摘要目的 探讨小儿法洛四联症(TOF)修复手术中减少肺动脉瓣反流的治疗策略和效果.方法 2009年1月至2015年12月,211例TOF患儿行肺动脉瓣保护(PVS)的心内修复手术,年龄2～ 36个月,其中术后右心室和左心室压(PRV/PLV)比值≥0.8者114例.114例中前54例全部在体外循环心脏跳动下采用右心室漏斗部保护方法(RVIS),切开肺动脉瓣环或右心室0.5～1.0 cm;后60例中8例采用以下标准决定行RVIS:多巴胺≥10 μg·kg-1·min-1和肾上腺素≥0.05 μg·kg-1·min-1维持下循环不稳定或者跨肺动脉瓣环压差≥30 mmHg(1mmHg =0.133 kPa),余52例未进一步处理.114例患儿按是否行RVIS分组,其中RVIS 62例,PVS组52例,比较两组的临床结果.结果 RVIS组体外循环时间明显延长[(110.3±12.0) min对(77.7±10.0) min,P＜0.01].与RVIS组相比,PVS组术后跨肺动脉瓣环压差[(21.0±5.4)mmHg对(16.0±3.6)mmHg,P＜0.05]、PRV/PLV(0.82 ±0.03对0.67±0.12,P＜0.01)明显高,PVS组术后早期血管活性药物(多巴胺和肾上腺素)的使用时间[(6.03±9.60)天对(4.20±1.90)天,P＜0.01]、呼吸机辅助时间[(81.2±27.6)h对(38.5±33.0)h,P＜0.01]和ICU滞留时间[(6.3±1.7)天对(4.3±1.9)天,P＜0.01]明显长.PVS组术后床旁腹膜透析比例明显高于RVIS组(8/52对4/62,P＜0.01).RVIS组术后1例死于心律失常.随访期间PVS组1例死于感染性心内膜炎.随访资料显示,术后52个月PVS组的肺动脉瓣反流程度明显小于RVIS组,两组的左、右心室功能差异无统计学意义,但是都明显低于健康同龄儿.结论 选择合适的TOF病例,采用保留肺动脉瓣或右心室小切口,能明显减轻修复术后肺动脉瓣的反流.

abstractsObjective To evaluate the surgical strategy for pulmonary valve preservation in repair of tetralogy of Fallot (TOF) and analyze the outcomes in young children patients.Methods A total of 211 TOF younger children less than threeyear-old between January 2009 and December 2015 had received pulmonary valve-sparing(PVS) surgical repair.At the end of the procedure,the peak RV/LV pressure ratio(PRV/PLV) and transannular pressure gradient were performed in all patients.114 patients had higher PRV/PLV rati ≥ 0.8.The former 54 patients,right ventricle infundubulum sparing (RVIS) stragery were made to relieve the RVOTO.However,only 8 patinets of the later 60 cases had received RVIS in TOF repair,whose systemic blood pressure was instable with the large dose of dopamine≥10 μg · kg-1 · min-1 and epinephrine≥0.05 μg · kg-1 · min-1 or the transannular pressure gradient≥30 mmHg (1 mmHg =0.133 kPa).114 patients were divided by two group(52 cases in PVS group and 62 cases in RVIS group) and compared by the early outcomes.Results The median cardiopulmonary bypass time of RVIS group was significantly more than that of PVS group[(110.3 ± 12.0)min vs(77.7 ± 10.0)min].The postoperative index of the patients in PVS group,including transannular pressure gradient [(21.0 ± 5.4) mmHg vs (16.0 ± 3.6) mmHg,P ＜ 0.05],PRV/PLV ratio(0.82 ± 0.03 vs.0.67 ± 0.12,P ＜ 0.01),median using time of dopamine and epinephrine[(6.03 ±9.60)days vs.(4.20 ±1.90)days,P＜0.01],median extubation time[(81.2 ±27.6)h vs.(38.5 ±33.0) h,P ＜ 0.01],ICU stay time [(6.3 ± 1.7) days vs.(4.3 ± 1.9) days,P ＜ 0.01],using of peritoneal dialysis (8/52 vs 4/62,P ＜ 0.01)were more than those in RVIS group.There was no difference of mortality between two groups.Fellow up 12-50 months,there was no difference of LVEF,MPI and TAPSE between two groups.However,the severity of pulmonary regurgitation in patients of PVS group was significant less than those of RVIS group.Conclusion PVS and RVIS in TOF repair could decrease the severity of pulmonary regurgitation after operation.