成人先天性心脏病合并重度肺动脉高压手术处置策略及效果分析  

Outcome analysis for the surgical treatment in adult patients with severe pulmonary arterial hypertension associated with congenital heart disease

作　　者：方敏华[1] 王镇龙[1] 张春振[1] 李波[1] 吴洪江[1] 

机构地区：[1]沈阳军区总医院心血管外科,110084

出　　处：《中华临床医师杂志（电子版）》2015年第22期12-15,共4页Chinese Journal of Clinicians(Electronic Edition)

摘　　要：目的 总结成人先天性心脏病合并重度肺动脉高压（PAH）患者围手术处理的经验,分析影响手术效果的高危因素,以期提高术后的效果.方法 2005 年1 月至2013 年12 月,外科手术治疗18 岁以上先天性心脏病合并重度PAH 患者202 例,男95 例,女107 例,年龄18～61 岁,肺动脉压与主动脉压比值（PAP/AOP）0.75～1.0,肺血管阻力2～14 Wood 单位.全组患者分为组Ⅰ肺血管阻力小于6 Wood 单位及临床无明显心衰表现的患者127 例,直接手术修复.组Ⅱ：肺血管阻力大于6 Wood 单位或临床有明显心衰证据的患者75 例,行急性肺血管反应试验,阳性患者48 例接受手术治疗,阴性患者27 例,口服靶向药物2～3 个月后复查右心导管检查,肺血管阻力降低20%或肺血管阻力小于6 Wood 单位以上接受手术治疗.结果 术后严重低心排综合征24 例,低氧血症（氧合指数小于100）19 例,肺动脉高压危象9 例.早期死亡7 例,死亡率3.5%.术后不良事件包括严重低心排综合征、低氧血症和肺动脉高压危象.单因素分析结果显示：术前合并中度以上二尖瓣关闭不全（P=0.014）、心房颤动（P=0.030）、胸心比值≥0.75（P=0.011）是术后早期死亡的危险因素.单因素分析结果显示：术前年龄（P=0.003）、合并中度以上二尖瓣关闭不全（P=0.001）、心房颤动（P=0.001）、肺血管阻力（P=0.025）、胸心比值≥0.75（P=0.001）和术后72 h PAP/AOP≥0.5（P=0.001）是术后不良事件的危险因素,Logistic 逐步回归分析结果显示,影响术后不良事件的相关危险因素是术前年龄（P=0.023）、合并中度以上二尖瓣关闭不全（P=0.026）和术后72 h PAP/AOP〉0.5（P=0.001）.结论 通过术前纠正心功能衰竭,围手术期靶向药物治疗和准确评估手术适应证,成年先天性心脏病合并重度PAH 患者外科手术治疗的效果是满意的。Objective To study the surgical strategy of adult patients with severe pulmonary arterial hypertension associated with congenital heart disease and to identify the risk factors for the outcomes. Methods Between January 2005 and December 2013, 202 adult patients with severe pulmonary arterial hypertension associated with congenital heart disease underwent the surgical repair. There were 95 male and 107 female with age ranged 18 to 61 years. The ratio of pulmonary arterial pressure/systemic arterial pressure (PAP/AOP) in all patients was more than 0.75 and pulmonary vascular resistance (PVR) was ranged from 2 to 14 Wood unit before operation. 127 patients with PVR less than 6 Wood unit and without heart failure symptom underwent the surgical repair directly. 75 patients with PVR more than 6 Wood unit or with heart failure symptom underwent acute pulmonary vasodilator testing. Among them, 48 patients with positive results received the surgical repair and 27 patients with negative results underwent the surgical repair after receiving targeted therapy about from 2 to 3 month and re-undergoing cardiac catheterization to judge the change of PVR. Results The early mortality was 3.5%. The early postoperative adverse events included severe low cardiac output syndrome occured in 24 patients, hypoxemia in 19 patients and pulmonary crisis in 9 patients. Univariate analysis revealed preoperative moderate or severe MI (P=0.014), atrial fibrillation (P=0.030), the size of heart (P=0.011) as risk factors for the early death. Univariate analysis revealed age (P=0.003), preoperative moderate or severe MI (P=0.001), atrial fibrillation (P=0.001), PVR (P=0.025), the size of heart (P=0.001), the postoperative PAP/AOP more than 0.5 after 72 hour (P=0.001) as risk factors for the early postoperative adverse events. In the multivariate analysis, age (P=0.023), with moderate or severe MI (P=0.026) and the postoperative PAP/AOP more than 0.5 after 72 hour (P=0.001) was independent risk factors for the early postoperative adverse event

关 键 词：高血压 肺性 心脏缺损 先天性 成人 修复 

分 类 号：R654.2[医药卫生—外科学]