249例儿童肺动脉瓣狭窄经皮球囊瓣膜成形术的病例分析与随访

发布时间：2018-06-21 05:02

本文选题：经皮球囊肺动脉瓣成形术 + 肺动脉瓣狭窄　；参考：《山东大学》2017年硕士论文

【摘要】：研究背景肺动脉瓣狭窄(PS)为一种较常见的先天性心脏病,约占所有先天性心脏病患者的8%～10%。传统的治疗方法是通过外科手术,但该方法存在需开胸、创伤大、遗留疤痕、术后恢复时间较长等缺点。1982年Kan等首先采用经皮球囊肺动脉瓣成形术(PBPV)成功为PS患儿解除狭窄,因该方法与外科手术相比具有操作简便、创伤小、不留手术瘢痕、恢复快、经济等优点,逐渐成为PS患儿首选的治疗方法。既往研究多为PBPV即刻及短中期疗效的评价,而对跨肺动脉瓣压差(AP)、瓣膜反流、再狭窄、右心室内径大小等评价PBPV疗效指标的长期观察研究的大样本报道较少。目的本研究旨在于探讨PBPV在我院儿童PS患儿中的应用情况,评估PBPV治疗儿童PS的安全性及有效性,结合患儿长期连续随访资料,观察研究PBPV术后患儿长期预后,并分析其影响因素。研究对象和方法选取山东省立医院小儿心脏科自1987年11月至2016年12月249例行PBPV治疗的PS患儿,收集患儿住院期间PBPV术前、术中、术后的症状体征、心电图、心脏正侧位片、超声心动图、心导管参数等资料,以及术后1个月、3个月、半年、1年及以后每隔1～2年的门诊复查随访资料,并在门诊收集同时期健康同龄人的超声心动图右心室内径资料,并对收集的资料进行统计学分析。结果1.249例患儿中,男134例,女115例,年龄4个月～17岁,中位数为3.20岁,体重为6～65 kg,平均为(17.96 ±9.96)kg,术后随访时间1个月～30年;年龄1岁有19例、1～3岁101例、3岁129例;轻度狭窄80例,中度狭窄148例,重度狭窄21例;30例患儿伴有不同程度右室流出道狭窄,13例患儿轻度肺动脉瓣发育不良;199例(80%)患儿存在不同程度的右心室壁增厚或右心室扩大。2.PBPV手术成功率为99%(247/249),2例未成功,心血管造影分别为右心室流出道明显肥厚性狭窄、合并肺动脉分支狭窄,转心外科治疗;术中选用球囊与瓣环比值(BAR)为1.17±0.11(1.00～1.40);心导管测得球囊扩张前右心室压力、△P 分别为(78.16±32.99)mmHg、(54.77±33.04)mmHg,球囊扩张后复测分别为(45.06± 19.66)mmHg、(20.06± 12.91)mmHg,右心室压力、AP在球囊扩张后均明显下降(P0.05);手术时间为(58.54 ±24.51)min,X线曝光时间为(10.52±4.14)min,住院时间为(6.12±1.54)天。3.患儿术中及术后短期严重并发症发生率为4.5%(11/247),其中心包积液2例,右室流出道痉挛6例,室上性心动过速、上消化道出血、主肺动脉夹层动脉瘤各1例,经积极对症或外科手术治疗,无死亡病例。4.超声心动图测得AP值较心导管检查测得值偏高(P0.05),两种检查方法AP值相关系数为0.78;两种检查方法测得肺动脉瓣环直径大小无差异(P0.05)。可见,超声心动图和心导管在测量AP和肺动脉瓣环直径上均具有良好的直线相关性。5.术后共随访223例,总随访率达90.3%(223/247),随访时间为1个月～30年,平均为(7.68±4.77)年。本组患儿术前、术后24h、术后半年、术后1～2年、术后5年、术后10年及以上的患儿AP分别为(63.56±24.07)mmHg、(26.65±11.19)mmHg、(24.23 ±11.41)mmHg、(20.93 ±8.94)mmHg、(18.27±8.83)mmHg、(15.27±7.25)mmHg,患儿术后各随访时间段AP与术前相比均明显降低,大部分患儿术后△P在随访过程中会进一步下降,术后5年、10年的患儿平均AP较术后24h的AP均有明显下降(P0.05)。Logistic回归分析结果显示瓣膜发育不良型或伴右室流出道狭窄、术后即刻残余较高△P为PBPV术后患儿中远期疗效不能达到优标准(≤25mmHg)的危险因素,而年龄、术前狭窄严重程度、BAR、是否同时合并其他畸形对中远期疗效没有明显影响。6.术后半年随访的患儿中有29例(14%)AP≥36mmHg,术后1～2年随访时仍有12例(6.5%)△P≥36mmHg,其中3例患儿先后住院再次给予手术治疗;3例患儿在随访过程中逐渐降至36 mmHg以下;2例患儿术后10年回院门诊复查时仍大于36mmHg;3例失访。随访中还发现1例患儿PBPV术后即刻、短期效果均达到优的标准,而在术后长期过程中△P逐渐增高,术后10年复查时升至41 mmHg。7.肺动脉瓣反流在术前24 h、术后24 h、术后半年、术后1～2年、术后5年及术后10年总发生率分别为58%、68%、73%、76%、80%、83%。随访时间在10年及以上的65例患儿中有14例(21%)患儿伴有中度及以上肺动脉瓣反流,12例中度反流,2例重度反流。肺动脉瓣反流发生情况在术前24 h、术后24 h及术后10年三个时间段存在显著差异(M=37.56,P0.05),术后随访10年及以上的患儿较术前24 h、术后24 h时间点肺动脉瓣反流总发生率及反流程度均显著增高(P0.05),PBPV术后的患儿随着时间的延长,其肺动脉瓣反流发生率及反流程度均增高。Kruskal-Wallis H秩和检验术后随访10年及以上患儿肺动脉瓣反流程度在不同年龄组、狭窄程度、BAR组间均无明显差异(P0.05)。8.随访时间长达10年及以上的患儿右心室舒张期内径为(19.27±3.03)mm,门诊同期健康同龄儿右心室舒张期内径为(15.24 ±2.89)mm,PBPV术后患儿远期右心室舒张期内径较健康同龄人明显偏高(P0.05)。9.本研究病例术前有43%(107/249)的患儿伴有三尖瓣反流,PBPV术后24h、术后半年、术后1～2年、术后5年及术后10年及以上患儿的TR总发生率分别为42%、41%、45%、43%、44%,三尖瓣反流总发生率在术后随访中无明显变化,但术前伴有中度及以上三尖瓣反流的20例患儿,17例患儿反流程度在术后随访过程中逐渐减轻或消失,仅有1例术后6年给予外科手术治疗。FriedmanM检验显示TR发生情况在术前24 h、术后24h及术后10年三个时间段存在显著差异(P0.05),术后随访10年及以上的患儿TR反流程度较术前24h、术后24h时间段均有明显减轻(P0.05)。结论1.经皮球囊肺动脉瓣成形术治疗儿童肺动脉瓣狭窄手术成功率高,术后即刻、近期、中远期疗效良好,并发症少,再狭窄率低,可作为儿童肺动脉瓣狭窄的首选治疗方法。2.患儿经皮球囊肺动脉瓣成形术中远期疗效不能达到优标准(≤25mmHg)的危险因素包括非典型肺动脉瓣瓣膜狭窄和术后即刻残余较高跨肺动脉瓣压差,而年龄、术前狭窄严重程度、球囊与瓣环比值、是否同时合并其他畸形等因素对中远期疗效没有明显影响。3.经皮球囊肺动脉瓣成形术术后中远期三尖瓣反流程度减轻,肺动脉瓣反流发生率及程度有增加趋势,右心室舒张期内径较健康同龄人群仍偏大,个别患儿可再次发生瓣膜狭窄,需引起重视,注重院外长期随访监测。
