大动脉复杂转位的修复：避免流出道梗阻的最佳技术是什么？

Repair of complex transposition of great arteries: What is the best technique to avoid outflow tract obstructions?

作者信息

Weixler Viktoria, Gaal Julia, Murin Peter, Kramer Peter, Romanchenko Olga, Cho Mi-Young, Schmitt Katharina, Ovroutski Stanislav, Photiadis Joachim

机构信息

Department of Congenital Heart Surgery-Pediatric Heart Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany.

Charité-Universitätsmedizin Berlin, Berlin, Germany.

出版信息

Eur J Cardiothorac Surg. 2024 Mar 29;65(4). doi: 10.1093/ejcts/ezae094.

DOI:10.1093/ejcts/ezae094

PMID:38597905

Abstract

OBJECTIVES

This study aimed to evaluate the short-/mid-term outcome of patients with complex dextro (d)-/levo (l)-transposition of the great arteries (TGA), ventricular septal defect and left ventricular outflow tract obstructions.

METHODS

A single-centre, retrospective review of all complex dextro-TGA (n = 85) and levo-TGA (n = 22) patients undergoing different surgeries [Arterial switch operation + left ventricular outflow tract obstruction-resection (ASO-R), half-turned truncal switch/Mair (HTTS), Nikaidoh and Rastelli] between May 1990 and September 2022 was performed. Groups were analysed using Kruskal-Wallis test with post hoc pairwise comparison and Kaplan-Meier time-to-event models.

RESULTS

A total of 107 patients [ASO-R (n = 20), HTTS (n = 23), Nikaidoh (n = 21), Rastelli (n = 43)] were included, with a median age of 1.0 year (0.5-2.5) and surgical repair median follow-up was 3.8 years (0.3-10.5). Groups did not differ in respect to early postoperative complications/early mortality. Five-year overall survival curves were comparable: ASO-R 78.9% (53.2-91.5), HTTS 75.3% (46.8-89.9), Nikaidoh 85% (60.4-94.9) and Rastelli 83.9% (67.5-92.5), P = 0.9. Highest rates of right ventricular outflow tract (RVOT) reinterventions [33.3% and 32.6% (P = 0.04)] and reoperations [28.6% and 32.6% (P = 0.02)] occurred after Nikaidoh and Rastelli procedures. However, overall freedom from RVOT reinterventions and RVOT reoperations at 5 years did not differ statistically significantly between the groups (ASO-R, HTTS, Nikaidoh and Rastelli): 94.4% (66.6-99.2), 69.1% (25.4-90.5), 67.8% (34-86.9), 64.4% (44.6-78.7), P = 0.2, and 90.0% (65.6-97.4), 91% (50.8-98.7), 65.3% (32.0-85.3) and 67.0% (47.4-80.6), P = 0.3.

CONCLUSIONS

Surgical repair of complex dextro-/levo-TGA can be performed with satisfying early/mid-term survival. RVOT reinterventions/reoperations were frequent, with highest rates after Nikaidoh and Rastelli procedures. Left ventricular outflow tract obstruction reoperations were rare with zero events after Nikaidoh and HTTS procedures.

摘要

目的

本研究旨在评估患有复杂右（d）/左（l）大动脉转位（TGA）、室间隔缺损和左心室流出道梗阻患者的短期/中期结局。

方法

对1990年5月至2022年9月期间接受不同手术[动脉调转术+左心室流出道梗阻切除术（ASO-R）、半转位干下型室间隔缺损修补术/迈尔手术（HTTS）、尼凯多手术和拉斯泰利手术]的所有复杂右型TGA（n = 85）和左型TGA（n = 22）患者进行单中心回顾性研究。采用Kruskal-Wallis检验及事后两两比较和Kaplan-Meier事件发生时间模型对各组进行分析。

结果

共纳入107例患者[ASO-R（n = 20）、HTTS（n = 23）、尼凯多手术（n = 21）、拉斯泰利手术（n = 43）]，中位年龄为1.0岁（0.5 - 2.5岁），手术修复后的中位随访时间为3.8年（0.3 - 10.5年）。各组术后早期并发症/早期死亡率无差异。5年总生存曲线具有可比性：ASO-R为78.9%（53.2 - 91.5），HTTS为75.3%（46.8 - 89.9），尼凯多手术为85%（60.4 - 94.9），拉斯泰利手术为83.9%（67.5 - 92.5），P = 0.9。尼凯多手术和拉斯泰利手术后右心室流出道（RVOT）再次干预率[分别为33.3%和32.6%（P = 0.04）]和再次手术率[分别为28.6%和32.6%（P = 0.02）]最高。然而，各组在5年时RVOT再次干预和RVOT再次手术的总体自由度在统计学上无显著差异（ASO-R、HTTS、尼凯多手术和拉斯泰利手术）：分别为94.4%（66.6 - 99.2）、69.1%（25.4 - 90.5）、67.8%（34 - 86.9）、64.4%（44.6 - 78.7），P = 0.2，以及90.0%（65.6 - 97.4）、91%（50.8 - 98.7）、65.3%（32.0 - 85.3）和67.0%（47.4 - 80.6），P = 0.3。