Zhu Zhong-qun, Liu Jin-fen, Zheng Jing-hao, Zhang Hai-bo, Xu Zhi-wei
Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Medical College of Shanghai Jiaotong University, Shanghai 200127, China.
Zhonghua Yi Xue Za Zhi. 2010 Apr 6;90(13):898-901.
To determine the choice of palliative procedures, timing and techniques of second-stage operations.
Between April 2004 to July 2008, 50 consecutive patients with pulmonary atresia with ventricular septal defect (PA/VSD) underwent two-stage operation. Palliative procedures included modified Blalock-Taussig shunt (n = 5), central shunt (n = 2), pericardial patch enlargement (n = 10), pericardial tube (n = 4) and Gore-Tex conduit (n = 29). The interval period was 7 - 49 months (20.0 +/- 10.0 months). In the second stage, a surgical shunt was interrupted in 7 cases. Ventricular septal defect was closed in all patients, but fenestrated ventricular septal defect patch was used in 6 cases. Right ventricular outlet tract (RVOT) was widened with pericardial patch in 42 cases and conduit exchange in 8 cases. Aortopulmonary collateral arteries (MAPCASs) unifocalization (n = 1), ligation or transcatheter occlusion with embolization coils (n = 4) and maintaining open or untreated (n = 4).
Death occurred in 2 and the mortality rate was 4%. Postoperative complications included residual shunt (n = 3), residual obstruction (n = 3), complete AV block (n = 1), athetosis (n = 1) and acute renal failure (n = 3). Neither death nor complication was reported during a follow-up period of 3 months to 4 years.
A palliative procedure should be individualized to the patient's morphology of central pulmonary artery and clinical status of a patient. Right ventricular outlet tract reconstruction, pulmonary arterioplasty, fenestration of VSD patch in baby with suprasystemic right ventricular pressure and appropriate interventions with MAPCASs are key to decrease the mortality and morbidity of staged operations for PA/VSD.
确定姑息手术的选择、二期手术的时机和技术。
2004年4月至2008年7月，50例连续性肺动脉闭锁合并室间隔缺损（PA/VSD）患者接受了二期手术。姑息手术包括改良布莱洛克-陶西格分流术（n = 5）、中心分流术（n = 2）、心包补片扩大术（n = 10）、心包管（n = 4）和戈尔特斯管道（n = 29）。间隔期为7至49个月（20.0±10.0个月）。在二期手术中，7例患者的外科分流被中断。所有患者的室间隔缺损均被闭合，但6例患者使用了带孔室间隔缺损补片。42例患者用心包补片扩大右心室流出道（RVOT），8例患者进行管道置换。对主肺动脉侧支动脉（MAPCASs）进行了单源化（n = 1）、结扎或用栓塞线圈经导管封堵（n = 4）以及保持开放或未处理（n = 4）。
2例患者死亡，死亡率为4%。术后并发症包括残余分流（n = 3）、残余梗阻（n = 3）、完全性房室传导阻滞（n = 1）、手足徐动症（n = 1）和急性肾衰竭（n = 3）。在3个月至4年的随访期内，未报告死亡或并发症。
姑息手术应根据患者的中心肺动脉形态和临床状况进行个体化选择。右心室流出道重建、肺动脉成形术、对右心室压力超过体循环压力的婴儿使用带孔VSD补片以及对MAPCASs进行适当干预是降低PA/VSD分期手术死亡率和发病率的关键。
