Warner K G, Anderson J E, Fulton D R, Payne D D, Geggel R L, Marx G R
Department of Cardiothoracic Surgery, New England Medical Center, Boston, MA 02111.
Circulation. 1993 Nov;88(5 Pt 2):II189-97.
Severe pulmonary regurgitation (PR) and associated right ventricular (RV) dilatation are late complications of surgical repair of tetralogy of Fallot (TOF). For the past several years, we have restored pulmonary valve competence with the exclusive use of cryopreserved allografts.
Sixteen patients with symptoms of diminished exercise tolerance and echocardiographic evidence of progressive PR with severe RV dilatation underwent placement of allografts in the RV outflow tract at a median age of 12 years (10 years after TOF repair). Abnormal exercise tolerance tests were documented in 10 patients. Additional surgical procedures included pulmonary artery augmentation (n = 6), closure of residual left to right shunts (n = 3), and subendocardial resection for monomorphic ventricular tachycardia (n = 1). Six patients had either preoperative or postoperative balloon dilations of pulmonary artery stenoses. All patients had symptomatic improvement after allograft insertion. At a mean follow-up of 26.4 +/- 3.4 months, the severity of PR improved in all but one patient. In 12 patients (group 1), conduit regurgitation was either trace (n = 11) or mild (n = 1). Four patients (group 2) had moderate conduit regurgitation. In a retrospective analysis, pulmonary artery diameters and cross-sectional areas were significantly smaller in the group 2 patients compared with the group 1 patients. With the exception of one patient, RV end-diastolic diameter (RVEDD/BSA) fell after allograft insertion in each patient (P < .01). The reduction in RVEDD/BSA was significantly greater in group 1 than in group 2 (31.8 +/- 3.4% versus 21.4 +/- 11.0%, P < .05).
Thus, restoration of the pulmonary valve with cryopreserved allografts improved exercise tolerance and diminished RV volume overload in patients with severe PR after previous repair of TOF. Optimal results were achieved in patients who did not have significant residual pulmonary artery distortion.
严重肺动脉反流（PR）及相关的右心室（RV）扩张是法洛四联症（TOF）手术修复后的晚期并发症。在过去几年中，我们仅使用冷冻保存的同种异体移植物来恢复肺动脉瓣功能。
16例运动耐量下降且经超声心动图证实存在进行性PR并伴有严重RV扩张的患者，在平均年龄12岁（TOF修复术后10年）时接受了同种异体移植物植入右心室流出道的手术。10例患者有异常运动耐量试验记录。其他手术操作包括肺动脉扩大术（n = 6）、关闭残余的左向右分流（n = 3）以及针对单形性室性心动过速的心内膜下切除术（n = 1）。6例患者术前或术后进行了肺动脉狭窄球囊扩张。所有患者在植入同种异体移植物后症状均有改善。平均随访26.4±3.4个月时，除1例患者外，所有患者的PR严重程度均有所改善。12例患者（第1组）的管道反流为微量（n = 11）或轻度（n = 1）。4例患者（第2组）有中度管道反流。在一项回顾性分析中，第2组患者的肺动脉直径和横截面积明显小于第1组患者。除1例患者外，每位患者植入同种异体移植物后右心室舒张末期直径（RVEDD/BSA）均下降（P <.01）。第1组患者RVEDD/BSA的下降幅度明显大于第2组（31.8±3.4%对21.4±11.0%，P <.05）。
因此，对于既往TOF修复术后严重PR的患者，使用冷冻保存的同种异体移植物恢复肺动脉瓣功能可改善运动耐量并减轻RV容量超负荷。在没有明显残余肺动脉扭曲的患者中可取得最佳效果。
