右心室流出道支架治疗危重法洛四联症的技术与效果

A. Pizzuto, Magdalena Cuman, N. Assanta, E. Franchi, C. Marrone, V. Pak, G. Santoro
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引用次数: 1

摘要

背景尽管目前有早期一期修复的趋势,但对于危重法洛四联症(TOF)和导管依赖性肺循环不适合一期修复患者,手术系统-肺分流仍然被认为是首选的缓解方法。然而,在选定的患者中,右心室流出道支架术(RVOT)目前正在成为一种有效的手术姑息替代方案。方法和结果。RVOT支架植入术通常从静脉途径进行,可以是股静脉,也可以是右颈内静脉。这种手术不太常见,主要是在肺漏斗/瓣膜闭锁中,可以使用混合手术/介入方法,通过手术暴露RVOT、穿刺闭锁瓣膜和在直视下部署支架来进行。根据右心室流出道的超声测量,可以选择最合适的支架的尺寸和类型,以完全覆盖右心室漏斗,同时保留肺动脉瓣,除非严重的肺动脉瓣环发育不全和/或瓣上狭窄是阻塞的重要组成部分。在迄今为止发表的大型系列中,RVOT支架置入术的早期死亡率低于2%,与Blalock-Thoma-Taussig分流或早期初级修复相比是有利的。此外,这种方法的发病率和临床后遗症与手术缓解没有显著差异,即使RVOT支架在中期随访中表现出较差的耐用性和较高的经导管再干预率。最后,在中期随访中,RVOT支架置入术后的肺动脉生长与手术缓解相似但更平衡。结论。RVOT支架植入术在技术上是可行的,耐受性良好,有效缓解关键TOF。无论是在高危新生儿中,还是在由于早期手术修复而预计会出现短期肺血流源的情况下,这种方法在手术缓解方面都具有成本效益。它有效地增加了肺血流量,改善了动脉饱和度,并在中期随访中促进了肺动脉的平衡生长。
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Right Ventricular Outflow Tract Stenting as Palliation of Critical Tetralogy of Fallot: Techniques and Results
Background. Despite current trends toward early primary repair, the surgical systemic-to-pulmonary shunt is still considered the first-choice palliation in patients with critical tetralogy of Fallot (TOF) and duct-dependent pulmonary circulation unsuitable for primary repair. However, stenting of the right ventricular outflow tract (RVOT) is nowadays emerging as an effective alternative to surgical palliation in selected patients. Methods and results. RVOT stenting is usually performed from a venous route, either femoral or, in selected cases, the right internal jugular vein. Less frequently, mostly in pulmonary infundibular/valvar atresia, this procedure can be performed using a hybrid surgical/interventional approach by surgical exposure of the RVOT, puncture of the atretic valve, and stent deployment under direct vision. The size and type of the most appropriate stent may be chosen, based on ultrasound measurements of the RVOT, to cover the right ventricular infundibulum completely and, at the same time, sparing the pulmonary valve, unless significant pulmonary valve annulus hypoplasia and/or supra-valvular stenosis is a significant component of the obstruction. In the large series so far published, early mortality of RVOT stenting is less than 2%, comparing favourably with either Blalock-Thomas-Taussig shunt or early primary repair. In addition, morbidity and clinical sequelae of this approach do not significantly differ from surgical palliation, even if RVOT stenting shows lesser durability and a higher rate of trans-catheter re-interventions over a mid-term follow-up. Finally, similar but more balanced pulmonary artery growth than surgical palliation following RVOT stenting is reported over a mid-term follow-up. Conclusions. RVOT stenting is a technically feasible, well-tolerated, and effective palliation in critical TOF. This approach is cost-effective with respect to surgical palliation either in high-risk neonates or whenever a short-term pulmonary blood flow source is anticipated due to the early surgical repair. It effectively increases pulmonary blood flow, improves arterial saturation, and promotes balanced pulmonary artery growth over a mid-term follow-up.
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