主动脉瓣下狭窄外科手术后复发性左心室流出道梗阻危险因素分析  

Risk factors for recurrent left ventricular outflow tract obstruction after surgical repair for subaortic stenosis

作　　者：董捷 刘顺 董硕 邹孟轩 杜楚豪 孙阳雪 徐海涛 孙家树 王强[1] 李守军 杨克明 闫军 Dong Jie;Liu Shun;Dong Shuo;Zou Mengxuan;Du Chuhao;Sun Yangxue;Xu Haitao;Sun Jiashu;Wang Qiang;Li Shoujun;Yang Keming;Yan Jun(Department of Pediatric Cardiac Surgery,Fuwai Hospital,National Center for Cardiovascular Diseases,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100037,China)

机构地区：[1]中国医学科学院、北京协和医学院、国家心血管病中心、阜外医院小儿外科中心,北京100037

出　　处：《中华胸心血管外科杂志》2023年第10期599-604,共6页Chinese Journal of Thoracic and Cardiovascular Surgery

基　　金：中国医学科学院临床与转化医学研究基金(2020-I2M-C&T-B-060)。

摘　　要：目的探讨各种类型主动脉瓣下狭窄(subaortic stenosis,SAS)患儿在行外科手术治疗后,再次出现左心室流出道梗阻及瓣膜功能受累的预后情况及风险分析。方法回顾性纳入于2016年1月至2019年12月在阜外医院进行开胸主动脉瓣下狭窄手术的18岁以下患儿。排除同时合并肥厚型梗阻性心肌病的患儿。首次SAS手术及后续每次随访的详细手术记录和病历、超声心动图资料由两位心外科医师提取、电话随访、背靠背分析,并达成一致意见。复发性SAS为SAS外科治疗1个月后左心室流出道压差30 mmHg(1 mmHg=0.133 kPa)。结果共137例患儿纳入研究。患儿SAS手术时中位年龄4.6岁(3个月~17.8岁)。平均随访4.36年(3.2~5.7年)后,中位30例患儿在随访中复发左心室流出道梗阻,复发率21.9%,7例(5.1%)患儿行二次手术治疗。二次手术后,截至最近回访时间,7例患儿均未再复发。对比未复发组,复发组患儿手术时年龄更小(P=0.0443),体表面积更小(P=0.0485),住院时间更长(P=0.0380)。Cox多因素分析中,如果仅考虑术前变量,较早术后复发的独立危险因素是超声心动图左心室流出道压差峰值高于50 mmHg(HR=5.25,P=0.001),BSA<0.9(HR=2.5,P=0.023),以及瓣下狭窄长度大于或等于5 mm(HR=2.29,P=0.050)。若同时考虑术前和术中变量,术前左心室流出道压力峰值高于50 mmHg(HR=4.91,P=0.002)和术中从主动脉瓣上剥离隔膜(HR=3.23,P=0.010)是术后复发的独立危险因素。结论主动脉瓣下狭窄术后复发左心室流出道梗阻较为常见,术后定期复查超声心动图对于判断患儿是否需要再次手术干预十分重要。SAS术后复发左心室流出道梗阻主要与瓣下狭窄长度,SAS累及主动脉瓣,患儿手术时年龄相关。因此,需对高危患儿进行术后定期随访,及时二次干预。Objective To investigate the prognosis and risk factors for children diagnosed with all types of subaortic stenosis(SAS)who developed recurrent left ventricular outflow tract obstruction after surgical treatment.Methods The study retrospectively included patients aged 0-18 years old who underwent open heart SAS surgery at Fuwai Hospital from 2016-2019.Children with hypertrophic obstructive cardiomyopathy were excluded.Detailed operative notes,medical records and ultrasound information,and follow-ups were extracted.Recurrent SAS was defined as left ventricular outflow tract gradient 30 mmHg(1 mmHg=0.133 kPa)1 month after SAS surgical treatment.Results A total of 137 children were included in this study.The medium age of children at the time of SAS surgery was 4.6 years old(3 months-17.8 years old).After a median follow-up of 4.36 years(3.2-5.7 years),a total of 30 patients developed recurrent LVOTO,with a recurrence rate of 21.9%,and 7(5.1%)underwent a second surgery.Compared to the non-recurrent group,children in the recurrent group were younger at the time of surgery(P=0.0443),had a smaller body surface area(P=0.0485),and a longer length of stay(P=0.0380).In Cox analysis,when only considering preoperative variables,the independent risk factor for LVOTO recurrence were a peak left ventricular outflow tract gradient higher than 50 mmHg(HR=5.25,P=0.001),a BSA less than 0.9(HR=2.5,P=0.023),and a length of SAS 5 mm(HR=2.29,P=0.050).When both preoperative and intraoperative variables were considered,preoperative peak left ventricular outflow tract gradient 50 mmHg(HR=4.91,P=0.002)and peeling from the aortic valve(HR=3.23,P=0.010)were independent risk factors for postoperative recurrence.Conclusion Recurrent LVOTO after SAS surgical repair is common,and regular postoperative follow-up is crucial to evaluate whether a secondary intervention is required.Regular postoperative follow-up is needed for children at high risk.

关 键 词：主动脉瓣下狭窄 左心室流出道狭窄 先天性心脏病 心脏手术 

分 类 号：R726.5[医药卫生—儿科]