Bando K, Turrentine M W, Sun K, Sharp T G, Ensing G J, Miller A P, Kesler K A, Binford R S, Carlos G N, Hurwitz R A
Section of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, USA.
J Thorac Cardiovasc Surg. 1995 Nov;110(5):1543-52; discussion 1552-4. doi: 10.1016/S0022-5223(95)70078-1.
Creation of a competent left atrioventricular valve is a cornerstone in surgical repair of complete atrioventricular septal defects. To identify risk factors for mortality and failure of left atrioventricular valve repair and to determine the impact of cleft closure on postoperative atrioventricular valve function, we retrospectively analyzed hospital records of 203 patients between January 1974 and January 1995. Overall early mortality was 7.9%. Operative mortality decreased significantly over the period of the study from 19% (4/21) before 1980 to 3% (2/67) after 1990 (p = 0.03). Ten-year survival including operative mortality was 91.3% +/- 0.004% (95% confidence limit): all survivors are in New York Heart Association class I or II. Preoperative atrioventricular valve regurgitation was assessed in 203 patients by angiography or echocardiography and was trivial or mild in 103 (52%), moderate in 82 (41%), and severe in 18 (8%). Left atrioventricular valve cleft was closed in 93% (189/203) but left alone when valve leaflet tissue was inadequate and closure of the cleft might cause significant stenosis. Reoperation for severe postoperative left atrioventricular valve regurgitation was necessary in eight patients, five of whom initially did not have closure of the cleft and three of whom had cleft closure. Six patients had reoperation with annuloplasty and two patients required left atrioventricular valve replacement. Five patients survived reoperation and are currently in New York Heart Association class I or II. On most recent evaluation assessed by angiography or echocardiography (a mean of 59 months after repair), left atrioventricular valve regurgitation was trivial or mild in 137 of the 146 survivors (94%) examined; none had moderate or severe left atrioventricular valve stenosis. By multiple logistic regression analysis, strong risk factors for early death and need for reoperation included postoperative pulmonary hypertensive crisis, immediate postoperative severe left atrioventricular valve regurgitation, and double-orifice left atrioventricular valve. These results indicate that complete atrioventricular septal defects can be repaired with low mortality and good intermediate to long-term results. Routine approximation of the cleft is safe and has a low incidence of reoperation for left atrioventricular valve regurgitation.
构建一个功能良好的左房室瓣是完全性房室间隔缺损外科修复的基石。为了确定左房室瓣修复术死亡和失败的风险因素，并确定裂隙闭合对术后房室瓣功能的影响，我们回顾性分析了1974年1月至1995年1月期间203例患者的医院记录。总体早期死亡率为7.9%。在研究期间，手术死亡率从1980年前的19%（4/21）显著下降至1990年后的3%（2/67）（p = 0.03）。包括手术死亡率在内的10年生存率为91.3%±0.004%（95%置信区间）：所有幸存者均为纽约心脏协会I级或II级。通过血管造影或超声心动图对203例患者术前的房室瓣反流情况进行了评估，其中103例（52%）为轻微或轻度反流，82例（41%）为中度反流，18例（8%）为重度反流。93%（189/203）的患者闭合了左房室瓣裂隙，但当瓣叶组织不足且裂隙闭合可能导致明显狭窄时则未进行闭合。8例患者因术后严重的左房室瓣反流需要再次手术，其中5例最初未闭合裂隙，3例进行了裂隙闭合。6例患者进行了瓣环成形术再次手术，2例患者需要置换左房室瓣。5例患者再次手术后存活，目前为纽约心脏协会I级或II级。在最近一次通过血管造影或超声心动图评估时（修复后平均59个月），146例接受检查的幸存者中有137例（94%）的左房室瓣反流为轻微或轻度；无一例有中度或重度左房室瓣狭窄。通过多因素logistic回归分析，早期死亡和再次手术的强烈风险因素包括术后肺动脉高压危象、术后即刻严重的左房室瓣反流以及双孔型左房室瓣。这些结果表明，完全性房室间隔缺损可以低死亡率进行修复，且中期至长期效果良好。常规闭合裂隙是安全的，因左房室瓣反流再次手术的发生率较低。
