Saygi Murat, Ergul Yakup, Tola Hasan Tahsin, Ozyilmaz Isa, Ozturk Erkut, Onan Ismihan Selen, Haydin Sertac, Erek Ersin, Yeniterzi Mehmet, Guzeltas Alper, Odemis Ender, Bakir Ihsan
Department of Pediatric Cardiology, Mehmet Akif Ersoy Cardiovascular Research and Training Hospital, Istanbul, Turkey.
Department of Pediatric Cardiovascular Surgery, Mehmet Akif Ersoy Cardiovascular Research and Training Hospital, Istanbul, Turkey.
Pediatr Int. 2015 Oct;57(5):832-9. doi: 10.1111/ped.12627. Epub 2015 May 29.
We evaluated the preoperative, operative and postoperative risk factors affecting early mortality in patients who underwent total correction of tetralogy of Fallot (TOF).
One hundred and twenty-two TOF patients who underwent reparative surgery between January 2010 and November 2013 were enrolled in the study.
Mean patient age and weight was 2.3 ± 2.5 years and 11.3 ± 6.4 kg, respectively. Cardiac catheterization was performed in 101 patients (83%),and coronary anomalies were found in 11 patients. Mean McGoon index, pulmonary annulus z-score, main pulmonary artery z-score, left pulmonary artery z-score and right pulmonary artery z-score were 2.0 ± 0.4, -1.85 ± 1.54, -2.84 ± 2.06, 1.17 ± 1.73, and 0.74 ± 1.57, respectively. Total reparative surgery with a transannular patch was performed in 97 patients (79.6%); the rest underwent valve-sparing surgery. Median duration of postoperative mechanical ventilation, intensive care and hospital stay were 19 h, 3 days and 9 days, respectively. Extracorporeal membrane oxygenation (ECMO) was required in 10 patients in the postoperative early period. Arrhythmias occurring in the early postoperative period were junctional ectopic tachycardia (n = 13), complete atrioventricular block(n = 10; permanent epicardial pacemaker implanted in four) and ventricular tachycardia (n = 4). Nine patients died in the early postoperative period (7.3%). Parameters found to be associated with increased mortality were low preoperative oxygen saturation; high right ventricular/aortic pressure ratio immediately after surgery; presence of coronary anomaly; requirement of postoperative ECMO; and pacemaker (P = 0.02, P = 0.04, P = 0.01, P = 0.0001, P = 0.03, respectively).
Poor preoperative oxygenation, presence of coronary anomaly, complete AV block in the early postoperative period, high RV pressure and requirement of ECMO appear to be the most significant factors that affect early mortality in the surgical treatment of TOF. Appropriate preoperative assessment, correct surgical strategies and attentive intensive care monitoring are required in order to reduce mortality.
我们评估了影响法洛四联症（TOF）患者接受根治性手术后早期死亡率的术前、术中和术后危险因素。
纳入2010年1月至2013年11月期间接受修复手术的122例TOF患者。
患者的平均年龄和体重分别为2.3±2.5岁和11.3±6.4千克。101例患者（83%）接受了心导管检查，其中11例发现冠状动脉异常。平均麦戈恩指数、肺动脉环Z值、主肺动脉Z值、左肺动脉Z值和右肺动脉Z值分别为2.0±0.4、-1.85±1.54、-2.84±2.06、1.17±1.73和0.74±1.57。97例患者（79.6%）接受了带跨环补片的根治性手术；其余患者接受了保留瓣膜手术。术后机械通气、重症监护和住院时间的中位数分别为19小时、3天和9天。10例患者术后早期需要体外膜肺氧合（ECMO）。术后早期发生的心律失常包括交界性异位性心动过速（n = 13）、完全性房室传导阻滞（n = 10；4例植入永久性心外膜起搏器）和室性心动过速（n = 4）。9例患者术后早期死亡（7.3%）。发现与死亡率增加相关的参数包括术前氧饱和度低；术后即刻右心室/主动脉压比值高；存在冠状动脉异常；术后需要ECMO；以及起搏器（P值分别为0.02、0.04、0.01、0.0001、0.03）。
术前氧合差、存在冠状动脉异常、术后早期出现完全性房室传导阻滞、右心室压力高以及需要ECMO似乎是影响TOF手术治疗早期死亡率的最重要因素。为降低死亡率，需要进行适当的术前评估、正确的手术策略和精心的重症监护监测。