[Abstract]:The research background of pulmonary valve stenosis (PS) is a common congenital heart disease, about one-third of all patients with congenital heart disease in 8% ~ 10%. is a traditional method of treatment by surgery, but this method is required to open the chest, trauma, scar, postoperative recovery time long time.1982 Kan first percutaneous balloon pulmonary valve Angioplasty (PBPV) for children with PS stenosis, because the method is compared with the surgery has the advantages of simple operation, small trauma, less scar, faster recovery, economic and other advantages, has gradually become the preferred method of treatment of children with PS. Previous studies to evaluate the efficacy of PBPV immediately and the short and medium term, while on the cross the pulmonary valve differential pressure (AP), valvular regurgitation, and The narrow, long term study of right ventricular diameter and PBPV evaluation indicators of the effect of the large sample are reported. The purpose of this research is to explore the application of PBPV in our hospital for children with PS, safety and effectiveness evaluation of PBPV treatment in children with PS, combined with long-term follow-up data, observation of postoperative children with PBPV long term pre After, and analyze its influencing factors. The research object and methods of Cardiology Shangdong Province-owned Hospital pediatric from November 1987 to December 2016 249 cases of PBPV treated with PS, were collected during hospitalization PBPV preoperative, intraoperative, postoperative symptoms and signs, electrocardiogram, cardiac radiographs, echocardiography, cardiac catheterization parameters data. And after 1 Month, 3 months, six months, 1 years and every 1~2 years after the outpatient follow-up data, ultrasound and collected during the same period healthy peers in the outpatient echocardiography right ventricular diameter data, and data were collected for statistical analysis. Results in 1.249 cases, male 134 cases, female 115 cases, age 4 months to 17 years, the median was 3.20 years old, the body weight is 6 65 ~ kg, the average (17.96 + 9.96) kg, followed up for 1 months to 30 years after the age of 1 years; 19 cases, 101 cases of 1~3 years old, 3 years old in 129 cases; 80 cases of mild stenosis, 148 cases of moderate stenosis, severe stenosis in 21 cases; 30 cases with different degree of right ventricle outflow tract stenosis, 13 cases with mild pulmonary valve dysplasia; 199 cases (80%) with different degree The right ventricular wall thickening or enlarged right ventricle.2.PBPV surgery success rate was 99% (247/249), 2 cases of cardiovascular angiography were not successful, right ventricular outflow tract was hypertrophic stenosis, branch pulmonary stenosis, turn heart surgery; the ratio of intraoperative balloon / annulus (BAR) was 1.17 + 0.11 (from 1 to 1.40); catheter before balloon dilation Right ventricular pressure, P were (78.16 + 32.99) mmHg, (54.77 + 33.04) mmHg, balloon dilatation after retest respectively (45.06 + 19.66) mmHg, (20.06 + 12.91) mmHg, right ventricular pressure, AP decreased significantly after balloon dilation (P0.05); operative time (58.54 + 24.51) min, X-ray exposure time (10.52 + 4.14) min, hospitalization