Mohammadi Siamak, Benhameid Osama, Campbell Andrew, Potts Jim, Joza Jacqueline, Al-Habib Hamad, Sett Suvro, Le Blanc Jacques
Department of Pediatric Cardiac Surgery, British Columbia Children's Hospital, Vancouver, BC, Canada.
Eur J Cardiothorac Surg. 2008 Sep;34(3):545-9; discussion 549. doi: 10.1016/j.ejcts.2008.06.001. Epub 2008 Jul 16.
To identify factors associated with in-hospital and interim mortality in children with a systemic-to-pulmonary shunt (SPS).
Between January 1988 and April 2005, 226 children with a median age of 17 days, and weight of 3.4 kg, underwent an isolated SPS for pulmonary atresia (PA)-VSD/ tetralogy (n=124, 54.9%), functional single ventricle PA (n=35, 5.5%), PA-intact septum (IS, n=31, 13.7%), transposition of the great arteries VSD-PA (n=30, 13.3%), and double outlet right ventricle-PA (n=6, 2.6%). Surgery was performed through sternotomy (group S, n=46) or thoracotomy (group T, n=180). The origin of the SPS was either the innominate artery (n=38) or ascending aorta (n=8) in group S, and the subclavian artery (n=180) in group T.
In-hospital mortality was 5.7%. Univariate and logistic regression analysis revealed younger age (p=0.01), lower body weight (p<0.04), a diagnosis of PA-IS with severe right ventricle hypoplasia (p=0.005), preoperative intubation (p=0.03), increased length of intubation (p<0.0001), longer ICU stay (p<0.0001), and group S (p=0.03) as risk factors for in-hospital death. Group S had a longer median ventilation time (112 vs 30 h, p<0.0001) despite the similar median age, weight, mean indexed shunt size (1.19 vs 1.15 mm/kg, p=0.2), and the number of patients with antegrade pulmonary flow. Interim mortality was 7% (n=15), and younger age (p=0.03), and group T (p=0.03) were independent risk factors for death prior to second-stage surgery. Absence of antiplatelet agents or anticoagulants was not a risk factor for interim mortality.
In-hospital mortality and longer ventilation time after SPS by sternotomy may be related to pulmonary over circulation due to shunt insertion origin and/or size, and pathologic features. Early and interim outcomes can be improved by using a smaller shunt or changing the SPS insertion origin when using a sternotomy approach.
确定与体肺分流术（SPS）患儿院内及中期死亡率相关的因素。
1988年1月至2005年4月期间，226例中位年龄17天、体重3.4 kg的患儿接受了孤立性SPS手术，用于治疗肺动脉闭锁（PA）-室间隔缺损（VSD）/法洛四联症（n = 124，54.9%）、功能性单心室PA（n = 35，5.5%）、PA-完整室间隔（IS，n = 31，13.7%）、大动脉转位VSD-PA（n = 30，13.3%）以及右心室双出口-PA（n = 6，2.6%）。手术通过胸骨切开术（S组，n = 46）或胸廓切开术（T组，n = 180）进行。S组中SPS的起源为无名动脉（n = 38）或升主动脉（n = 8），T组中为锁骨下动脉（n = 180）。
院内死亡率为5.7%。单因素和逻辑回归分析显示，年龄较小（p = 0.01）、体重较低（p < 0.04）、诊断为伴有严重右心室发育不全的PA-IS（p = 0.005）、术前插管（p = 0.03）、插管时间延长（p < 0.0001）、ICU停留时间延长（p < 0.0001）以及S组（p = 0.03）是院内死亡的危险因素。尽管中位年龄、体重、平均分流指数大小相似（1.19 vs 1.15 mm/kg，p = 0.2）以及顺行性肺血流患者数量相似，但S组的中位通气时间更长（112 vs 30小时，p < 0.0001）。中期死亡率为7%（n = 15），年龄较小（p = 0.03）和T组（p = 0.03）是二期手术前死亡的独立危险因素。未使用抗血小板药物或抗凝剂不是中期死亡的危险因素。
胸骨切开术后SPS的院内死亡率及更长的通气时间可能与分流插入起源和/或大小以及病理特征导致的肺过度循环有关。使用较小的分流或在采用胸骨切开术时改变SPS插入起源可改善早期和中期结局。
