Randomized trial of pulmonary valve replacement with and without right ventricular remodeling surgery.
Randomized trial of pulmonary valve replacement with and without right ventricular remodeling surgery.
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DOI：
10.1161/circulationaha.110.951178
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发表时间：
2010-09-14
期刊：
影响因子：
37.8
通讯作者：
del Nido P
中科院分区：
文献类型：
--
作者：
Geva T;Gauvreau K;Powell AJ;Cecchin F;Rhodes J;Geva J;del Nido P
尽管肺动脉瓣置换术(PVR)能有效减轻慢性肺返流(PR)患者的右室容量超负荷，但持续性的RV功能障碍和随后的不良临床结果已有报道。本研究旨在探讨与单纯PVR相比，去除瘢痕组织的外科RV重建术是否会改善RV的功能以及实验室和临床参数。2004年2月至2008年10月，收治的儿童早期接受右室流出道手术的患者，≥中度PR，符合房室重构标准的患者被随机分为单纯房室成形术(n=34)和合并房室重塑的房室成形术(n=30)。术后6个月随访时，两组患者的一次结局(右室射血分数变化：单纯PVR组为-2±7%，PVR合并右室重建组为-1±7%，P=0.38)及二次结局均无显著差异。对整个队列的多变量分析确定，术前右室收缩末期容量指数90ml/m2和QRS持续时间140ms与最佳的术后结果(正常的右室大小和功能)相关，右室射血分数和QRS持续时间≥160ms与次佳的术后结果(右室扩张和功能障碍)相关。在慢性PR患者中，在PVR中加入RV外科重塑并没有带来可测量的早期益处。根据QRS间期、右室收缩末期容量或右室射血分数参考PVR可能是有益的。
Although pulmonary valve replacement (PVR) is effective in reducing right ventricular (RV) volume overload in patients with chronic pulmonary regurgitation (PR), persistent RV dysfunction and subsequent adverse clinical outcomes have been reported. This trial was conducted to investigate whether the addition of surgical RV remodeling with exclusion of scar tissue to PVR would result in improved RV function and laboratory and clinical parameters, as compared with PVR alone. Between February 2004 and October 2008, 64 patients who underwent RV outflow tract procedures in early childhood, had ≥moderate PR, and fulfilled defined criteria for PVR were randomly assigned to undergo either PVR alone (n = 34) or PVR with surgical RV remodeling (n = 30). No significant difference was observed in the primary outcome (change in RV ejection fraction: -2±7% in the PVR alone group and -1±7% in the PVR with RV remodeling group, P = 0.38) or in any of the secondary outcomes at 6-month postoperative follow-up. Multivariable analysis of the entire cohort identified preoperative RV end-systolic volume index <90 ml/m2 and QRS duration <140 ms to be associated with optimal postoperative outcome (normal RV size and function), and RV ejection fraction <45% and QRS duration ≥160 ms to be associated with suboptimal postoperative outcome (RV dilatation and dysfunction). The addition of surgical remodeling of the RV to PVR in patients with chronic PR did not result in a measurable early benefit. Referral to PVR based on QRS duration, RV end-systolic volume, or RV ejection fraction may be beneficial.