time was (6.12 + 1.54) days.3 Patients. Intraoperative and postoperative complications of short-term incidence was 4.5% (11/247), including 2 cases of pericardial effusion, 6 cases of right ventricular outflow tract spasm, supraventricular tachycardia, upper gastrointestinal bleeding, main pulmonary artery dissection in 1 cases, after positive symptomatic treatment or surgical operation, no death the death cases of.4. echocardiography measured AP values were measured in heart catheterization The high value (P0.05), the two methods AP value of the correlation coefficient is 0.78; the two methods measured the pulmonary valve ring diameter had no difference (P0.05). Thus, echocardiography and cardiac catheterization showed good linear correlation between the.5. operation in AP and measuring the diameter of pulmonary valve ring after follow-up in 223 cases, the total follow-up rate was 90.3% (223/247), follow-up Between 1 months to 30 years, the average (7.68 + 4.77) years. The patients with preoperative, postoperative 24h, six months after surgery, after 1~2 years, 5 years after the operation, after 10 years and above with AP respectively (63.56 + 24.07) mmHg, (26.65 + 11.19 mmHg), (24.23 + 11.41) mmHg, (20.93 + 8.94) mmHg, (18.27 + 8.83) mmHg, (15.27 + 7.25) mmHg, the follow-up time after surgery in children with A P compared with the preoperative were significantly reduced, most of the postoperative patients with P during follow-up will further decline, 5 years after surgery, with an average of 10 years of AP compared with 24h after AP were significantly decreased (P0.05).Logistic regression analysis results showed that the valve dysplasia or with right ventricular outflow tract stenosis, surgery immediately after P for high residual postoperative children with PBPV Not long term effects to achieve excellent standards (25mmHg) risk factors, age, preoperative stenosis severity, BAR, is also associated with other malformations of the long-term curative effect has no obvious influence on.6. after six months follow-up were 29 cases (14%) AP = 36mmHg, after 1~2 years of follow-up is still 12 cases (6.5%) P = 36mmHg, of which 3 cases were first After the hospital again received surgery; 3 cases were gradually reduced to 36 mmHg during follow-up; 2 cases of postoperative 10 years back to the hospital was still greater than 36mmHg; 3 cases were lost. 1 patients immediately after PBPV also found that short-term follow-up, the effect was better, and the long-term process in the postoperative P increased gradually after 10 year review When up to 41 mmHg.7. of pulmonary regurgitation in 24 h before operation, 24 h after the operation, after half a year, after 1~2 years, 5 years after surgery and postoperative 10 year rates were 58%, 68%, 73%, 76%, 80%, 83%. were followed up in 10 years and above in 65 cases children in 14 cases (21%) - degree and above the pulmonary artery flow valve in patients with moderate regurgitation, 12 cases, 2 cases of severe reflux. Pulmonary regurgitation occurred in 24 h before operation, 24 h after operation and 10 years after operation for three time periods are