Division of Cardiovascular Surgery, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA.
Ann Thorac Surg. 2013 Apr;95(4):1383-9. doi: 10.1016/j.athoracsur.2012.12.009. Epub 2013 Feb 22.
Repeat operations are common in adult congenital heart disease (ACHD) and valve-related procedures are the most frequent indication for intervention. The purpose of this study is to review a single institution's experience with a large number of patients with ACHD undergoing reoperation requiring multivalve intervention.
Data from the most recent repeat median sternotomy of 254 consecutive ACHD patients with simultaneous intervention on 2 or more valves were analyzed. Mean age of 136 (54%) female and 118 (46%) male patients was 37.9 years (range, 18 to 83). Diagnoses were conotruncal anomaly 132 (52%), Ebstein-tricuspid valve 41(16%), pulmonary stenosis and right ventricular outflow tract obstruction 37 (14%), atrioventricular septal defect 22 (9%), and other 22 (9%). It was the second sternotomy in 130 (51%) patients, third in 80 (31%), fourth in 34 (13%), and fifth in 10 (4%).
Intervention was on 2 valves in 219 patients (86.2%), 3 in 34 patients (13.4%), and 4 in 1 patient (0.4%). The most common valve combination was tricuspid and pulmonary (117, 43%). Early mortality overall was 4.7% (12 of 254) and 2.9% (7 of 239) after elective operation. Potentially modifiable risk factors identified for early mortality were preoperative hematocrit less than 35 (p=0.01), cross-clamp time (p<0.001), and cardiopulmonary bypass time (p<0.001). Late survival was 96%, 89%, and 77% at 1, 5, and 10 years, respectively. Independent risk factors for late mortality were prolonged ventilation (p=0.002), coronary artery disease (p=0.005), and cardiac injury (p=0.018).
The need for simultaneous intervention on multiple valves is relatively common in ACHD, particularly with conotruncal anomalies. Prolonged bypass and cross-clamp times, lower hematocrit, and acquired coronary artery disease are significant predictors of adverse outcome. The number or position of valves requiring intervention did not affect early or late survival.
成人先天性心脏病（ACHD）常需再次手术，而瓣膜相关手术是最常见的干预指征。本研究旨在回顾单中心大量 ACHD 患者再次行正中开胸手术并同期行多瓣膜干预的经验。
分析最近对 254 例 ACHD 患者进行的第 2 次正中开胸手术，这些患者同时干预 2 个或更多瓣膜。136 例（54%）为女性，118 例（46%）为男性，平均年龄 37.9 岁（18-83 岁）。诊断为圆锥动脉干畸形 132 例（52%）、Ebstein 三尖瓣畸形 41 例（16%）、肺动脉瓣狭窄伴右心室流出道梗阻 37 例（14%）、房室间隔缺损 22 例（9%）和其他 22 例（9%）。130 例（51%）患者为第 2 次正中开胸手术，80 例（31%）为第 3 次，34 例（13%）为第 4 次，10 例（4%）为第 5 次。
219 例（86.2%）患者行 2 个瓣膜干预，34 例（13.4%）行 3 个瓣膜干预，1 例（0.4%）行 4 个瓣膜干预。最常见的瓣膜联合为三尖瓣和肺动脉瓣（117 例，43%）。总体早期死亡率为 4.7%（254 例中有 12 例），择期手术中为 2.9%（239 例中有 7 例）。早期死亡的潜在可修正危险因素为术前血球比容小于 35（p=0.01）、体外循环时间（p<0.001）和转流时间（p<0.001）。1 年、5 年和 10 年的晚期存活率分别为 96%、89%和 77%。晚期死亡的独立危险因素为机械通气时间延长（p=0.002）、冠状动脉疾病（p=0.005）和心脏损伤（p=0.018）。
ACHD 患者常需同期行多瓣膜干预，尤其是圆锥动脉干畸形患者。体外循环和转流时间延长、血球比容降低和获得性冠状动脉疾病是不良预后的显著预测因素。需要干预的瓣膜数量或位置不影响早期或晚期生存率。
