本文選題：經(jīng)皮球囊肺動脈瓣成形術(shù) + 肺動脈瓣狹窄��； 參考：《山東大學(xué)》2017年碩士論文

【摘要】：研究背景肺動脈瓣狹窄(PS)為一種較常見的先天性心臟病,約占所有先天性心臟病患者的8%～10%。傳統(tǒng)的治療方法是通過外科手術(shù),但該方法存在需開胸、創(chuàng)傷大、遺留疤痕、術(shù)后恢復(fù)時間較長等缺點。1982年Kan等首先采用經(jīng)皮球囊肺動脈瓣成形術(shù)(PBPV)成功為PS患兒解除狹窄,因該方法與外科手術(shù)相比具有操作簡便、創(chuàng)傷小、不留手術(shù)瘢痕、恢復(fù)快、經(jīng)濟等優(yōu)點,逐漸成為PS患兒首選的治療方法。既往研究多為PBPV即刻及短中期療效的評價,而對跨肺動脈瓣壓差(AP)、瓣膜反流、再狹窄、右心室內(nèi)徑大小等評價PBPV療效指標(biāo)的長期觀察研究的大樣本報道較少。目的本研究旨在于探討PBPV在我院兒童PS患兒中的應(yīng)用情況,評估PBPV治療兒童PS的安全性及有效性,結(jié)合患兒長期連續(xù)隨訪資料,觀察研究PBPV術(shù)后患兒長期預(yù)后,并分析其影響因素。研究對象和方法選取山東省立醫(yī)院小兒心臟科自1987年11月至2016年12月249例行PBPV治療的PS患兒,收集患兒住院期間PBPV術(shù)前、術(shù)中、術(shù)后的癥狀體征、心電圖、心臟正側(cè)位片、超聲心動圖、心導(dǎo)管參數(shù)等資料,以及術(shù)后1個月、3個月、半年、1年及以后每隔1～2年的門診復(fù)查隨訪資料,并在門診收集同時期健康同齡人的超聲心動圖右心室內(nèi)徑資料,并對收集的資料進行統(tǒng)計學(xué)分析。結(jié)果1.249例患兒中,男134例,女115例,年齡4個月～17歲,中位數(shù)為3.20歲,體重為6～65 kg,平均為(17.96 ±9.96)kg,術(shù)后隨訪時間1個月～30年;年齡1歲有19例、1～3歲101例、3歲129例;輕度狹窄80例,中度狹窄148例,重度狹窄21例;30例患兒伴有不同程度右室流出道狹窄,13例患兒輕度肺動脈瓣發(fā)育不良;199例(80%)患兒存在不同程度的右心室壁增厚或右心室擴大。2.PBPV手術(shù)成功率為99%(247/249),2例未成功,心血管造影分別為右心室流出道明顯肥厚性狹窄、合并肺動脈分支狹窄,轉(zhuǎn)心外科治療;術(shù)中選用球囊與瓣環(huán)比值(BAR)為1.17±0.11(1.00～1.40);心導(dǎo)管測得球囊擴張前右心室壓力、△P 分別為(78.16±32.99)mmHg、(54.77±33.04)mmHg,球囊擴張后復(fù)測分別為(45.06± 19.66)mmHg、(20.06± 12.91)mmHg,右心室壓力、AP在球囊擴張后均明顯下降(P0.05);手術(shù)時間為(58.54 ±24.51)min,X線曝光時間為(10.52±4.14)min,住院時間為(6.12±1.54)天。3.患兒術(shù)中及術(shù)后短期嚴(yán)重并發(fā)癥發(fā)生率為4.5%(11/247),其中心包積液2例,右室流出道痙攣6例,室上性心動過速、上消化道出血、主肺動脈夾層動脈瘤各1例,經(jīng)積極對癥或外科手術(shù)治療,無死亡病例。4.超聲心動圖測得AP值較心導(dǎo)管檢查測得值偏高(P0.05),兩種檢查方法AP值相關(guān)系數(shù)為0.78;兩種檢查方法測得肺動脈瓣環(huán)直徑大小無差異(P0.05)�？梢�,超聲心動圖和心導(dǎo)管在測量AP和肺動脈瓣環(huán)直徑上均具有良好的直線相關(guān)性。5.術(shù)后共隨訪223例,總隨訪率達90.3%(223/247),隨訪時間為1個月～30年,平均為(7.68±4.77)年。本組患兒術(shù)前、術(shù)后24h、術(shù)后半年、術(shù)后1～2年、術(shù)后5年、術(shù)后10年及以上的患兒AP分別為(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,患兒術(shù)后各隨訪時間段AP與術(shù)前相比均明顯降低,大部分患兒術(shù)后△P在隨訪過程中會進一步下降,術(shù)后5年、10年的患兒平均AP較術(shù)后24h的AP均有明顯下降(P0.05)。