儿童室间隔缺损合并二尖瓣关闭不全的外科治疗及中期随访

摘要

Objective To summarize our clinical experience of surgical treatment for pediatric patients with ventricular septal defect(VSD) and mitral regurgitation(MR).Methods A retrospective study was performed including consecutive 84 patients with VSD and MR receiving mitral valvuloplasty(MVP) and VSD closure from January 2006 to January 2012 in Shanghai Xinhua Hospital.All patients were associated with pulmonary hypertension(PH,32-85 mm Hg).The diameters of ventricular septal defects were between 0.7 and 1.6 cm.Echocardiography showed that trivial MR (+) in 9 cases,mild MR (++)in 18 cases,moderate MR(+++) in 33 cases,and severe MR(++++) in 24 cases.VSD closure and MVP were performed with cardiopulmonary bypass under moderate systemic hypothermia.The results of repair were evaluated by transesophageal echocardiography (TEE) during operation.Results Intra-operative TEE results: no residual shunt of VSD,none MR in 80 cases,residual trivial MR in 4 cases.Mean Cardiopulmonary bypass (CPB) time was (84.6 ± 18.5) mins.Mean Aortic clump time was(50.8 ± 11.5) mins.Mean postoperative ventilation time was (38.7 ± 30.2) hours,and mean postoperative inhosptial time was(10.5 ±4.6) days.The in-hospital mortality was 1.2％ (1 case died).78 cases were fully followed up.There was no late death.Echocardiography showed that none MR in 62 cases,trivial MR in 10 cases,mild MR in 4 cases,moderate MR in 2 patients.The overall freedom from reoperation at 5 years was (97.4 ± 1.8) ％.Conclusion Ventricular septal defect with pulmonary hypertension need early surgical repair.MR was treated at the same time of VSD closure could effectively improve the surgical outcome of pediatric patients with ventricular septal defect and mitral regurgitation.%目的 总结同期行手术治疗儿童室间隔缺损合并二尖瓣关闭不全的临床经验.方法 回顾性分析2006年1月至2012年1月同期手术治疗84例室间隔缺损(VSD)合并二尖瓣关闭不全患儿,男33例,女51例；年龄2个月～6岁,平均(15.6±6.9)个月；体质量3～ 20 kg,平均(10.6±3.2) kg.患儿术前肺动脉压32～85 mm Hg,中重度肺动脉高压45例,术前多有反复肺部感染.VSD直径0.7～1.6cm;左向右分流45例,双向分流39例.二尖瓣反流轻度(+～++)27例,“+”9例,“++”18例；中度(+++)33例；重度(++++)24例.均在全麻中低温体外循环下应用人工dacron补片修补VSD,并同期行二尖瓣成形术,术中通过食管超声(TEE)评价VSD修补及二尖瓣成形的效果.结果 术中TEE提示,患儿均无残余分流,二尖瓣成形效果满意,无反流80例,反流程度“+”4例.术中体外循环(84.6±18.5) min,主动脉阻断(50.8 ±11.5) min.术后呼吸机辅助(38.7 ±30.2)h,术后住院(10.5±4.6)天.术后早期死亡1例(1.2％).随访2 ～ 72个月,完整随访78例,随访期间无死亡.复查超声心动图,VSD均无残余分流,二尖瓣无反流62例,反流程度“+”10例,“++”4例,“+++”2例.术后5年免除再手术率(97.4±1.8)％.结论 室间隔缺损合并肺动脉高压患儿应尽早行手术根治,同期矫治合并的二尖瓣关闭不全,患儿预后良好.正确的围术期处理是降低患儿病死率的重要因素.