Bando K, Turrentine M W, Ensing G J, Sun K, Sharp T G, Sekine Y, Girod D A, Brown J W
Section of Cardiothoracic Surgery, James W. Riley Hospital for Children, Indianapolis, IN, USA.
Circulation. 1996 Nov 1;94(9 Suppl):II12-6.
Reports of surgical correction of total anomalous pulmonary venous connection (TAPVC) over the past 30 years indicate a general improvement in operative survival. However, prevention of late pulmonary venous obstruction continues to be a cornerstone of successful repair. The purpose of the study was to identify factors associated with improvement in perioperative mortality and to determine risk factors for death and reoperation due to pulmonary vein stenosis after repair of TAPVC.
Using univariate and multiple regression analysis, we analyzed risk of early and late mortality and need for reoperation in 105 patients operated on between April 1966 and June 1995. Despite increased frequency of neonatal repair in the most recent time period (29% in 1966 through 1985; 55% in 1991 through 1995, P < .05), operative mortality declined (13% in 1966 through 1985; 0% in 1991 through 1995). The incidence of postoperative pulmonary hypertensive episodes and death related to pulmonary hypertension decreased significantly over the study period (P < .001). Aggressive preoperative elective medical stabilization and prophylaxis of postoperative pulmonary hypertensive episodes may have contributed to this improvement. By univariate analysis, preoperative pulmonary hypertension (P < .02) and preoperative pulmonary vein obstruction (P < .01) correlated with early mortality up to 1990 but not in the past 5 years. Multiple logistic regression analysis showed that only a small pulmonary confluence associated with diffuse pulmonary vein stenosis was an independent risk factor for early (P < .001) and late (P = .01) death as well as need for reoperation (P = .007). Type of TAPVC was not a significant risk factor throughout the three decades of our experience. At a median follow-up of 87 months, late survival was 98% (93 of 95 operative survivors), and all are NYHA class I.
Improvements on surgical technique as well as preoperative and postoperative management account for the reduction in mortality and need for reoperation for most types of TAPVC. However, the presence of a small venous confluence and diffuse pulmonary vein stenosis remains a risk factor for adverse outcome.
过去30年中关于完全性肺静脉异位连接（TAPVC）手术矫正的报告表明手术生存率总体有所提高。然而，预防晚期肺静脉梗阻仍然是成功修复的基石。本研究的目的是确定与围手术期死亡率改善相关的因素，并确定TAPVC修复术后因肺静脉狭窄导致死亡和再次手术的危险因素。
我们采用单因素和多因素回归分析，对1966年4月至1995年6月期间接受手术的105例患者的早期和晚期死亡风险以及再次手术需求进行了分析。尽管最近一段时间新生儿修复的频率有所增加（1966年至1985年为29%；1991年至1995年为55%，P <.05），但手术死亡率有所下降（1966年至1985年为13%；1991年至1995年为0%）。在研究期间，术后肺动脉高压发作及与肺动脉高压相关的死亡发生率显著下降（P <.001）。积极的术前选择性药物稳定治疗和术后肺动脉高压发作的预防可能促成了这一改善。通过单因素分析，术前肺动脉高压（P <.02）和术前肺静脉梗阻（P <.01）在1990年前与早期死亡率相关，但在过去5年中并非如此。多因素逻辑回归分析显示，仅与弥漫性肺静脉狭窄相关的小肺静脉汇合是早期（P <.001）和晚期（P =.01）死亡以及再次手术需求（P =.007）的独立危险因素。在我们30年的经验中，TAPVC的类型并非显著危险因素。中位随访87个月时，晚期生存率为98%（95例手术幸存者中的93例）；所有患者均为纽约心脏协会（NYHA）I级。
手术技术以及术前和术后管理的改进导致大多数类型TAPVC的死亡率和再次手术需求降低。然而，小静脉汇合和弥漫性肺静脉狭窄的存在仍然是不良结局的危险因素。
