Agnoletti Gabriella, Raisky Olivier, Boudjemline Younes, Ou Phalla, Bonnet Damien, Sidi Daniel, Vouhé Pascal
Pediatric Cardiology, Necker Enfants Malades, Paris, France.
Ann Thorac Surg. 2006 Nov;82(5):1585-92. doi: 10.1016/j.athoracsur.2006.05.049.
The objective of this study was to review our institutional experience concerning neonatal aortic commissurotomy and to identify predictors of outcome.
From January 1, 1990, to January 1, 2005, 65 neonates were referred for critical aortic stenosis. Among these 36 consecutive patients underwent surgical valvotomy by the same surgeon and 16 patients had balloon valvotomy. We examined clinical records to establish determinants of outcome and illustrate long-term results.
In the surgical group 6 patients had nonstenotic parachute mitral valve, 6 had aortic coarctation, 13 had endocardial fibroelastosis; and 15 had depressed fractional shortening. In the balloon valvotomy group most infants had associated mitral stenosis (n = 7), small aortic annulus (n = 5), multiple anomalies (n = 2), endocardial fibroelastosis (n = 9), and depressed fractional shortening (n = 13). In the surgical group global mortality was 19%; 47% in infants with depressed fractional shortening and 0% in infants with normal fractional shortening. Mortality in the balloon valvotomy group was 56%. Low fractional shortening, low mean aortic gradient, endocardial fibroelastosis, and small aortic annulus were associated with fatal outcome. In the surgical group 6 patients needed Ross operation at a median interval of 4 years from commissurotomy. In the balloon valvotomy group 3 patients needed early mitral replacement and 5 aortic valve surgery. At a median follow-up of 6 years, all children are in New York Heart Association class I, all have a normal ventricular function, 2 have aortic restenosis, and 5 have at least moderate aortic incompetence.
In a selected population of neonates with isolated aortic stenosis, surgical valvotomy offers an excellent long-term outcome to patients with a normokinetic left ventricle, while patients with a hypokinetic left ventricle have a poor outcome. Balloon valvotomy offers poor results when performed in patients with complex anomalies.
本研究的目的是回顾我们机构关于新生儿主动脉瓣交界切开术的经验，并确定预后的预测因素。
从1990年1月1日至2005年1月1日，65例新生儿因严重主动脉瓣狭窄前来就诊。其中36例连续患者由同一位外科医生进行了手术瓣膜切开术，16例患者接受了球囊瓣膜切开术。我们检查了临床记录以确定预后的决定因素并阐述长期结果。
手术组中，6例患者有非狭窄性降落伞样二尖瓣，6例有主动脉缩窄，13例有心内膜弹力纤维增生症；15例有缩短分数降低。球囊瓣膜切开术组中，大多数婴儿伴有二尖瓣狭窄（n = 7）、主动脉瓣环小（n = 5）、多发畸形（n = 2）、心内膜弹力纤维增生症（n = 9）和缩短分数降低（n = 13）。手术组的总体死亡率为19%；缩短分数降低的婴儿中死亡率为47%，缩短分数正常的婴儿中死亡率为0%。球囊瓣膜切开术组的死亡率为56%。缩短分数降低、平均主动脉梯度低、心内膜弹力纤维增生症和主动脉瓣环小与致命结局相关。手术组中有6例患者在交界切开术后中位间隔4年需要进行罗斯手术。球囊瓣膜切开术组中有3例患者需要早期二尖瓣置换，5例需要主动脉瓣手术。中位随访6年时，所有儿童的心功能均为纽约心脏协会I级，心室功能均正常，2例有主动脉瓣再狭窄，5例至少有中度主动脉瓣关闭不全。
在选定的孤立性主动脉瓣狭窄新生儿群体中，手术瓣膜切开术为左心室运动正常的患者提供了良好的长期预后，而左心室运动减弱的患者预后较差。对有复杂畸形的患者进行球囊瓣膜切开术效果不佳。
