Ersin EREK, Selim AYDIN, İbrahim Halil DEMİR, Bahar TEMUR, Müzeyyen İYİGÜN, Dilek SUZAN, Barış KIRAT, Ender ÖDEMİŞ

Pulmoner kapak koruma yöntemlerinin Fallot tetralojisi tamirinde erken ve orta dönem sonuçlara etkisi

Amaç: Bu çalışmada pulmoner kapağı korunarak ameliyat edilen hastalar, transanüler yama tekniği uygulanan hastalarla erken ve orta dönem sonuçları açısından incelendi. Çalışma planı: Fallot tetralojisi tanısı ile Kasım 2010 - Eylül 2015 tarihleri arasında aynı cerrah tarafından tam düzeltme uygulanan toplam 64 hasta bu çalışmaya dahil edildi. Hastaların ortalama yaşı 20.0±14.2 ay (5.5-96 ay) idi. Kırk hasta (%62.5) erkek idi. Otuz iki hasta (%50) bir yaşın altındaydı. Otuz beş hastaya transanüler yama tekniği ile (Grup 1), 29 hastaya pulmoner kapak koruma tekniği ile (Grup 2) cerrahi uygulandı. Grup 1’deki hastaların 15’ine otojen perikard ile pulmoner monokusp oluşturuldu. Grup 2’deki hastaların dokuzuna transatriyal, sekizine transatriyal-transpulmoner, sekizine infundibüler yama, dördüne kombine infundibüler ve pulmoner yama ile tam düzeltme uygulandı. Bulgular: Grup 2’de erken mortalite görülmedi. Grup 1’de beş hasta (%14.2) erken dönemde kaybedildi (p=0.058). Bu hastaların ikisine monokusp replasmanı (%13.3) uygulanmıştı (p=1). Mortalite nedenleri ani kardiyak arrest (n=2), multiorgan yetmezliği (n=1), düşük kardiyak debi (n=1), nörolojik komplikasyon (n=1) idi. Grup 1’de beş hasta ekstrakorporeal membran oksijenasyon (ECMO) desteğine alındı. Üç hasta ECMO’dan ayrıldı. ECMO’dan ayrılan iki hasta sorunsuz taburcu edildi. Total ameliyat sonrası morbidite oranı Grup 1’de anlamlı olarak yüksekti (%51.4’e karşın %6.8) (p=0.0001). Grup 1’de pulmoner monokusp uygulanan hastalarda morbidite oranı aynı gruptaki diğer hastalara göre anlamlı olarak düşüktü (p=0.0176). Hastalardan 49’u (%83), median 6.5 ay (1-24 ay) takip edildi. Grup 1’de monokusp uygulanmayan tüm hastalarda serbest pulmoner kapak yetmezliği saptanırken, grup 2’deki hastalarda pulmoner kapak yetmezliği yoktu veya hafif derecede idi. Grup 1 içerisindeki monokusp uygulanan hastaların 12’si (%80) takip edildi. Bu hastaların sadece ikisinde serbest pulmoner kapak yetmezliği (%16.6) tespit edildi. Geri kalanlarda hafif (n=6) veya hafif-orta pulmoner kapak yetmezliği (n=4) vardı. Sonuç: Fallot tetralojisi tamiri sırasında, pulmoner kapağı korunan hastalarda mortalite ve morbidite daha düşüktür. Transanüler yama gereken hastalarda monokusp pulmoner kapak uygulaması sonuçları iyileştirebilir. Tamir sırasında kompetan bir pulmoner kapak elde etmek için çaba gösterilmesi önerilebilir.

The impact of pulmonary valve-sparing techniques on postoperative early and midterm results in tetralogy of Fallot repair

Background: In this study, we analyzed the impact of pulmonary valve-sparing techniques on early and midterm postoperative results of tetralogy of Fallot repair.Methods: A total of 64 patients diagnosed with tetralogy of Fallot, who underwent total correction operation by the same surgeon between November 2010 and September 2015 were included in this retrospective study. Mean age of the patients was 20.0±14.2 months (5.5-96 months). Forty patients (62.5%) were male. Thirty two of the patients (50%) were under one year of age. Pulmonary valve-sparing techniques were performed in 29 patients (Group 2), while transannular patch was applied in the remaining 35 patients (Group 1). Pericardial monocusp valve was constructed in 15 patients in Group 1. In Group 2, pulmonary valve-sparing techniques were transatrial repair in nine patients; transatrial-transpulmonary in eight, infundibular patch in eight, and infundibular-pulmonary patch in four patients.Results: There was no early postoperative mortality in Group 2. Five patients (14.2%) in Group 1 died in the early postoperative period (p=0.058). Pulmonary monocusp insertion was performed in 2 (13.3%) of these patients (p=1). The causes of mortality were sudden cardiac arrest (n=2), multiorgan failure (n=1), low cardiac output (n=1), and neurological complications (n=1). Five patients in Group 1 required extracorporeal membrane oxygenation support (ECMO). Three of them were separated from ECMO and two of the patients that were separated were discharged uneventfully. Total postoperative morbidity rate was significantly higher in Group 1 (51.4% vs. 6.8%) (p=0.0001). Morbidity rate was significantly lower in patients with pulmonary monocusp insertion than patients in the same group without a monocusp (p=0.0176). Forty nine (83%) of the patients were followed up for a median of 6.5 (1-24) months. While free pulmonary regurgitation was detected in all non-monocusp patients in Group 1, pulmonary regurgitation was absent or mild in Group 2. Twelve (80%) of the patients in Group 1 who had monocusp insertion were followed up. Only two of these patients had free pulmonary regurgitation (16.6%). The rest of them had mild (n=6) or mild-moderate pulmonary regurgitation (n=4).Conclusion: Mortality and morbidity rates are lower when pulmonary valve-sparing techniques are used in repair of tetralogy of Fallot. Monocusp pulmonary valve insertion may improve results in patients who require transannular patch repair. It is suggested that every effort should be made to achieve a competently working pulmonary valve during repair.

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