Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
Semin Thorac Cardiovasc Surg. 2019 Summer;31(2):253-263. doi: 10.1053/j.semtcvs.2018.10.014. Epub 2018 Nov 5.
We hypothesized that optimal pulmonary valve annulus (PVA) diameter upon annulus preservation (AP) in tetralogy of Fallot (ToF) may be far smaller than the normal diameter. Retrospective review of the 61 consecutive patients who underwent ToF repair between January 2016 and September 2017 was performed. Median age, body weight, and median PVA (Z) at repair were 166 days (interquartile range, IQR, 141-182 days), 7.4 kg (IQR, 6.6-8.0 kg), and -1.83 (IQR, -2.56 to -0.90), respectively. Upon AP, subvalvar and supravalvar obstructions were completely eliminated, leaving a pressure gradient only at the valve level. AP was achieved in 58 patients (95.1%). Pulmonary valve intervention comprised commissurotomy in 35 patients, commissurotomy with bougination in 8 patients, and transannular patching in 3 patients. For 15 patients, the pulmonary valve was left intact. Median PVA diameter measured by Hegar dilator after PV intervention was 8 mm (IQR, 7-9 mm), which was 3.9 mm (IQR, 2.3-4.3 mm) smaller than normal dimension and translated to a PVA (Z) of -1.85 (IQR, -2.40 to -0.78). Postrepair right and left ventricular pressure ratio was 0.47 ± 0.12. During the median follow-up duration of 353 days (IQR, 191-482 days), 4 patients (including 3 who underwent transannular patching) developed significant pulmonary regurgitation. Freedom from reintervention for PS, significant PS, and PR at 1 year was 92.4%, 83.2%, and 90.6%, respectively. Optimal PVA for AP may be far smaller than the normal diameter. Minimizing PV intervention upon AP can prevent superfluous postoperative PR.
我们假设在法洛四联症（ToF）的瓣环保存（AP）中，最佳肺动脉瓣环（PVA）直径可能远小于正常直径。回顾性分析了 2016 年 1 月至 2017 年 9 月期间连续接受 ToF 修复的 61 例患者。中位年龄、体重和修复时的中值 PVA（Z）分别为 166 天（四分位距，IQR，141-182 天）、7.4kg（IQR，6.6-8.0kg）和-1.83（IQR，-2.56 至-0.90）。在 AP 时，瓣下和瓣上梗阻完全消除，仅在瓣膜水平留有压力梯度。58 例患者（95.1%）实现了 AP。肺动脉瓣干预包括 35 例交界切开术、8 例交界切开加球囊扩张术和 3 例跨瓣环补片术。15 例患者保留了肺动脉瓣。PV 干预后 Hegar 扩张器测量的中值 PVA 直径为 8mm（IQR，7-9mm），比正常尺寸小 3.9mm（IQR，2.3-4.3mm），相当于 PVA（Z）为-1.85（IQR，-2.40 至-0.78）。修复后右心室和左心室压力比为 0.47±0.12。在中位随访 353 天（IQR，191-482 天）期间，4 例患者（包括 3 例接受跨瓣环补片术的患者）出现严重的肺动脉瓣反流。PS、严重 PS 和 PR 的 1 年无再干预率分别为 92.4%、83.2%和 90.6%。AP 的最佳 PVA 可能远小于正常直径。AP 时最小化 PV 干预可以预防术后过多的 PR。
