Division of Cardiology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada.
J Thorac Cardiovasc Surg. 2011 Dec;142(6):1341-7.e4. doi: 10.1016/j.jtcvs.2010.11.065. Epub 2011 Jun 24.
Long-term functional outcomes after Norwood palliation are likely to depend on tricuspid valve performance in the systemic role. We therefore aimed to characterize features associated with tricuspid valve intervention.
All 219 children (1990-2007) who underwent Norwood stage 1 palliation resulting in a systemic right ventricle were investigated. In parametric competing risks analyses, primary end points included surgical tricuspid valve intervention (repair = 27, replacement = 3) and death (N = 105). All 2705 echocardiogram reports were included in time-related analyses of outcome adjusted for repeated measures. Variable selection used bootstrapping.
Approximately 25% of survivors underwent tricuspid valve repair at some point, especially in children with mitral atresia (P = .04, 53% reliability), longer myocardial ischemic time during Norwood (P = .02, 50%), and moderate/severe tricuspid regurgitation immediately post-Norwood (P = .006, 86%). Risk of tricuspid valve intervention was mainly early, but a late risk emerged 10 to 15 years after Norwood. Tricuspid valve intervention was successful in restoring functional natural history to that of the remainder of the cohort. Tricuspid valve intervention did not compromise survival (82% ± 2% 5 years after tricuspid valve intervention), and right ventricular function was not worse in patients requiring tricuspid valve intervention. Repeat tricuspid valve interventions were undertaken in 6 patients (3 repairs, 3 replacements). At latest follow-up, the degree of tricuspid valve regurgitation was not different between those who did and did not receive intervention.
Tricuspid valve surgery is common after single ventricle palliation for hypoplastic left heart syndrome, necessary in up to 25% of survivors. Mitral atresia and lengthy myocardial ischemic times during Norwood surgery are prominent risks. Right ventricular function was preserved by tricuspid repair. However, the emerging late hazard for tricuspid valve intervention may have implications for long-term outcome and should be explored further.
经诺伍德一期姑息治疗后，长期功能预后可能取决于三尖瓣在体循环中的功能。因此，我们旨在确定与三尖瓣干预相关的特征。
共纳入 219 例（1990-2007 年）接受诺伍德 1 期姑息治疗后右心室系统功能不全的患儿。在参数竞争风险分析中，主要终点包括三尖瓣手术干预（修复=27 例，置换=3 例）和死亡（N=105 例）。所有 2705 份超声心动图报告均纳入时间相关的结局分析中，并进行重复测量校正。采用自举法进行变量选择。
约 25%的幸存者在某一时间点进行了三尖瓣修复，尤其是在患有二尖瓣闭锁的患儿中（P=0.04，可靠性 53%）、在诺伍德手术期间心肌缺血时间较长（P=0.02，可靠性 50%）和即刻诺伍德手术后中/重度三尖瓣反流（P=0.006，可靠性 86%）。三尖瓣干预的风险主要为早期，但在诺伍德术后 10 至 15 年出现晚期风险。三尖瓣干预成功地恢复了功能，使其恢复到队列其余部分的自然史。三尖瓣干预并未影响生存（三尖瓣干预后 5 年存活率为 82%±2%），且需要进行三尖瓣干预的患者右心室功能无恶化。6 例患者（3 例修复，3 例置换）再次进行了三尖瓣干预。在最新的随访中，接受和未接受干预的患者之间的三尖瓣反流程度没有差异。
左心发育不全综合征单心室姑息治疗后，行三尖瓣手术较为常见，高达 25%的幸存者需要手术。二尖瓣闭锁和诺伍德手术期间较长的心肌缺血时间是突出的风险因素。三尖瓣修复可保留右心室功能。然而，三尖瓣干预的新出现晚期风险可能对长期结局产生影响，应进一步探讨。
