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经胸与经皮肺动脉瓣球囊成形术治疗肺动脉瓣狭窄的临床对比研究

Comparison of transthoracic or percutaneous balloon pulmonary valvuloplasty in the therapy of pulmonary valve stenosis

摘要:

目的 比较经胸和经皮肺动脉瓣球囊成形术治疗肺动脉瓣狭窄的疗效及特点.方法回顾性分析2006年2月至2016年1月在中国医学科学院阜外医院接受经胸和经皮肺动脉瓣球囊成形术治疗的806例肺动脉瓣狭窄患者的临床资料,其中经胸组171例,经皮组635例.经胸组男性72例(42.1%),平均年龄(1.6±1.1)岁,体重7.65(7.68)kg [M(QR)].经皮组男性344例(54.2%),平均年龄(21.0±18.5)岁,体重43.75(47.38)kg.术后随访3个月至10年,平均随访时间(6.3±3.6)年,随访率90.9%(732/806).每次复诊均复查超声心动图,评估肺动脉瓣跨瓣压差、肺动脉瓣反流程度.采用t检验、秩和检验和χ2检验比较两组临床资料.结果 住院期间所有患者无死亡及心包填塞等严重并发症,经胸组患者术后住院时间与经皮组差异有统计学意义[8(5)d比2(2)d,Z=-9.404,P=0.000].手术前肺动脉瓣跨瓣压差经胸组与经皮组的差异有统计学意义[(80.6±22.4)mmHg比(72.6±20.5)mmHg,t=1.611,P=0.032,1 mmHg=0.133 kPa],手术前后降低值经胸组与经皮组差异有统计学意义[(55.9±21.0)mmHg比(46.6±23.4)mmHg,t=-1.710,P=0.026].随访两组患者心功能均良好,肺动脉瓣跨瓣压差经胸组与经皮组[(22.3±6.5)mmHg比(25.2±12.6)mmHg]两者差异无统计学意义(t=1.320,P=0.072),经胸组患者肺动脉瓣关闭不全的发生率低于经皮组(56.1%比65.2%,χ2=4.755,P=0.029).结论 经胸肺动脉瓣球囊成形术应用于婴幼儿重症患者,疗效与经皮肺动脉瓣球囊成形术相似.经皮肺动脉瓣球囊成形术创伤更小,适用于儿童及成人患者的治疗.

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abstracts:

Objective To compare the clinical outcome of patients with pulmonary valve stenosis underwent transthoracic and percutaneous balloon pulmonary valvuloplasty. Methods Clinical data of 806 patients diagnosed as pulmonary valve stenosis underwent transthoracic(171 patients as group A)or percutaneous balloon pulmonary valvuloplasty (635 patients as Group B) in Fuwai Hospital from February 2006 to January 2016 were analyzed retrospectively. There were 72 males in group A (42.1%) and 344 males in group B (54.2%). The average age was (1.6±1.1) years in group A and (21.0±18.5) years in group B. The median weight was 7.65 (7.68) kg (M(QR)) in group A and 43.75 (47.38) kg in group B. There were 732 (90.9%) patients followed up from 3 months to 10 years, with an average interval of (6.3±3.6) years. Sixty cases were ligated patent ductus arteriosus simultaneously, and 20 cases got Blalock-Taussig shunt at the same time of valvuloplasty in group A. There were 47 cases of transcatheter closure of atrial septal defect and 6 cases of transcatheter closure of patent ductus arteriosus in group B. The t test, rank sum test and χ2 test were used to compare data of two groups.Results There were no hospital death or cardiac tamponade and other serious complications for all patients. The postoperative hospital stayin group A was significantly longer than that in group B (8(5) days vs. 2(2) days, Z=-9.404, P=0.000).In every further consultation, patients were reviewed with transthoracic echocardiography to assess transpulmonary gradient and pulmonary regurgitation.There were significant difference between group A and B of preoperative transpulmonary pressure gradient ((80.6±22.4) mmHg vs.(72.6±20.5) mmHg, t=1.611, P=0.032, 1 mmHg=0.133 kPa) and so as transpulmonary pressure gradient reduction value ((55.9±21.0) mmHg vs. (46.6±23.4) mmHg, t=-1.710, P=0.026).Patients in both groups had good cardiac function during follow-up interval. One patient needed surgical valvuloplasty 10 months after percutaneous balloon pulmonary valvuloplasty and 1 case occurred moderate to severe tricuspid regurgitation in group B. During follow-up period, there was no significant difference between group A and B of transpulmonary pressure gradient ((22.3±6.5) mmHg vs. (25.2±12.6) mmHg, t=1.320, P=0.072), the incidence of pulmonary valve regurgitation in patients of group A was significantly lower than patients of group B (56.1% vs.65.2%, χ2=4.755, P=0.029). Conclusions The clinical outcome and complications are similar between patients underwent two different routes of balloon pulmonary valvuloplasty. Transthoracic balloon pulmonary valvuloplasty is more suitable for infant and underweight children patients with pulmonary valve stenosis. Percutaneous balloon pulmonary valvuloplasty is more suitable for the treatment of the elder children or adults.

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