Section of Pediatric Cardiovascular Surgery, Arnold Palmer Hospital for Children, Orlando, Florida; Department of Surgery, University of Central Florida College of Medicine, Orlando, Florida.
Department of Surgery, University of Central Florida College of Medicine, Orlando, Florida.
Ann Thorac Surg. 2018 Sep;106(3):814-821. doi: 10.1016/j.athoracsur.2018.02.083. Epub 2018 Apr 4.
Different techniques have been used for exposure of ventricular septal defect (VSD) margins when there is crowding of the VSD anatomy by tricuspid valve subvalvar apparatus. This study compared surgical outcomes for the two techniques of tricuspid valve leaflet detachment and the rarely described tricuspid valve chordal detachment for hard-to-expose VSDs.
Patients undergoing transatrial VSD repair were identified from our institutional database. Follow-up echocardiography and patient data were obtained from medical records. Between January 2005 and August 2016, 130 isolated conoventricular VSDs were repaired. Among these, 26 patients underwent leaflet detachment, 15 underwent chordal detachment, and 89 underwent regular VSD repair (reference group).
The groups did not differ significantly in age, weight, postoperative length of stay, genetic/syndromic abnormalities, time to extubation, and left and right ventricular systolic function. The cardiopulmonary bypass and cross-clamp time were significantly longer in the leaflet detachment group than in the reference group (118 ± 28 vs 102 ± 32 minutes [p = 0.02] and 73 ± 20 vs 61 ± 23 minutes [p = 0.01], respectively). Echocardiographic follow-up was available for 87 patients at a mean of 2.6 years (range, 1 month to 11 years). Tricuspid regurgitation was rated as none or trivial in 66 (76%), mild in 20 (23%), and moderate in 1 reference group patient. There was no difference in presence of residual VSD or degree of tricuspid regurgitation among the three groups. There was no reoperation for tricuspid regurgitation.
Tricuspid valve leaflet and chordal detachment techniques provide an equally viable and safe alternative to closure of hard-to-expose VSDs while maintaining appropriate tricuspid valve function. Their use in our series did not lead to increased tricuspid valve dysfunction at early-to-midterm echocardiographic assessment.
当三尖瓣瓣下结构使室间隔缺损（VSD）边缘暴露困难时，已经使用了不同的技术来暴露 VSD 边缘。本研究比较了两种三尖瓣瓣叶游离术和很少描述的三尖瓣腱索游离术治疗难以暴露的 VSD 的手术结果。
从我们的机构数据库中确定了接受经房间隔 VSD 修复的患者。从病历中获得了随访超声心动图和患者数据。2005 年 1 月至 2016 年 8 月，共修复了 130 例单纯圆锥动脉干 VSD。其中，26 例行瓣叶游离术，15 例行腱索游离术，89 例行常规 VSD 修复（对照组）。
三组在年龄、体重、术后住院时间、遗传/综合征异常、拔管时间、左心室和右心室收缩功能方面无显著差异。瓣叶游离组体外循环和主动脉阻断时间明显长于对照组（118±28 比 102±32 分钟[P=0.02]和 73±20 比 61±23 分钟[P=0.01]）。87 例患者获得了平均 2.6 年（1 个月至 11 年）的超声心动图随访。66 例（76%）三尖瓣反流程度为无或轻度，20 例（23%）为中度，1 例对照组为中度。三组之间残余 VSD 存在与否和三尖瓣反流程度无差异。无三尖瓣反流再手术。
三尖瓣瓣叶和腱索游离术为难以暴露的 VSD 提供了一种同样可行和安全的替代方法，同时保持适当的三尖瓣功能。在我们的系列研究中，它们的使用在早期至中期超声心动图评估时并没有导致三尖瓣功能障碍的增加。
