Surgical management of competing pulmonary blood flow affects survival before Fontan/Kreutzer completion in patients with tricuspid atresia type I.
Surgical management of competing pulmonary blood flow affects survival before Fontan/Kreutzer completion in patients with tricuspid atresia type I.
复制标题
竞争性肺血流的手术治疗会影响 I 型三尖瓣闭锁患者在 Fontan/Kreutzer 完成前的生存。
DOI：
10.1016/j.jtcvs.2015.05.067
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发表时间：
2015
期刊：
影响因子：
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通讯作者：
B. McCrindle
中科院分区：
文献类型：
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作者：
T. Wilder;G. Ziemer;E. Hickey;P. Gruber;T. Karamlou;P. Kirshbom;E. Blackstone;W. DeCampli;W. Williams;B. McCrindle
目的 确定三尖瓣闭锁患者初始和分期手术时肺血流量 (PBF) 的手术管理与 Fontan/Kreutzer 手术 (Fontan) 生存率之间的关系。方法从 34 个机构（1999-2013 年）招募了 3 个月以下患有 I 型三尖瓣闭锁的婴儿 (n = 303)。在接受手术干预的患者中 (n = 302)，初始手术包括： 全身至肺动脉分流术 (SPS；n = 189；62%)；肺动脉束带（PAB；n = 50；17%）；和上腔静脉肺动脉连接（SCPC；n = 63；21%）。使用多相参数风险模型来分析竞争结果。结果与 PAB (93%) 或 SCPC (93%) 相比，SPS 后风险调整后的 6 年生存率 (85%;P=0.04) 较低。当主肺动脉 (MPA) 闭合 (n = 21) 或束带 (n = 4) 时，SPS 后的存活率为 60%，而没有 MPA 干预的存活率为 93% (P= .02)。 SPS 后，动脉导管开放的 SCPC 前存活率较低 (n = 7; 76% vs 97%;P= .02)。同样，SPS 后，当避免 MPA 干预且动脉导管在 SPS 前自发闭合或在 SPS 期间闭合时，风险调整生存期与初次发生 PAB 或 SCPC 的患者相似。对于所有达到 SCPC 的患者 (n = 277)，PBF 是否持续通过 MPA 并不会显着影响 Fontan 的生存率。 结论 患有 SPS 的三尖瓣闭锁患者代表一个高风险亚组。在 SPS 期间避免开放动脉导管和伴随的 MPA 干预可能有助于减轻与 SPS 相关的风险。在初始和分期手术中，通过 MPA 的顺行 PBF 的存在不会显着影响 Fontan 手术的生存率。
ObjectivesTo determine the association between surgical management of pulmonary blood flow (PBF) at initial and staged procedures with survival to Fontan/Kreutzer operation (Fontan) in patients with tricuspid atresia.MethodsInfants aged <3 months with tricuspid atresia type I (n = 303) were enrolled from 34 institutions (1999-2013). Among those who underwent surgical intervention (n = 302), initial procedures were: systemic to pulmonary artery shunt (SPS; n = 189; 62%); pulmonary artery banding (PAB; n = 50; 17%); and superior cavopulmonary connection (SCPC; n = 63; 21%). Multiphase parametric-hazard models were used to analyze competing outcomes.ResultsRisk-adjusted 6-year survival was lower after SPS (85%;P= .04) versus PAB (93%) or SCPC (93%). Survival after SPS when the main pulmonary artery (MPA) was closed (n = 21) or banded (n = 4) was 60%, versus 93% without MPA intervention (P= .02). After SPS, survival before SCPC was lower with an open ductus arteriosus (n = 7; 76% vs 97%;P= .02). Similarly, after SPS, risk-adjusted survival was similar to that for patients who had an initial PAB or SCPC when MPA intervention was avoided and the ductus arteriosus either closed spontaneously before SPS, or was closed during SPS. For all patients reaching SCPC (n = 277), survival to Fontan was not significantly influenced by whether PBF persisted through the MPA.ConclusionsTricuspid atresia patients with SPS represent a high-risk subgroup. Avoiding an open ductus arteriosus and concomitant MPA intervention during SPS may help mitigate the risk associated with SPS. The presence of antegrade PBF through the MPA, at initial and staged operations, did not significantly influence survival to Fontan operation.