Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Cardiovascular Surgery, West China Hospital of Sichuan University, Chengdu, China.
Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Department of Diagnostic Imaging, The Hosptial for Sick Children, University of Toronto, Toronto, Ontario, Canada.
Ann Thorac Surg. 2019 Mar;107(3):844-851. doi: 10.1016/j.athoracsur.2018.08.090. Epub 2018 Oct 23.
We hypothesized that reconstructed pulmonary artery (PA) size and postrepair PA pressure are associated with airway compression (AC) after complete unifocalization for pulmonary atresia, ventricular septal defects, and major aortopulmonary collateral arteries.
Complete unifocalization was performed in 48 consecutive patients between 2000 and 2016. Clinical course and outcome were reviewed, predictors for AC were identified by logistic regression, and the freedom from death was analyzed using Kaplan-Meier method.
Postoperative respiratory distress occurred in 23 patients (48%), and AC occurred in 14 (29%). The median duration of follow-up was 3.7 years. AC was caused by central PA and aorta in 7, conduit in 3, and branch PA in 4. Surgical treatment was required in 5 patients (conduit downsizing, suspension of branch PA, conduit + aorta, branch PA + aorta, and aorta + trachea in 1 patient each). Three patients (21%) subsequently required airway stenting. Most (85.7%) of the AC occurred in patients with high right ventricular systolic pressure/left ventricular systolic pressure (>65%), large Nakata index (>200 mm/m), and large conduit index (>35 mm/m). Patients with AC had significantly worse 3-year survival (no AC, 91.2%; AC, 64.2%; p = 0.01). Multivariate analysis identified higher right ventricular systolic pressure/left ventricular systolic pressure (p = 0.04), larger conduit index (p = 0.03), and Nakata index (p = 0.004) as predictors for AC.
AC is a common cause of postoperative respiratory distress and tends to be associated with higher postrepair PA pressure, more frequent right ventricular dysfunction, and worse medium-term survival. The study underscores the importance of incorporating all available lung segments to achieve a low PA pressure, potentially preventing pathologic dilatation of the reconstructed PA. Management of patients with poor major aortopulmonary collateral arteries anatomy and physiology remains a challenge.
我们假设，在完全单腔化治疗肺动脉闭锁、室间隔缺损和主-肺动脉侧支血管后，重建肺动脉（PA）大小和修复后 PA 压力与气道压迫（AC）有关。
2000 年至 2016 年，连续 48 例患者接受了完全单腔化治疗。回顾临床过程和结果，通过逻辑回归识别 AC 的预测因素，并采用 Kaplan-Meier 法分析无死亡的生存率。
术后呼吸窘迫发生在 23 例患者（48%）中，AC 发生在 14 例患者（29%）中。中位随访时间为 3.7 年。AC 由中央 PA 和主动脉引起 7 例，由导管引起 3 例，由分支 PA 引起 4 例。5 例患者需要手术治疗（导管缩小、分支 PA 悬吊、导管+主动脉、分支 PA+主动脉和主动脉+气管各 1 例）。3 例患者（21%）随后需要气道支架置入。大多数（85.7%）AC 发生于右心室收缩压/左心室收缩压较高（>65%）、Nakata 指数较大（>200 mm/m）和导管指数较大（>35 mm/m）的患者中。有 AC 的患者 3 年生存率明显较差（无 AC 为 91.2%，AC 为 64.2%，p=0.01）。多变量分析显示，较高的右心室收缩压/左心室收缩压（p=0.04）、较大的导管指数（p=0.03）和较大的 Nakata 指数（p=0.004）是 AC 的预测因素。
AC 是术后呼吸窘迫的常见原因，往往与修复后 PA 压力较高、右心室功能障碍更频繁和中期生存率较差有关。该研究强调了将所有可用的肺段纳入其中以实现低 PA 压力的重要性，这可能防止重建 PA 的病理性扩张。对于主-肺动脉侧支血管解剖和生理学较差的患者的管理仍然是一个挑战。