significantly different (M=37.56, P0.05), postoperative follow-up of 10 years and above were compared with preoperative 24 h, postoperative 24 h time point of pulmonary regurgitation incidence and the reflux degree were significantly higher (P0.05), PBPV after operation in children with the extension of time, the Pulmonary regurgitation occurred 10 years follow-up rate and reflux degree were increased in.Kruskal-Wallis H test after surgery and children over the degree of pulmonary regurgitation in different age groups, the degree of stenosis, there were no significant differences between the BAR group (P0.05).8. were followed for 10 years and above in patients with right ventricular diastolic diameter for (19.27 + 3.03) mm, with clinic Healthy infants right ventricular diastolic diameter (15.24 + 2.89) mm, PBPV after operation in children with long-term right ventricular diastolic diameter was significantly higher than healthy peers (P0.05) of 43%.9. cases of this study before operation (107/249) of the three patients with tricuspid regurgitation, PBPV postoperative 24h, postoperative half year after operation. 1~2 years, 10 years and 5 years after surgery and postoperative patients and above The total incidence rate of TR were 42%, 41%, 45%, 43%, 44%, three of the total incidence of tricuspid regurgitation in postoperative follow-up had no obvious change, but the preoperative with moderate and above three tricuspid reflux in 20 cases, 17 cases of children with reflux in the follow-up process gradually reduce or disappear, only 1 cases 6 years after surgical treatment of the.FriedmanM test The occurrence of TR in the preoperative 24 h, postoperative 24h and 10 years in three periods, there were significant differences (P0.05) during the follow-up period of 10 years and above with TR regurgitation compared with preoperative 24h, 24h period were significantly reduced after surgery (P0.05). Conclusion percutaneous balloon pulmonary 1. the aortic valve plasty in the treatment of children's pulmonary stenosis surgical success rate, postoperative Moment, recently, the long-term curative effect is good, fewer complications, low restenosis rate, can be used as the preferred method of treatment of children with pulmonary stenosis with.2. percutaneous balloon pulmonary valvuloplasty can achieve excellent curative effect in the long term standard (25mmHg) risk factors including atypical pulmonary artery valve stenosis and immediately after operation the residual higher cross pulmonary artery Valve pressure difference, age, preoperative stenosis, balloon / annulus ratio, is also associated with other malformations and other factors have no obvious effect on.3. percutaneous balloon pulmonary valvuloplasty surgery three tricuspid regurgitation reduced the long-term efficacy, pulmonary regurgitation and incidence degree right ventricular diastolic diameter increased. A healthy population is still relatively large, individual children can happen again valvular stenosis, need to pay attention, pay attention to hospital long-term follow-up monitoring.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R726.5

【相似文献】