Department of Cardiovascular Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany.
Department of Cardiovascular Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany.
J Thorac Cardiovasc Surg. 2018 Feb;155(2):701-709.e6. doi: 10.1016/j.jtcvs.2017.08.122. Epub 2017 Sep 15.
The study objective was to determine the mechanisms of atrioventricular valve regurgitation in single-ventricle physiology and their influence on outcomes after total cavopulmonary connection.
Among 460 patients who underwent a total cavopulmonary connection, 101 (22%) had atrioventricular valve surgery before or coincident with total cavopulmonary connection.
Atrioventricular valve morphology showed 2 separated in 33 patients, mitral in 11 patients, tricuspid in 41 patients, and common in 16 patients. Patients with a tricuspid and a common atrioventricular valve underwent atrioventricular valve surgery frequently, 27% and 36%, respectively. Atrioventricular valve regurgitation was due to 1 or more of the following mechanisms: dysplastic leaflet (62), prolapse (53), annular dilation (27), cleft (22), and chordal anomaly (14). Structural anomalies were observed in 89 patients (88%). The procedure was atrioventricular valve repair in 81 patients, atrioventricular valve closure in 16 patients, and atrioventricular valve replacement in 4 patients. Among 81 patients who underwent initial repair, repeat repair was required in 20 patients, atrioventricular valve replacement was required in 7 patients, and atrioventricular valve closure was required in 3 patients. Among patients undergoing atrioventricular valve surgery, overall survival after total cavopulmonary connection (88% vs 95% at 15 years, P = .01), freedom from atrioventricular valve reoperation after total cavopulmonary connection (75% vs 99% at 15 years, P < .01), and grade of atrioventricular valve regurgitation at a median follow-up of 6.6 years (P < .01) were worse than in those who did not require atrioventricular valve surgery.
Atrioventricular valve regurgitation in univentricular heart is more frequently associated with a tricuspid or a common atrioventricular valve, and structural anomalies are the primary cause. Significant atrioventricular valve regurgitation requiring surgery influences survival after total cavopulmonary connection, especially when atrioventricular valve replacement was needed. Surgical management based on mechanisms of regurgitation is mandatory.
本研究旨在确定单心室生理学中心房-心室瓣反流的机制及其对全腔肺动脉连接术后结局的影响。
在 460 例行全腔肺动脉连接术的患者中，101 例（22%）在全腔肺动脉连接术前或同期行房室瓣手术。
房室瓣形态为 33 例为 2 个瓣叶分离，11 例为二尖瓣，41 例为三尖瓣，16 例为共同瓣。三尖瓣和共同房室瓣的患者行房室瓣手术的比例分别为 27%和 36%。房室瓣反流的机制包括：瓣叶发育不良（62 例）、瓣叶脱垂（53 例）、瓣环扩张（27 例）、裂孔（22 例）和腱索异常（14 例）。89 例（88%）患者存在结构性异常。81 例行初始修复，16 例行房室瓣关闭，4 例行房室瓣置换。在 81 例行初始修复的患者中，20 例需再次修复，7 例需行房室瓣置换，3 例需行房室瓣关闭。行房室瓣手术的患者，全腔肺动脉连接术后总生存率（15 年时为 88%对 95%，P=0.01）、全腔肺动脉连接术后房室瓣再手术无失败率（15 年时为 75%对 99%，P<0.01）以及中位随访 6.6 年时的房室瓣反流程度（P<0.01）均差于未行房室瓣手术的患者。
单心室中心房-心室瓣反流更常与三尖瓣或共同房室瓣相关，结构性异常是主要原因。需要手术的严重房室瓣反流会影响全腔肺动脉连接术后的生存，尤其是需要行房室瓣置换时。基于反流机制的手术治疗是必需的。
