Sojak Vladimir, Kooij Marlotte, Yazdanbakhsh Aria, Koolbergen Dave R, Bruggemans Eline F, Hazekamp Mark G
Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands.
Eur J Cardiothorac Surg. 2016 Feb;49(2):538-44; discussion 544-5. doi: 10.1093/ejcts/ezv115. Epub 2015 Apr 7.
To evaluate our experience with patients reoperated after primary repair of atrioventricular septal defect (AVSD) and identify predictors of poor outcome.
Between 1976 and 2014, 69 patients were reoperated after primary repair of partial (n = 28), intermediate (n = 15) or complete (n = 26) AVSD.
Median age at first reoperation was 62.4 (range, 1.6-845) months, median interval to first reoperation was 22.3 (range, 0.2-598) months. Main indications for first reoperation included left atrioventricular valve (LAVV) pathology (66%), residual septal defect (19%) and left ventricle outflow tract obstruction (LVOTO; 4%). Procedures to address LAVV pathology included various valvuloplasties in 47 (77%) patients and valve replacement in 14 (23%) patients. A second, third, fourth and fifth reoperation was required in 27, 12, 4 and 1 patient, respectively. Most common procedures were LAVV replacement (LAVVR), LVOTO relief, pacemaker implantation and right atrioventricular valve procedure. Freedom from reoperation after LAVV valvuloplasty (LAVVP) was 84 and 62% at 1 and 10 years, respectively. There were 10 early and 4 late deaths. Estimated overall survival at 1, 5 and 10 years was 87, 83 and 83%, respectively. Double orifice LAVV (DOLAVV) was a risk factor for in-hospital and overall mortality [odds ratio (OR) = 14.5; 95% confidence interval (CI) = 1.2-178.7; P = 0.037 and hazard ratio (HR) = 6.8; 95% CI = 1.5-31.7; P = 0.015, respectively]. Patients with LAVVP and LAVVR differed significantly in overall survival (P = 0.014). At the last follow-up (median, 9.8; range, 0-34 years), 84% survivors were in New York Heart Association Class I or II.
Many patients reoperated after primary AVSD repair needed surgical reintervention. LAVV pathology was the most common indication for reoperation. DOLAVV was a risk factor for mortality. Particular AVSD type did not appear to be a risk factor for mortality or LAVVP failure. There is some evidence for the close relationship between LAVV pathology and LVOTO in subjects undergoing reoperation after primary AVSD repair as some patients with initial LAVV problems needed LVOTO repair later on and vice versa.
评估我们对房室间隔缺损（AVSD）一期修复术后再次手术患者的经验，并确定预后不良的预测因素。
1976年至2014年间，69例患者在部分型（n = 28）、中间型（n = 15）或完全型（n = 26）AVSD一期修复术后接受了再次手术。
首次再次手术的中位年龄为62.4（范围1.6 - 845）个月，首次再次手术的中位间隔时间为22.3（范围0.2 - 598）个月。首次再次手术的主要指征包括左房室瓣（LAVV）病变（66%）、残余间隔缺损（19%）和左心室流出道梗阻（LVOTO；4%）。处理LAVV病变的手术包括47例（77%）患者进行的各种瓣膜成形术和14例（23%）患者进行的瓣膜置换术。分别有27、12、4和1例患者需要进行第二次、第三次、第四次和第五次再次手术。最常见的手术是LAVV置换（LAVVR）、LVOTO解除、起搏器植入和右房室瓣手术。LAVV瓣膜成形术（LAVVP）后1年和10年的再次手术免发生率分别为84%和62%。有10例早期死亡和4例晚期死亡。1年、5年和10年的估计总生存率分别为87%、83%和83%。双孔LAVV（DOLAVV）是住院和总死亡率的危险因素[比值比（OR）= 14.5；95%置信区间（CI）= 1.2 - 178.7；P =
0.037，风险比（HR）= 6.8；95% CI = 1.5 - 31.7；P = 0.015]。接受LAVVP和LAVVR的患者在总生存率方面有显著差异（P = 0.014）。在最后一次随访时（中位时间9.8；范围0 - 34年），84%的幸存者为纽约心脏协会I或II级。
许多AVSD一期修复术后再次手术的患者需要手术再次干预。LAVV病变是再次手术最常见的指征。DOLAVV是死亡率的危险因素。特定的AVSD类型似乎不是死亡率或LAVVP失败的危险因素。有一些证据表明，在AVSD一期修复术后再次手术的患者中，LAVV病变与LVOTO之间存在密切关系，因为一些最初有LAVV问题的患者后来需要进行LVOTO修复，反之亦然。
