Dawoud Mohammed Ahmed, Abd Al Jawad Mohammed Nabil, Hikal Tamer, Samir Khaled
Department of Cardiothoracic Surgery, Al Ahrar Hospital, Zagazig, Egypt.
Department of Cardiothoracic Surgery, Ain Shams University, Cairo, Egypt.
Heart Surg Forum. 2018 Nov 13;21(6):E466-E471. doi: 10.1532/hsf.2075.
Tetralogy of Fallot is the most common cyanotic congenital heart defect. Borderline pulmonary anatomy has been associated with a higher risk of mortality and morbidity. Strategies to manage this condition-namely, single- or multistage repair-have long been debated.
The overall outcomes of patients with tetralogy of Fallot with borderline pulmonary arteries (McGoon ratio 1.3 to 1.7) with regard to the need for a single-stage or multistage repair and the outcome of each surgical management were evaluated.
A retrospective, nonrandomized comparative study designed to evaluate patient outcomes comprised 60 patients with tetralogy of Fallot with borderline pulmonary arteries who underwent surgery at the Cardiothoracic Surgery Academy, Ain Shams University, Cairo, Egypt, between January 2016 and December 2017. After gaining approval from the affiliated ethical and research committee, and informed consent of the guardians, the patients were assigned into one of two groups. Shunt group included 30 patients managed surgically by a modified Blalock-Taussig (MBT) shunt as a part of a multistage repair, and repair group included 30 patients managed surgically by single-stage complete repair. The medical records of the patients were reviewed, and data relating to age, sex, weight, and preoperative oxygen saturation were collected. All patients underwent preoperative echocardiography and multislice computed tomography (CT) with angiography. The follow-up was performed by echocardiography at discharge and at one month and six months after surgery. Multislice CT with angiography was performed in patients who received a shunt once the echocardiography showed acceptable pulmonary arteries.
The patients' age ranged from 5 to 50 months with a mean age of 18.63 ± 9.15 (19.84 ± 12.34 for the shunt group and 17.43 ± 8.54 for the repair group). The weight ranged from 5 kg to 18 kg with a mean of 9.6 ± 2.53 (8.82 ± 2.79 for the shunt group and 10.41 ± 2.63 for the repair group). The mean preoperative O2 saturation was 68.95% ± 7.8% for the shunt group and 87.93% ± 6.18% for the repair group. The median McGoon ratio was 1.4 for the shunt group and 1.6 for the repair group, the difference of which was highly significant (P < .0001). The mortality rate in our study was 10% (10% for the shunt group and 10% for the repair group). The morbidity incidence rate was 26.6% for the shunt and repair groups. The ICU stay ranged from 2 to 31 days, with a median of three days for the shunt group (mean 3.61 ± 1.91) and four days for the repair group (mean 6.07 ± 6.63 days). The calculated P value showed a significant difference between the two groups concerning ICU stay. The postoperative SO2 significantly increased to a mean of 85.58 ± 7.05 in the shunt group and 98.14 ± 3.36 in the repair group (P < .0001).
There was no statistically significant difference between multistage repair and single-stage complete repair regarding morbidity and mortality. Regarding ICU stay, patients in the single-stage had a better outcome. A McGoon ratio of 1.5 can be used as a guideline in the decision-making process.
法洛四联症是最常见的青紫型先天性心脏病。临界性肺血管解剖结构与更高的死亡和发病风险相关。长期以来，对于这种疾病的治疗策略，即单阶段或多阶段修复，一直存在争议。
评估法洛四联症合并临界性肺动脉（麦戈恩比率为1.3至1.7）患者进行单阶段或多阶段修复的必要性以及每种手术治疗的结果。
一项回顾性、非随机对照研究旨在评估患者结局，该研究纳入了60例法洛四联症合并临界性肺动脉的患者，他们于2016年1月至2017年12月在埃及开罗艾因夏姆斯大学心胸外科医学院接受手术。在获得附属伦理和研究委员会的批准以及监护人的知情同意后，将患者分为两组。分流组包括30例患者，作为多阶段修复的一部分，通过改良布莱洛克-陶西格（MBT）分流术进行手术治疗；修复组包括30例患者，通过单阶段完全修复进行手术治疗。回顾患者的病历，收集有关年龄、性别、体重和术前氧饱和度的数据。所有患者均接受术前超声心动图检查和多层螺旋计算机断层扫描（CT）血管造影。出院时、术后1个月和6个月通过超声心动图进行随访。对于接受分流术的患者，一旦超声心动图显示肺动脉可接受，则进行多层螺旋CT血管造影。
患者年龄范围为5至50个月，平均年龄为18.63±9.15岁（分流组为19.84±12.34岁，修复组为17.43±8.54岁）。体重范围为5千克至18千克，平均为9.6±2.53千克（分流组为8.82±2.79千克，修复组为|0.41±2.63千克）。分流组术前平均氧饱和度为68.95%±7.8%，修复组为87.93%±6.18%。分流组麦戈恩比率中位数为1.4，修复组为1.6，差异具有高度统计学意义（P<.0001）。本研究中的死亡率为10%（分流组为10%，修复组为10%）。分流组和修复组的发病率为26.6%。重症监护病房（ICU）住院时间为2至31天，分流组中位数为3天（平均3.61±1.91天），修复组为4天（平均6.07±6.63天）。计算出的P值显示两组在ICU住院时间方面存在显著差异。术后分流组氧饱和度显著升高至平均85.58±7.05，修复组为98.14±3.36（P<.0001）。
在发病率和死亡率方面，多阶段修复和单阶段完全修复之间无统计学显著差异。在ICU住院时间方面，单阶段修复的患者结局更好。麦戈恩比率为1.5可作为决策过程中的指导原则。
