Tefera Endale, Qureshi Shakeel A, Bermudez-Cañete Ramón, Rubio Lola
Department of Pediatrics and Child Health, Cardiology Division, School of Medicine, Addis Ababa University and Cardiac Center, Addis Ababa, Ethiopia.
Catheter Cardiovasc Interv. 2014 Aug 1;84(2):E7-15. doi: 10.1002/ccd.25324. Epub 2014 Jan 7.
This article reports outcomes of percutaneous balloon dilation in patients with severe pulmonary valve stenosis, in particular in those treated late with cyanosis, congestive heart failure, and pericardial effusion.
Percutaneous balloon dilation is the treatment of choice for pulmonary valve stenosis. Although earlier intervention may produce better results, patients may present late with congestive heart failure and cyanosis.
Fifty-five patients who underwent pulmonary valve balloon dilation, were grouped into two groups, based on the presence or absence of congestive right heart failure and/or central cyanosis. Group I included 33 patients with severe pulmonary valve stenosis, but without clinical evidence of congestive right heart failure in the form of liver enlargement, raised jugular venous pressure, and peripheral edema and/or central cyanosis and group II included 22 patients with severe pulmonary valve stenosis and congestive right heart failure and/or central cyanosis. Their outcomes were compared.
Doppler measured transvalvar pressure gradient decreased from 110.2 ± 34.0 mm Hg before to 52.5 ± 28.7 mm Hg in group I after dilation (P < 0.001), and from 138.4 ± 32.3 mm Hg to 53.9 ± 19.3 mm Hg in group II, (P < 0.001). Complications included ventricular tachycardia/fibrillation in three patients and severe bradycardia in one patient in group II. Twelve patients in group II developed clinical and radiologic evidence of reperfusion injury/pulmonary edema within the first 24 hr of intervention and needed ventilation for 2-9 days. Three of these patients died from intractable pulmonary edema. On follow up, clinical and echocardiographic improvement parameters were similar in the two groups.
Those patients with severe pulmonary valve stenosis with congestive right heart failure, especially those with pericardial effusion, ascites and cyanosis, represent an important technical and clinical challenge. They are a high-risk group with or without treatment. If they survive the procedure, they may still remain at a high risk in the first few days afterward. Maintaining their ventilator and inotropic support after balloon dilation may increase survival. However, excellent results can be obtained.
本文报告重度肺动脉瓣狭窄患者经皮球囊扩张术的治疗结果，尤其是那些出现发绀、充血性心力衰竭和心包积液后才接受治疗的患者。
经皮球囊扩张术是肺动脉瓣狭窄的首选治疗方法。尽管早期干预可能会产生更好的效果，但患者可能在出现充血性心力衰竭和发绀后才前来就诊。
55例行肺动脉瓣球囊扩张术的患者，根据是否存在充血性右心衰竭和/或中心性发绀分为两组。第一组包括33例重度肺动脉瓣狭窄患者，但无肝肿大、颈静脉压升高、外周水肿等充血性右心衰竭的临床证据和/或中心性发绀；第二组包括22例重度肺动脉瓣狭窄合并充血性右心衰竭和/或中心性发绀的患者。比较两组的治疗结果。
第一组患者经扩张后，多普勒测量的跨瓣压差从术前的110.2±34.0 mmHg降至术后的52.5±28.7 mmHg（P<0.001）；第二组从138.4±32.3 mmHg降至53.9±19.3 mmHg（P<0.001）。并发症包括第二组3例患者发生室性心动过速/心室颤动，1例患者发生严重心动过缓。第二组12例患者在干预后的头24小时内出现再灌注损伤/肺水肿的临床和影像学证据，需要通气2-9天。其中3例患者死于顽固性肺水肿。随访时，两组的临床和超声心动图改善参数相似。
那些重度肺动脉瓣狭窄合并充血性右心衰竭的患者，尤其是伴有心包积液、腹水和发绀的患者，是一项重要的技术和临床挑战。无论是否接受治疗，他们都是高危人群。如果他们在手术中存活下来，术后最初几天仍可能处于高风险状态。球囊扩张术后维持呼吸机和正性肌力支持可能会提高生存率。然而，可以获得良好的治疗效果。