Logistic回歸分析結(jié)果顯示瓣膜發(fā)育不良型或伴右室流出道狹窄、術(shù)后即刻殘余較高△P為PBPV術(shù)后患兒中遠期療效不能達到優(yōu)標(biāo)準(zhǔn)(≤25mmHg)的危險因素,而年齡、術(shù)前狹窄嚴(yán)重程度、BAR、是否同時合并其他畸形對中遠期療效沒有明顯影響。6.術(shù)后半年隨訪的患兒中有29例(14%)AP≥36mmHg,術(shù)后1～2年隨訪時仍有12例(6.5%)△P≥36mmHg,其中3例患兒先后住院再次給予手術(shù)治療;3例患兒在隨訪過程中逐漸降至36 mmHg以下;2例患兒術(shù)后10年回院門診復(fù)查時仍大于36mmHg;3例失訪。隨訪中還發(fā)現(xiàn)1例患兒PBPV術(shù)后即刻、短期效果均達到優(yōu)的標(biāo)準(zhǔn),而在術(shù)后長期過程中△P逐漸增高,術(shù)后10年復(fù)查時升至41 mmHg。7.肺動脈瓣反流在術(shù)前24 h、術(shù)后24 h、術(shù)后半年、術(shù)后1～2年、術(shù)后5年及術(shù)后10年總發(fā)生率分別為58%、68%、73%、76%、80%、83%。隨訪時間在10年及以上的65例患兒中有14例(21%)患兒伴有中度及以上肺動脈瓣反流,12例中度反流,2例重度反流。肺動脈瓣反流發(fā)生情況在術(shù)前24 h、術(shù)后24 h及術(shù)后10年三個時間段存在顯著差異(M=37.56,P0.05),術(shù)后隨訪10年及以上的患兒較術(shù)前24 h、術(shù)后24 h時間點肺動脈瓣反流總發(fā)生率及反流程度均顯著增高(P0.05),PBPV術(shù)后的患兒隨著時間的延長,其肺動脈瓣反流發(fā)生率及反流程度均增高。Kruskal-Wallis H秩和檢驗術(shù)后隨訪10年及以上患兒肺動脈瓣反流程度在不同年齡組、狹窄程度、BAR組間均無明顯差異(P0.05)。8.隨訪時間長達10年及以上的患兒右心室舒張期內(nèi)徑為(19.27±3.03)mm,門診同期健康同齡兒右心室舒張期內(nèi)徑為(15.24 ±2.89)mm,PBPV術(shù)后患兒遠期右心室舒張期內(nèi)徑較健康同齡人明顯偏高(P0.05)。9.本研究病例術(shù)前有43%(107/249)的患兒伴有三尖瓣反流,PBPV術(shù)后24h、術(shù)后半年、術(shù)后1～2年、術(shù)后5年及術(shù)后10年及以上患兒的TR總發(fā)生率分別為42%、41%、45%、43%、44%,三尖瓣反流總發(fā)生率在術(shù)后隨訪中無明顯變化,但術(shù)前伴有中度及以上三尖瓣反流的20例患兒,17例患兒反流程度在術(shù)后隨訪過程中逐漸減輕或消失,僅有1例術(shù)后6年給予外科手術(shù)治療。FriedmanM檢驗顯示TR發(fā)生情況在術(shù)前24 h、術(shù)后24h及術(shù)后10年三個時間段存在顯著差異(P0.05),術(shù)后隨訪10年及以上的患兒TR反流程度較術(shù)前24h、術(shù)后24h時間段均有明顯減輕(P0.05)。結(jié)論1.經(jīng)皮球囊肺動脈瓣成形術(shù)治療兒童肺動脈瓣狹窄手術(shù)成功率高,術(shù)后即刻、近期、中遠期療效良好,并發(fā)癥少,再狹窄率低,可作為兒童肺動脈瓣狹窄的首選治療方法。2.患兒經(jīng)皮球囊肺動脈瓣成形術(shù)中遠期療效不能達到優(yōu)標(biāo)準(zhǔn)(≤25mmHg)的危險因素包括非典型肺動脈瓣瓣膜狹窄和術(shù)后即刻殘余較高跨肺動脈瓣壓差,而年齡、術(shù)前狹窄嚴(yán)重程度、球囊與瓣環(huán)比值、是否同時合并其他畸形等因素對中遠期療效沒有明顯影響。3.經(jīng)皮球囊肺動脈瓣成形術(shù)術(shù)后中遠期三尖瓣反流程度減輕,肺動脈瓣反流發(fā)生率及程度有增加趨勢,右心室舒張期內(nèi)徑較健康同齡人群仍偏大,個別患兒可再次發(fā)生瓣膜狹窄,需引起重視,注重院外長期隨訪監(jiān)測。
[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.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R726.5

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