Yoshimura Naoki, Fukahara Kazuaki, Yamashita Akio, Doi Toshio, Takeuchi Katsunori, Yamashita Shigeyuki, Homma Takahiro, Yokoyama Shigeki, Aoki Masaya, Ikeno Yuki
Department of Cardiothoracic Surgery, University of Toyama, Graduate School of Medicine, 2630 Sugitani, Toyama, 930-0194, Toyama, Japan.
Gen Thorac Cardiovasc Surg. 2017 May;65(5):245-251. doi: 10.1007/s11748-017-0769-x. Epub 2017 Mar 22.
Despite recent advances in surgical technique and perioperative care, the surgical correction of total anomalous pulmonary venous connection (TAPVC) remains a challenge. The major complication and the main cause of reoperation in TAPVC surgery are the occurrence of pulmonary venous obstruction (PVO). In the 1990s, sutureless repair was introduced as a technique to relieve PVO after TAPVC repair. Following the favorable outcomes for postoperative PVO, the indications for sutureless repair as a primary operation have been expanded to include infants who have preoperative PVO or those at risk of developing PVO after the repair of TAPVC. However, the indications of "prophylactic" primary sutureless repair still remain controversial. Recent studies have shown that normal-risk patients have excellent early and long-term outcomes and a low incidence of reoperation for postoperative PVO. Most patients who survived beyond 2 years after TAPVC surgery were in NYHA class I and offered good outcomes. Although favorable early and mid-term outcomes of primary sutureless repair are reported, the long-term outcomes of this technique are still unclear. The influence of non-contractile pericardial tissue interposed between the PV vessel wall and LA myocardium on the atrial function is also unclear in patients who undergo sutureless repair. Another disadvantage of primary sutureless repair is potential bleeding from the gap between the confluence and pericardium into the posterior mediastinum or pleural cavity. Thus, it might be best for primary sutureless repair to be indicated for high-risk infants, such as those with TAPVC associated with single-ventricular physiology, mixed-type TAPVC, or small PV confluence.
尽管近年来手术技术和围手术期护理取得了进展，但完全性肺静脉异位连接（TAPVC）的手术矫正仍然是一项挑战。TAPVC手术的主要并发症和再次手术的主要原因是肺静脉梗阻（PVO）的发生。在20世纪90年代，无缝合修复作为一种缓解TAPVC修复术后PVO的技术被引入。鉴于术后PVO的良好结果，无缝合修复作为初次手术的适应症已扩大到包括术前有PVO的婴儿或TAPVC修复后有发生PVO风险的婴儿。然而，“预防性”初次无缝合修复的适应症仍存在争议。最近的研究表明，低风险患者具有良好的早期和长期结果，术后PVO再次手术的发生率较低。大多数TAPVC手术后存活超过2年的患者心功能分级为纽约心脏协会（NYHA）I级，预后良好。虽然有报道称初次无缝合修复有良好的早期和中期结果，但该技术的长期结果仍不清楚。在接受无缝合修复的患者中，PV血管壁和左房心肌之间插入的无收缩性心包组织对心房功能的影响也不清楚。初次无缝合修复的另一个缺点是汇合处与心包之间的间隙可能出血进入后纵隔或胸腔。因此，初次无缝合修复可能最适合高危婴儿，如那些合并单心室生理、混合型TAPVC或PV汇合较小的TAPVC婴儿。
