解剖性双心室流出道重建技术:双根部调转手术

摘要

Objective The surgical management of anomalies of ventriculoarterial with ventricular septal defect (VSD) and left ventricular outflow tract obstruction(LVOTO) continues to present a surgical challenge because of the wide variability in anatomy and the disappointing late results with current approaches.For this reason,several techniques for surgical repair have been proposed.The optimal surgical strategy remains controversial.Here we present a mid term result of an alternative solution for these anomalies by a new technique named double-root translocation.Methods Between December 2007 and September 2013,a total of 78 consecutive patients underwent a double-root translocation procedure,at a median age of 3.0 (range,0.3-22.0) years.The VSD was repaired with a dacron patch,and the aortic root translocation was done with coronary reimplantation.The neopulmonary artery was reconstructed with a monocusp bovine jugular vein patch or a homograft patch.The mean follow-up interval was 56 months (range,2 to 98 months).Biventricular outflow tract function was assessed by echocardiography.Results In-hospital mortality was 4.4％ (3 patients).The causes of death are as follows,renal failure,low cardiac output,septicemia.During the follow-up period,no patient requiring reintervention,and 2 follow-up deaths caused by heart failure and sudden death.Postoperative echocardiography showed satisfactory hemodynamic effect of the reconstructed biventricular outflow tract and ventricular function.LVOT gradient was very low,indicating that root translocation procedures offer satisfying relief of LVOT obstruction.Mean RVOT gradient was only 10.4 mmHg (1.38 kPa),and in most of cases,the pulmonary valves only present mild or moderate regurgitation.Conclusion Our strategy for RVOT reconstruction is to reconstruct a free neo-pulmonary root with a monovalve patch plus native pulmonary artery.Therefore,the competence and the growth potential of the neo-pulmonary root can be expected.The double root transloction procedure is a true-meaning anatomic repair for transposition of the great arteries or double outlet of right ventricle,with ventricular septal defect and pulmonary stenosis in terms of physiologic cardiac hemodynamics.%目的 总结双根部调转术治疗合并室间隔缺损(VSD)和左心室流出道狭窄的心室大动脉连接异常的中期结果.方法 2007年12月至2013年9月,78例患者接受双根部调转手术.男55例,女23例;年龄0.3～22.0岁,中位年龄3.0岁.涤纶补片修补VSD,主动脉根部调转时进行冠状动脉再植,用带单瓣的牛颈静脉或同种血管片重建肺动脉.随访2～ 98个月,中位随访时间56个月,超声心动图评估双侧心室流出道功能.结果 院内死亡3例,占4.4％,死因分别为肾功能衰竭、低心排血量综合征和脓毒血症.随访期间无再次手术;2例死亡,原因分别是心功能衰竭和猝死.术后超声心动图提示患者重建后的双心室流出道血流动力学满意,心功能正常.左心室流出道压差接近正常,提示左心室流出道疏通满意;平均右心室流出道压差10.4 mmHg(1.38 kPa),多数患者的肺动脉仅少到中量反流.结论 采用带单片的补片和自体肺动脉重建的右心室流出道,保持通畅性和生长潜能.双根部调转手术中期随访结果良好,从心脏血流动力学的角度来看,此方法是对合并室间隔缺损和左心室流出道狭窄的大动脉转位和右心室双出口这一疾患的真正意义上的解剖学矫治.