Department of Cardiology, Children's Hospital Boston, Boston, Mass.
Department of Cardiology, Children's Hospital Boston, Boston, Mass.
J Thorac Cardiovasc Surg. 2023 Oct;166(4):1168-1177. doi: 10.1016/j.jtcvs.2023.04.004. Epub 2023 May 7.
Acute outcomes after atrioventricular canal defects (AVCD) surgery in the current era are excellent; yet despite surgical advances, ∼15% of patients require future left atrioventricular valve (LAVV) repair. Among patients with AVC who undergo LAVV repair after primary AVC surgery, we sought to characterize the durability of these repairs. Specifically, we aimed to determine predictors for reintervention following an LAVV repair in patients with repaired AVCD, with a focus on postoperative transesophageal echocardiography (TEE).
We reviewed all patients undergoing LAVV repair (after a primary AVCD surgery) at Boston Children's Hospital between 2010 and 2020. Competing risk analysis was performed to evaluate cumulative incidence of LAVV reinterventions. Predictors of LAVV reintervention were evaluated using multivariable Cox regression.
A total of 137 LAVV repairs following primary AVCD surgery were performed in 113 patients. Median age and weight at LAVV repair were 25 months (interquartile range, 12-76 months) and 11.1 kg (interquartile range, 7.8-19.4 kg). Original anatomy was complete AVCD in 87 (63%), transitional AVCD in 27 (20%), and partial AVCD in 23 (17%) cases. Over a median follow-up of 12 months (interquartile range, 1.3 months-4 years), 47 (34%) of the LAVV repairs required LAVV reintervention. Reinterventions included a total of 27 LAVV re-repairs and 20 LAVV replacements. In multivariable analysis, age at LAVV repair younger than 72 months, partial AVCD anatomy, left ventricle dysfunction, mean LAVV stenosis gradient ≥5 mm Hg, and multiple jets of regurgitation on postoperative LAVV repair TEE were associated with LAVV reintervention. Grade of LAVV regurgitation on postoperative TEE was not an independent risk factor, but reintervention rates were high when residual LAVV stenosis gradient was ≥5 mm Hg and residual mild LAVV regurgitation was present on postoperative TEE (47%) and even higher when residual LAVV stenosis gradient was ≥5 mm Hg and LAVV regurgitation was greater than mild (73%).
Reintervention rates remain high for LAVV repairs that occur after primary AVCD surgery, particularly for patients with LAVV stenosis gradient ≥5 mm Hg and mild or greater LAVV regurgitation on postoperative TEE.
房室管缺损（AVCD）患者在当前时代接受手术后的急性结局极佳；然而，尽管手术取得了进展，但仍有约 15%的患者需要未来进行左房室瓣（LAVV）修复。在接受过初次 AVCD 手术的接受 LAVV 修复的患者中，我们旨在评估这些修复的耐久性。具体而言，我们旨在确定接受过修复的 AVCD 患者的 LAVV 修复后再次干预的预测因素，重点是术后经食管超声心动图（TEE）。
我们回顾了 2010 年至 2020 年期间在波士顿儿童医院接受 LAVV 修复（在初次 AVCD 手术后）的所有患者。采用竞争风险分析评估 LAVV 修复后 LAVV 再干预的累积发生率。使用多变量 Cox 回归评估 LAVV 再干预的预测因素。
共有 113 例患者在初次 AVCD 手术后进行了 137 次 LAVV 修复。LAVV 修复时的中位年龄和体重分别为 25 个月（四分位距，12-76 个月）和 11.1 千克（四分位距，7.8-19.4 千克）。原始解剖结构为完全性 AVCD 占 87（63%），过渡性 AVCD 占 27（20%），部分性 AVCD 占 23（17%）。在中位随访 12 个月（四分位距，1.3 个月-4 年）期间，47（34%）例 LAVV 修复需要进行 LAVV 再干预。再干预包括总共 27 次 LAVV 再修复和 20 次 LAVV 置换。多变量分析显示，LAVV 修复时年龄小于 72 个月、部分性 AVCD 解剖结构、左心室功能障碍、平均 LAVV 狭窄梯度≥5mmHg 和术后 LAVV 修复 TEE 上多个反流射流与 LAVV 再干预相关。术后 TEE 上的 LAVV 反流分级不是独立的危险因素，但当术后 TEE 上残留 LAVV 狭窄梯度≥5mmHg 和残留轻度 LAVV 反流（47%）时，再干预率较高，当术后 TEE 上残留 LAVV 狭窄梯度≥5mmHg 和 LAVV 反流大于轻度时（73%），再干预率更高。
初次 AVCD 手术后的 LAVV 修复后，再干预率仍然很高，特别是对于术后 TEE 上 LAVV 狭窄梯度≥5mmHg 和轻度或更严重的 LAVV 反流的患者。
