Atallah-Yunes N H, Kavey R E, Bove E L, Smith F C, Kveselis D A, Byrum C J, Gaum W E
Division of Pediatric Cardiology and Cardio-Thoracic Surgery, State University of New York Health Science Center at Syracuse 13210, USA.
Circulation. 1996 Nov 1;94(9 Suppl):II22-6.
After repair of tetralogy of Fallot, right ventricular (RV) dilation has been associated with increased risk of ventricular arrhythmias and sudden death. To address this, a modified repair was developed.
We followed two postoperative groups: group 1 (n = 20) received repair of tetralogy of Fallot with the modified technique with transatrial ventricular septal defect closure, a short infundibular incision with avoidance of muscle resection, and patch expansion of the RV outflow tract; group 2 (n = 22) received repair of tetralogy of Fallot by the traditional technique with ventricular septal defect closure through a ventriculotomy with resection of obstructing muscle. Six patients were excluded from further follow-up: two patients, one in each group, who required RV-pulmonary artery conduit placement at original repair; one patient in group 1 who developed double-chamber RV; and three patients, two in group 1 and one in group 2, who were lost to our follow-up < 5 years postoperatively. We compared postoperative findings > 10 years after repair. Despite similar residual RV outflow tract stenosis and obligatory pulmonary insufficiency by examination and Doppler echocardiography, RV size was smaller in the modified group, as reflected by RV/left ventricle on M-mode echocardiography (0.66 +/- 0.22 versus 0.81 +/- 0.17, P = .02), cardiothoracic ratio (0.53 +/- 0.04 versus 0.58 +/- 0.06, P = .03), and QRS duration (126 +/- 19 versus 143 +/- 23, P = .03). RV systolic function was more impaired in group 2, as reflected by decreased systolic tricuspid annulus excursion on two-dimensional echocardiography. Exercise endurance time was significantly higher in group 1 patients. Lown grade 4 ventricular ectopy on ambulatory ECG was present in three patients in group 2 and none in group 1.
The modified technique results in significantly less RV dilation and better preservation of RV function at late follow-up.
法洛四联症修复术后，右心室（RV）扩张与室性心律失常及猝死风险增加相关。为解决这一问题，研发了一种改良修复方法。
我们对两个术后组进行了随访：第1组（n = 20）采用改良技术修复法洛四联症，经心房室间隔缺损闭合、短漏斗部切口且避免肌肉切除，并对右心室流出道进行补片扩张；第2组（n = 22）采用传统技术修复法洛四联症，通过心室切开术闭合室间隔缺损并切除梗阻肌肉。6例患者被排除在进一步随访之外：每组各有1例患者，在初次修复时需要植入右心室 - 肺动脉导管；第1组有1例患者发生双腔右心室；3例患者失访，第1组2例，第2组1例，术后随访时间均<5年。我们比较了修复术后10年以上的结果。尽管通过检查和多普勒超声心动图显示两组残余右心室流出道狭窄及必然存在的肺动脉瓣关闭不全相似，但改良组的右心室大小较小，M型超声心动图显示右心室/左心室比值（0.66±0.22对0.81±0.17，P = 0.02）、心胸比率（0.53±0.04对0.58±0.06，P = 0.03）及QRS波时限（126±19对143±23，P = 0.03）均反映了这一点。二维超声心动图显示第2组右心室收缩功能受损更严重，表现为三尖瓣环收缩期位移降低。第1组患者的运动耐力时间明显更长。动态心电图显示第2组有3例患者出现洛恩4级室性早搏，第1组无。
改良技术在晚期随访时可显著减少右心室扩张并更好地保留右心室功能。
