3 - 13.2；p < 0.001）。41例患者（18%）需要对CPA进行经导管再次干预。1年、5年和10年的再次干预无事件生存率分别为98±1%、72±4%和58±6%。CPA问题几乎完全局限于左肺动脉近端。多变量分析显示，随着时间的推移，经导管再次干预变得更加常见。主动脉缩窄的完全切除增加了再次干预的风险（LR 3.9，1.6 - 9.6；p < 0.005）。主动脉弓重建和CPA修复技术不影响对CPA再次手术或再次干预的风险。
在接受NP的所有患者中，约一半患者的CPA狭窄和发育不全需要外科关注。使用RV-PA管道技术时再次手术的需求增加（尽管其中大多数是作为二期手术的一部分进行的）。导管再次干预几乎完全局限于左CPA，并且在NP时通过切除缩窄组织缩短主动脉弓时会增加。
