Dorobantu Dan Mihai, Pandey Ragini, Sharabiani Mansour Taghavi, Mahani Alireza Shahidzadeh, Angelini Gianni Davide, Martin Robin Peter, Stoica Serban Constantin
Department of Cardiac Surgery, University Hospitals Bristol NHS Trust, Bristol, UK Department of Cardiology, 'Prof. C.C. Iliescu' Emergency Institute for Cardiovascular Diseases, Bucharest, Romania
Department of Cardiac Surgery, University Hospitals Bristol NHS Trust, Bristol, UK.
Eur J Cardiothorac Surg. 2016 Jun;49(6):1553-63. doi: 10.1093/ejcts/ezv435. Epub 2016 Jan 13.
The systemic-to-pulmonary shunt (SPS) remains an important palliative therapy in many congenital heart defects. Unlike other surgical treatments, the mortality after shunt operations has risen. We used an audit dataset to investigate potential reasons for this change and to report national results.
A total of 1993 patients classified in 13 diagnoses underwent an SPS procedure between 2000 and 2013. Indication trends by era and also results before repair or next stage are reported. A dynamic hazard model with competing risks and modulated renewal was used to determine predictors of outcomes.
The usage of SPS in Tetralogy of Fallot (ToF) has significantly decreased in the last decade, with cases of single ventricle (SV) and pulmonary atresia (PA) with septal communication increasing (P < 0.001 for trends). This is correlated with an increase of early mortality from 5.1% in the first half of the decade to 9.8% in the latter (P = 0.007 for trend). At 1.5 years, 13.9% of patients have died, 17.8% had a shunt reintervention and 68.3% of patients are alive and reintervention-free. Low weight, PA-intact septum, SV and central shunt type are among the factors associated with increased mortality, whereas PA-ventricular septal defect, corrected transposition, isomerism, central shunt and low weight are among those associated with increased reintervention, also having a dynamic effect on the relative risk when compared with ToF patients. Shunt reinterventions are not associated with worse outcomes when adjusted by other covariates, but they do have higher 30-day mortality if occurring earlier than 30 days from the index (P < 0.001). Patients operated in later years were found to have significantly lower survival at a distance from index.
The observed historical rise in mortality for shunt operations relates to complex factors including changing practice for repair of ToF and for univentricular palliation. PA and SV patients are the groups of patients at the highest risk of death. Small size, shunt type and underlying anatomical defect are the main determinants of outcomes. Trends in indication and mortality seem to indicate that more severely ill patients benefit from shunting, but with an increase in mortality.
体肺分流术（SPS）在许多先天性心脏病中仍然是一种重要的姑息治疗方法。与其他外科治疗不同，分流手术后的死亡率有所上升。我们使用一个审计数据集来调查这种变化的潜在原因并报告全国范围内的结果。
2000年至2013年间，共有1993例被归类为13种诊断的患者接受了SPS手术。报告了不同时期的适应症趋势以及修复前或下一阶段的结果。使用具有竞争风险和调制更新的动态风险模型来确定结果的预测因素。
在过去十年中，法洛四联症（ToF）中SPS的使用显著减少，单心室（SV）和伴有房间隔交通的肺动脉闭锁（PA）病例增加（趋势P<0.001）。这与早期死亡率从十年前半期的5.1%上升到后半期的9.8%相关（趋势P = 0.007）。在1.5岁时，13.9%的患者死亡，17.8%的患者进行了分流再干预，68.3%的患者存活且未进行再干预。低体重、PA完整隔、SV和中心分流类型是与死亡率增加相关的因素，而PA室间隔缺损、矫正性大动脉转位、异构、中心分流和低体重是与再干预增加相关的因素，与ToF患者相比，它们对相对风险也有动态影响。当通过其他协变量进行调整时，分流再干预与更差的结果无关，但如果在指数后30天内发生，则其30天死亡率更高（P<0.001）。发现后期手术的患者在离指数较远的时间点生存率显著较低。
观察到的分流手术死亡率的历史性上升与复杂因素有关，包括ToF修复和单心室姑息治疗实践的变化。PA和SV患者是死亡风险最高的患者群体。体型小、分流类型和潜在的解剖缺陷是结果的主要决定因素。适应症和死亡率趋势似乎表明，病情更严重的患者从分流中获益，但死亡率会增加。
